California Healthy Kids Survey Research Articles

Mental Health Needs, Barriers, and Receipt of Care Among Transgender and Nonbinary Adolescents

PurposeTransgender and nonbinary youth disproportionately experience adverse mental health outcomes compared to cisgender youth. This study examined differences in their mental health needs and supports, barriers to care, and receipt of mental health care. MethodsThis study examined cross-sectional data from 43,339 adolescents who completed the California Healthy Kids Survey, 4% (n = 1,876) of whom identified as transgender and/or nonbinary. Chi-square test and t-test were used to compare mental health needs and supports, resilience, and barriers to and receipt of care experienced by transgender and nonbinary youth compared to cisgender youth. ResultsTransgender and nonbinary youth were significantly more likely to experience chronic sadness/hopelessness (74% vs. 35%) and consider suicide (53% vs. 14%) and less likely to report resilience factors (school connectedness: mean score 3.12 vs. 3.52). Transgender and nonbinary youth were significantly less likely to be willing to talk to teachers/adults from school (12% vs. 18%) or parents/family members (21% vs. 43%), but more willing to talk to counselors (25% vs. 19%) regarding mental health concerns. Transgender and nonbinary youth were significantly more likely to select being afraid (48% vs. 20%), not knowing how to get help (44% vs. 30%), or concern their parents would find out (61% vs. 36%) as barriers to seeking mental health care, yet reported slightly higher odds of receiving care when needed (odds ratio: 1.2). DiscussionTransgender and nonbinary youth are more likely to report mental health concerns and barriers to seeking care than cisgender youth. Increasing access to care is critical for this population.

Co-Use of Tobacco Products and Cannabis Is Associated with Absenteeism and Lower Grades in California High School Students

To examine the association between co-use of commercial tobacco product (hereafter referred to as tobacco) and cannabis with educational outcomes among high school students. We analyzed high school student data from the 2021-2022 California Healthy Kids Survey (n=287 653). Current (past-month) or ever tobacco and cannabis use was categorized as co-use, only tobacco or cannabis, or neither. Two self-reported educational outcomes were examined: absenteeism and grades. Adjusted logistic and linear regression models were used to examine the association between tobacco/cannabis use and absenteeism or grades, respectively. Estimates were adjusted for individual, peer, and school covariates, and clustering within schools. Current co-use of tobacco and cannabis was more than double the use of only tobacco (3.7% vs 1.7%) and similar to only cannabis (3.7%). Almost 18% of students reported absenteeism. Compared with students who used neither substance, students with current co-use had greater odds of absenteeism (aOR 1.41, 95% CI 1.33-1.49) and lower grades (β=-0.87, 95% CI -0.92 to -0.82). Compared with students using tobacco alone, students with co-use also had a significant elevated odds of absenteeism (aOR1.19, 95% CI 1.10-1.29) and lower grades (β=-0.39, 95% CI -0.46 to -0.32). Similar results were found for students who ever used tobacco and cannabis. California youth who co-use tobacco and cannabis were most likely to have absenteeism and lower grades. Comprehensive efforts to prevent or reduce youth substance use may improve educational outcomes.

Examination of the "model minority" stereotype through ethnicity and sexual orientation heterogeneity among Asian American youth.

The "model minority" stereotype disguises heterogeneity among Asian American youth, many of whom are harmed by policies and attitudes that assume this population to be uniformly high achieving and "problem free." The current study uses an intersectional lens to disaggregate this population by ethnicity and sexual orientation subgroups to demonstrate differences in academic performance and substance use behavior among Asian American youth. This study also investigates the extent to which racial/ethnicity and sexual orientation-based bullying may explain such links. Participants included 65,091 Asian American youth (46.41% Southeast Asian; 37.01% East Asian; 16.58% South Asian) in grades 6-12, who were part of the California Healthy Kids Survey (2015-2017). Participants were 49.4% female and about a third each were in grades 6-8, grades 9-10, and grades 11-12. School-based surveys were administered. Youth reported on substance use, grades, and bias-based bullying experiences in the past 12 months. Generalized linear mixed-effects model results showed that outcomes varied widely across youth ethnicity and sexual orientation subgroups. Inclusion of racial/ethnic and sexual orientation bullying in these models attenuated the direct effects between ethnic and sexual identities and academic performance and substance use outcomes. Implications of this work suggest that research and policy should not treat Asian American students as uniformly high-performing and low-risk, because the experiences of those who deviate from these assumptions will be left undetected. Interventions targeting bias-based bullying may be able to reduce disparities in academic and substance use outcomes among Asian American youth.

Age Trends in Bias-Based Bullying and Mental Health by Sexual Orientation and Gender Identity.

Disparities in mental health and bullying between SGM youth and their heterosexual, cisgender peers are well-established. There remain questions about whether the onset and progression of these disparities differ across adolescence-knowledge critical for screening, prevention, and intervention. To address this, the current study estimates age-based patterns of homophobic bullying, gender-based bullying, and mental health across groups of adolescents defined by sexual orientation and gender identity (SOGI). Data are from the 2013-2015 cycle of the California Healthy Kids Survey (n = 728,204). We estimated the age-specific prevalence rates of past-year homophobic bullying, gender-based bullying, and depressive symptoms using three- and two-way interactions by (1) age,sex, and sexual identity and (2) age andgender identity, respectively. We also tested how adjustments for bias-based bullying alter predicted prevalence rates of past-year mental health symptoms. Results showed that SOGI differences in homophobic bullying, gender-based bullying, and mental health were already present among youth aged 11 and younger. SOGI differences by age were attenuated when adjusting models for homophobic and gender-based bullying, particularly among transgender youth. SOGI-related bias-based bullying and mental health disparities were present early andgenerally persisted throughout adolescence. Strategies that prevent exposure to homophobic and gender-based bullying would significantly reduce SOGI-relateddisparities in mental health across adolescence.

Adolescent use and co-use of tobacco and cannabis in California: The roles of local policy and density of tobacco, vape, and cannabis retailers around schools

Adolescent tobacco use (particularly vaping) andco-use of cannabis and tobacco have increased, leading some jurisdictions to implement policies intended to reduce youth access to these products; however, their impacts remainunclear. We examine associations between local policy, density of tobacco, vape, and cannabis retailers around schools, and adolescent use and co-use of tobacco/vape and cannabis.We combined 2018 statewide California(US) data on: (a) jurisdiction-level policies related to tobacco and cannabis retail environments, (b) jurisdiction-level sociodemographic composition, (c) retailer locations (tobacco, vape, and cannabis shops), and (d) survey data on 534,176 middle and high school students (California Healthy Kids Survey). Structural equation models examined how local policies and retailer density near schools are associated with frequency of past 30-day cigarette smoking or vaping, cannabis use, and co-use of tobacco/vape and cannabis, controlling for jurisdiction-, school-, and individual-level confounders.Stricter retail environment policies were associated with lower odds of past-month use of tobacco/vape, cannabis, and co-use of tobacco/vape and cannabis. Stronger tobacco/vape policies were associated with higher tobacco/vape retailer density near schools, while stronger cannabis policies and overall policy strength (tobacco/vape and cannabis combined) were associated with lower cannabis and combined retailer densities (summed tobacco/vape and cannabis), respectively. Tobacco/vape shop density near schools was positively associated with tobacco/vape use odds, as was summed retailer density near schools and co-use of tobacco, cannabis.Considering jurisdiction-level tobacco and cannabis control policies are associated with adolescent use of these substances, policymakers may proactively leverage such policies to curb youth tobacco and cannabis use.

22 Flavored tobacco sales restrictions and youth e-cigarette use by tobacco retailer density

OBJECTIVES/GOALS: Flavored tobacco sales restrictions (FTSR) may reduce youth tobacco use, but may not be as effective in areas with greater tobacco retailer density (TRD), which is associated with greater tobacco access and more common in low-income areas. We examined the association between FTSRs and e-cigarette use for youth in high and low TRD cities. METHODS/STUDY POPULATION: We analyzed data from the California Healthy Kids Survey using a difference-in-differences (DID) strategy. We compared pre- and post-policy changes in ease of access to e-cigarettes, current use, and ever use one year after implementation among students (9th and 11th graders) attending school in a city with a FTSR (n=20,832) versus without (n=66,126). Separate analyses were conducted for students in cities with low and high TRD, with a median cutoff of 3.3 tobacco retailers per square mile. RESULTS/ANTICIPATED RESULTS: Students attending schools in cities with high TRD (compared with low TRD) had a higher percentage of parents with a high school education or less, and were more likely to identify as Hispanic or Non-Hispanic Asian/Pacific Islander. Among students with low TRD, FTSRs were associated with reduced ease of access to e-cigarettes (DID=0.76, 95% CI: 0.58, 0.99). However, among students with high TRD, FTSRs were associated with increased ease of access (DID: 1.25, 95% CI: 1.02, 1.56) and current use (DID=1.57, 95% CI: 1.31, 1.87). DISCUSSION/SIGNIFICANCE: FTSRs were associated with lower youth e-cigarette access in low, but not high TRD areas. Stronger policies or enforcement may be needed in high TRD areas.

An eighteen-year longitudinal examination of school victimization and weapon use in California secondary schools.

School safety has been a major public health issue in the United States and internationally for more than three decades. Many policies and programs have been developed and implemented to prevent school violence, improve the school climate, and increase safety. There are only a few peer-reviewed studies of changes in school violence over time. The study examined changes over time in school victimization, weapon involvement and school climate, comparing change trajectories by gender and race and different change trajectories among schools. A longitudinal study of the biennial California Healthy Kids Survey in secondary schools from 2001 to 2019. The representative sample included 6,219,166 students in grades 7, 9, and 11 (48.8% male) from 3253 schools (66% high schools). All victimization and weapon involvement items had significant and substantial linear reductions. The largest reduction involved being in a physical fight (from 25.4% to 11.0%). There were reductions in weapon involvement (d = 0.46) and victimization (d = 0.38). Biased-based victimization only declined slightly (d = -0.05). School belongingness and safety increased (d = 0.27), adult support increased a small amount (d = 0.05), and student participation declined (d = -0.10). Changes were smallest among White students. Ninety-five percent of the schools showed the same pattern of reductions. The findings are in contrast to the public's concerns that school violence is a growing problem. Reductions in school violence may result from social investment in school safety. A distinction should be made between school shootings and other forms of school violence.

Bias-Based Bullying in California Schools: The Impact of the 2016 Election Cycle.

The purpose of this study is to examine the trends in bias-based bullying between 2013 and 2019 among California youth overall and by type of bias-based bullying and explore the extent to which Trump's announcement of his candidacy for U.S. President in June 2015 impacted these bullying outcomes. We pooled the student-level survey data from multiple waves of the California Healthy Kids Survey. The final study sample included 2,817,487 middle- and high-school students (48.3% female, 47.9% male, and 3.7% not reported). We examined five specific types of bias-based bullying and any bias-based bullying overall. We employed logistic regression and calculated odds ratios to compare differences in the odds of bias-based bullying before and after Trump announced his candidacy for U.S. President. Between 2013 and 2019, approximately one in four students reported experiencing at least one type of bias-based bullying, based on race, ethnicity, or national origin being the most commonly reported. Trump's announcement for candidacy was inconsistently associated with differences in the odds of bias-based bullying. Counties in which a higher proportion of the electorate voted for Trump had slightly higher odds of bullying for any bias-based bullying and for all specific types of bias-based bullying. Findings highlight the need for a commitment to protecting students from bullying regardless of their identity. Public health and education researchers and practitioners should draw on our growing understanding of the different dimensions of bullying in designing, implementing, and evaluating intervention approaches that address bias-based bullying, a particularly important cause given the growing polarization in the United States and the increasing salience of identity in the lead-up to and since the 2016 and 2020 elections.

Housing status as a social determinant of disparities in adolescent smoking, vaping, and dual use of cigarettes and e-cigarettes

Little is known about how various housing situations among adolescents may be associated with differential patterns of smoking and vaping—information with practical relevance for tobacco prevention and control efforts. We analyzed disparities by housing status in past 30-day smoking, vaping, and dual use of cigarettes and e-cigarettes/vape products among adolescents participating in the population-based California Healthy Kids Survey (N = 931,355; 2017–2019). Generalized linear mixed models for a categorical outcome quantified differences in prevalence and adjusted odds ratios (AORs) of smoking only, vaping only, and dual use among adolescents in various housing situations relative to their peers living in a home with one or more parents/guardians or other relatives. Our findings suggest adolescents living in a friend’s home; adolescents living in a hotel, motel, shelter, car, campground, or other transitional or temporary housing; and adolescents living in a foster home, group care, or waiting placement evidenced pronounced disparities in past 30-day smoking only (AORs: 3.16–3.40, ps < 0.0001) and dual use of cigarettes and e-cigarettes/other nicotine vape products (AOR: 3.73–5.83, ps < 0.0001) relative to their peers living in a home with one or more parents/guardians or other relatives. Vaping only disparities, although significant, were relatively smaller (AORs: 1.53–1.88, ps < 0.0001). These findings emphasize housing as a social determinant of smoking, vaping, and dual use disparities among adolescents and have implications for multilevel preventive intervention development.

Adolescent substance use at the intersections of foster care, sexual orientation and gender identity, racial/ethnic identity, and sex assigned at birth

BackgroundLesbian, gay, bisexual, transgender, queer and questioning (LGBTQ) youth are overrepresented in foster care and report greater substance use during adolescence. ObjectiveUsing an intersectional lens, the current study investigates differences in foster care placement and variation in substance use at the intersections of foster care and sexual orientation, gender identity, racial/ethnic identities, and sex assigned at birth. Participants and settingsA sample of 121,910 LGBTQ youth (grades 6–12) completed either the Minnesota Student Survey in 2019, the California Healthy Kids Survey from 2017 to 2019, or the 2017 LGBTQ National Teen Study. MethodsYouth reported their substance use in the past 30 days (alcohol, binge drinking, cigarette, marijuana), social positions (sexual orientation, gender identity, racial/ethnic identities, sex assigned at birth), living arrangement (foster care or not), and grade in school. Logistic regression was used to examine the main and interaction effects of foster care and social positions on youth substance use. ResultsResults indicated significant differences in substance use at the intersection of foster care placement and youth social positions. Significant two-way interactions for foster care placement and social positions emerged predicting alcohol, binge drinking, and marijuana use. ConclusionsFindings show that LGBTQ youth in foster care are at higher risk for substance use than those not in foster care. Particular support is needed for lesbian, gay, and questioning youth, transgender youth, LGBTQ youth assigned male at birth, and Asian or Pacific Islander LGBTQ youth in foster care.

The association of parentification indicators with substance use patterns among military-connected adolescents.

Military-connected youths are a vulnerable population exposed to a unique set of stressors, which may put them at increased risk for adverse mental and behavioral health outcomes, compared to their civilian counterparts. Among military-connected adolescents, emotional and instrumental parentification are mechanisms hypothesized to account for negative outcomes, including substance use. However, parentification may be protective in some cultures and has not been examined in the military population. Data were drawn from 1,441 7th-, 9th-, and 11th-graders who had a parent in the military and completed the 2013 California Healthy Kids Survey. Latent class analysis was used to examine patterns of instrumental parentification indicators among military-connected youths and associated patterns of substance use. Military-connected students in the high parentification class were significantly less likely to be in the frequent polysubstance using class (odds ratio = 0.376, 95% confidence interval [0.180, 0.782]). Findings suggest that experiences of instrumental parentification, including having more responsibilities at home, being more independent, and being able to solve problems better than peers, may be protective. For military-connected youths, these skills, developed in the context of their families, may translate to better coping with other stressful situations. Professionals may be able to build on these strengths and develop adaptive coping strategies to support military-connected youths in managing the stressors of wartime military life. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Collateral consequences of the school-to-prison pipeline: Adolescent substance use and developmental risk

ObjectiveThe adolescent health consequences of the school-to-prison pipeline remain underexplored. We test whether initiating components of the school-to-prison pipeline—suspensions, expulsions, and school policing—are associated with higher school-average levels of student substance use, depressed feelings, and developmental risk in the following year. MethodWe linked 2003–2014 data from the California Healthy Kids Survey and the Civil Rights Data Collection from over 4,800 schools and 4,950,000 students. With lagged multi-level models, we estimated relationships between the school prevalence of total discipline, out-of-school discipline, and police-involved discipline, and standardized school-average levels of 6 substance use measures and 8 measures of developmental risk, respectively. ResultsThe prevalence of school discipline predicted subsequent school-mean substance use and developmental risk. A one-unit higher prevalence of total discipline predicted higher school levels (in standard deviations) of binge drinking alcohol (0.14, 95% CI: 0.11, 0.17), drinking alcohol (0.15, 95% CI: 0.12, 0.18), smoking tobacco (0.09, 95% CI: 0.06, 0.12), using cannabis (0.16, 95% CI: 0.14, 0.19), using other drugs (0.17, 95% CI: 0.14, 0.21), and violence/harassment (0.16, 95% CI: 0.12, 0.2). Total discipline predicted lower levels of reported community support (−0.07, 95% CI: −0.1, −0.05), feeling safe in school (-0.12, 95% CI: −0.16, −0.09), and school support (−0.16, 95% CI: −0.19, −0.12). Associations were greater in magnitude for more severe out-of-school discipline. Findings were inconsistent for police-involved discipline. ConclusionExclusionary school discipline and school policing—core elements of the school-to-prison pipeline—are previously unidentified population predictors of adolescent substance use and developmental risk.

Comparing Substance Use and School-Based Stressors Among Black and Latinx Transgender Youth and Peers With Shared Minoritized Identities

PurposeThe aim of this study is to compare substance use and school-based stressors among Black and Latinx transgender youth (trans BLY), White transgender youth (trans WY), and Black and Latinx cisgender youth (cis BLY) and identify associations between substance use and stressors among trans BLY. MethodsWe analyzed 2015–2017 Biennial California Healthy Kids Survey data with a weighted sample of the state’s secondary school population. The analytic sample included 9th and 11th grade trans BLY, trans WY, and cis BLY. Past 30-day and lifetime substance use (cigarettes, e-cigarettes/vaping, marijuana, and alcohol) and school-based stressors (victimization, race-, gender-, and sexuality-based harassment) were compared between cohorts via logistic regression. For trans BLY, associations between substance use and stressors were assessed via logistic regression. ResultsThe analytic sample (n = 19,780) included 252 trans BLY, 104 trans WY, and 19,424 cis BLY. Among trans BLY, estimated prevalence of 30-day (and lifetime) use of cigarettes, e-cigarette/vaping, marijuana, and alcohol were 13% (23%), 19% (39%), 27% (42%), and 29% (48%), respectively. Trans BLY had similar odds of 30-day and lifetime use of all substances compared to trans WY but higher odds of use compared to cis BLY. For trans BLY, race- and gender-based harassment and higher victimization levels were associated with higher odds of 30-day and lifetime use of all substances. Sexuality-based harassment was associated with higher odds of 30-day and lifetime marijuana and alcohol use. DiscussionTrans BLY have high prevalence of substance use, comparable with trans WY but higher than cis BLY. Substance use among trans BLY is associated with school-based stressors.

Flavored Tobacco Sales Restrictions and Teen E-cigarette Use: Quasi-experimental Evidence From California.

Flavored tobacco sales restrictions (FTSRs) are implemented to reduce access to flavored tobacco products. We examined the association between seven cities with local FTSRs implemented in 2018/2019 and e-cigarette use among high school students in the California Bay Area. We analyzed data from the California Healthy Kids Survey using a difference-in-differences (D-I-D) strategy. We compared pre- and post-policy changes one year after implementation in current and ever e-cigarette use among students attending school in a city with a FTSR (exposed) (n = 20 832) versus without (unexposed) (n = 66 126). Other outcomes included ever marijuana use in an e-cigarette and ease of access to e-cigarettes. Pre- to post-policy, the adjusted odds of current and ever e-cigarette use did not significantly change among students exposed and unexposed to a FTSR. In the adjusted D-I-D analysis, the odds of current (aOR: 1.25, 95% CI: 0.95, 1.65) and ever e-cigarette use (aOR: 1.06, 95% CI: 0.89, 1.26) did not significantly change by exposure group. However, one year post-implementation, the odds of ease of access to e-cigarettes significantly increased among exposed (aOR: 1.57, 95% CI: 1.27, 1.95) and unexposed students (aOR: 1.54, 95% CI: 1.39, 1.70). Similarly, the odds of ever using marijuana in an e-cigarette significantly increased among exposed (aOR: 1.35, 95% CI: 1.19, 1.53) and unexposed students (aOR: 1.29, 95% CI: 1.20, 1.39). Local FTSRs in the California Bay Area were not associated with a change in e-cigarette use one year post-implementation. Increased ease of access and marijuana use may be explanatory factors. FTSRs were not associated with a decrease in current or ever e-cigarette use among high school students in the California Bay Area one-year post-implementation. Potential explanatory factors are that ease of access to e-cigarettes and using marijuana in an e-cigarette increased. More research is needed to understand the influence of these factors on youth access and behaviors. To address the youth e-cigarette epidemic, a comprehensive approach is needed, including policies, media campaigns, education programs, and cessation tools targeted to youth.

Lesbian, Gay, and Bisexual Students Experiencing Homelessness and Substance Use in the School Context: A Statewide Study.

This study explored differences between lesbian, gay, and bisexual (LGB)-housed and homeless students regarding substance use patterns on and off school grounds and the unique contribution of homelessness to substance use in school. Data were from the 2013-2015 California Healthy Kids Survey, a statewide survey of school protective factors and risk behaviors. A representative sample of 9th- and 11th-grade students (N=20,337) was used. Comparisons between housed (n=19,456) and homeless (doubled up: n=715; acute homeless: n=166) LGB students were conducted. We used chi-square tests to compare rates of lifetime, past-30-day, and in-school substance use and conducted multivariate logistic regression models for each substance use variables. Chi-square test results indicated significant differences in rates of substance use among students experiencing homelessness (both categories) and housed LGB students. Lesbian, gay, and bisexual students experiencing homelessness were more likely to report substance use off and on school grounds. Results from logistic regression analyses indicated that LGB students who experience homelessness were significantly more likely to report recent and in-school substance use. For example, students experiencing acute homelessness were about 3 times as likely to report heavy episodic drinking (adjusted odds ratio [AOR]=3.13; 95% confidence interval [CI]=2.13, 4.26) and more than 5 times as likely to smoke marijuana in school (AOR=5.38; 95% CI=3.46, 8.36), compared to housed LGB students. LGB students who experience homelessness are at higher risk than housed LGB students of substance use on and off school grounds. Findings highlight the need to provide support in the school context for this subpopulation.

Binge drinking disparities by gender identity, race, and ethnicity in California secondary schools

Our objective was to estimate disparities in binge drinking among secondary school students in California at the intersection of gender identity, race, and ethnicity, without aggregating racial and ethnic categories. We combined two years of the statewide middle and high school California Healthy Kids Survey (n = 951,995) and regressed past month binge drinking on gender identity (i.e., cisgender, transgender, or not sure of their gender identity), race (i.e., white, American Indian or Alaskan Native, Asian, Black or African American, Native Hawaiian or Pacific Islander, or multiracial), and ethnicity (i.e., Hispanic/Latinx or non-Hispanic/Latinx), and their interaction. Transgender students had greater odds of reporting past month binge drinking than cisgender students, with greater magnitudes among students with minoritized racial or ethnic identities compared to non-Hispanic/Latinx white students. For example, among non-Hispanic/Latinx white students, transgender students had 1.3 times greater odds (AOR = 1.30, 95% CI = 1.12—1.50), whereas among Hispanic/Latinx Black or African American students, transgender students had 5.3 times greater odds (AOR = 5.33, 95% CI = 3.84—7.39) of reporting past month binge drinking than cisgender students. Transgender adolescents, particularly those with minoritized racial or ethnic identities, may be at disproportionate risk of binge drinking. Interventions that address systemic racism and cisgenderism from an intersectional perspective are needed.

Substance Use Behaviors Among LGBTQ+ Youth of Color: Identification of the Populations Bearing the Greatest Burden in Three Large Samples

PurposeResearch has identified persistent disparities in alcohol, e-cigarette, and marijuana use, by sexual orientation, gender identity, and race/ethnicity. Using an intersectionality framework, the present study analyzes three large datasets to identify intersecting social positions bearing the highest burden of substance use. MethodsData from adolescents in grades 9–12 in three samples (2019 Minnesota Student Survey, 2017–2019 California Healthy Kids Survey, and 2017 National Teen Survey) were harmonized for an analysis (N = 602,470). A Chi-squared Automatic Interaction Detection analysis compared the prevalence of four types of substance use across all combinations of four social positions (six racial/ethnic identities, five sexual orientations, three gender identities, and two sexes assigned at birth). For each substance, 10 intersectional groups with the highest prevalence of use were examined. ResultsIn the full sample, 12%–14% of participants reported past 30-day alcohol, e-cigarette, or marijuana use and 7% reported past 30-day binge drinking. Several intersecting marginalized social positions were consistently found to bear a high burden of substance use. For example, transgender and gender diverse (TGD) Latina/x/o young people, particularly those assigned male at birth, were in the high prevalence groups for alcohol use, binge drinking, and marijuana use. Black TGD or gender-questioning youth were commonly in the high prevalence groups. DiscussionFindings suggest that support, resources, and structural changes specifically tailored to youth with multiple marginalized identities (especially TGD) may be needed. The results argue for intersectional efforts that explicitly address racial/ethnic and cultural differences, while also integrating awareness and understanding of sexual and gender diversity.

Associations of California's Tobacco 21 Minimum Sales Age Law with Tobacco Use Among Sexual Minority Adolescents: A Trends Analysis.

In 2016, California enacted a law (T21) prohibiting tobacco product sales to individuals under 21 years of age. Given tobacco use disparities among sexual minority (SM) youth, this study investigated whether California's T21 law was differentially associated with changes in tobacco use for SM and non-SM adolescents. Secondary analyses of California Healthy Kids Survey data from 2013-2014 to 2018-2019 for 7th, 9th, and 11th graders (N = 2 229 401). Multilevel mixed-effects logistic regression analyses showed that SM students were more likely than non-SM students to report past-30-day and lifetime cigarette (odds ratio (OR) = 2.47; OR = 2.37), e-cigarette (OR = 1.21; OR = 1.10), smokeless tobacco use (OR = 1.95; OR = 1.56), and use of any tobacco product (OR = 1.94; OR = 1.61). Among SM youth, T21 was associated with significant reductions in lifetime e-cigarette use (OR = 0.66), and lifetime use of any tobacco products (OR = 0.75). These decreases generally were greater than or equivalent to those observed for non-SM youth. For 30-day e-cigarette and any tobacco use, SM youth showed no significant increases, whereas non-SM youth showed significant increases (OR = 1.06; OR = 1.11) following T21. T21 was associated with smaller increases in lifetime cigarette use (OR = 1.34), and larger increases for past-30-day and lifetime smokeless tobacco use (OR = 1.34; OR = 1.28) among SM students, to those observed for non-SM students. California's T21 policy may help reduce tobacco use disparities among SM students who are more at risk for tobacco use than their non-SM peers. Research on associations of T21 laws with tobacco use among sexual minority (SM) adolescents is lacking. The potential for unintended consequences of T21 for these adolescents raises concerns about increased health disparities. Importantly, our study generally found California's T21 was associated with reductions in tobacco use among SM students that were equivalent to or greater than those for non-SM students. Future research should investigate whether T21 laws and similar policies have differential effects for other marginalized groups and, if so, identify mechanisms that can be targeted in prevention efforts.

109 Flavored tobacco sales restrictions and e-cigarette use among high school students in California

OBJECTIVES/GOALS: Flavored tobacco sales restrictions (FTSRs) are implemented to reduce access to flavored tobacco products. We examined the association between seven local FTSRs implemented in 2018/2019 and e-cigarette use among high school students in the Bay Area region of California. METHODS/STUDY POPULATION: We analyzed data from the California Healthy Kids Survey using a difference-in-differences (D-I-D) strategy. We compared pre- and post-policy changes one year after implementation in current tobacco use (e-cigarettes and cigarettes) among students exposed (n=20,832) versus unexposed (n=66,126) to a FTSR. Exposed students attended school in a city with a FTSR. Other outcomes included ever use of e-cigarettes, ever marijuana use in an e-cigarette, and ease of access to e-cigarettes. RESULTS/ANTICIPATED RESULTS: Pre- to post-policy, current tobacco use did not change in exposed students (e-cigarette: 10.5% to 11.1%; cigarette 2.6% to 2.5%) and decreased in unexposed students (e-cigarette: 12.8% to 11.4%; cigarette: 2.2% to 1.7%). FTSRs were not associated with a change in odds of current e-cigarette (adjusted D-I-D OR: 1.25, 95% CI: 0.95, 1.65) or cigarette use (adjusted D-I-D OR: 1.24, 95% CI: 0.94, 1.63), relative to unexposed students. For both exposed and unexposed groups, there was a 54-57% increased odds of reporting ease of access to e-cigarettes and a 29-35% increased odds of ever using marijuana in an e-cigarette. No change was detected for ever e-cigarette use. DISCUSSION/SIGNIFICANCE: Local FTSRs in California were not associated with a decrease in e-cigarette or cigarette use one-year post-implementation. Increased ease of access and marijuana use may be explanatory factors.

Substance use among transgender youth: associations with school-based victimization and school protective factors

This paper examines the extent to which transgender students’ experiences with school-based victimization and school protective factors contribute to or reduce substance use. We conducted secondary analyses of school-based victimization, school protective factors, and substance use of a subsample of transgender students from the 2013–2015 California Healthy Kids Survey. Results indicate that among transgender students, school-based victimization is a risk factor for substance use. School protective factors, including school connectedness and school adult support, were associated with a decreased likelihood of substance use among transgender students; for instance, higher levels of school connection were associated with a 30% decreased odds of past 30-day cigarette use (AOR = .70; 95% CI = .60–.82), above and beyond the key risk factor of school-based victimization. This study’s findings suggest that school educators, staff, and administration should receive training around transgender-inclusive practices, and schools should implement transgender-affirming education, programming, and services to improve school connection and school adult support for transgender students.