ADHD symptoms increase risk of e-cigarette and tobacco use in U.S. youths

Youths with ADHD symptoms are at a higher risk of nicotine addiction, with e-cigarettes playing a major role in early tobacco use—raising concerns about long-term health consequences.

Study: Attention-Deficit/Hyperactivity Disorder Symptoms and Later E-Cigarette and Tobacco Use in US Youths.  Image Credit: Drawlab19 / Shutterstock.com

A recent JAMA Network Open study investigates whether youths with symptomatic and asymptomatic attention-deficit hyperactivity disorder (ADHD) are at a greater risk of incident e-cigarette and tobacco use as compared to those without ADHD.

The effect of nicotine and tobacco use on ADHD

Tobacco use is directly associated with the onset of many diseases and, as a result, is a leading cause of mortality worldwide. Previous studies have established a link between ADHD and tobacco use; however, it remains unclear how the widespread availability of electronic nicotine delivery systems like e-cigarettes may have exacerbated this issue. In 2018, e-cigarette use surpassed cigarette smoking and has continued to increase to become the second most prevalent substance use behavior.

ADHD, which is characterized by functional impairment, hyperactivity, and/or inattention, is one of the most common psychiatric disorders among children and adolescents in the United States. In fact, current estimates indicate that one in nine children and adolescents in the U.S. received an ADHD diagnosis in their lifetime. Moreover, about 53.6% of U.S. youths are currently diagnosed with ADHD and prescribed ADHD pharmacotherapy, whereas 44.4% receive psychosocial treatment to manage their symptoms.

A recent meta-analysis revealed that youths with ADHD are at a significantly higher risk of nicotine use by middle adolescence as compared to their peers without ADHD. Similarly, a population-based study conducted in Sweden revealed that impulsive symptoms of ADHD were associated with early-onset tobacco use.

Early onset of tobacco use may predict substance use disorders later in life; therefore, early management of ADHD symptoms has the potential to reduce the risk of future engagement in substance use and other risky behaviors.

About the study

The current cohort study aims to clarify the relationship between ADHD and tobacco use, as well as determine how the presence of ADHD symptoms may be involved in this association. To this end, nationally representative longitudinal data of 13,651 U.S. youths between 12 and 17 years of age, as well as their parents, were obtained from the Population Assessment of Tobacco and Health (PATH) Study.

PATH collected survey data through questionnaires between September 2013 and April 2023 in seven waves. At each wave, youths provided information about their lifetime and past-year use of nine different nicotine or tobacco products including e-cigarettes, vape pens, e-hookahs, e-cigars, cigarettes, cigars, smokeless tobacco, dissolvable tobacco, and snus.

Based on wave one data, nine mutually exclusive subgroups of U.S. youths were categorized into three mutually exclusive groups of ADHD diagnosis with pharmacotherapy, ADHD diagnosis without pharmacotherapy, and controls, which comprised individuals without an ADHD diagnosis or pharmacotherapy. Within each subgroup, ADHD symptom severity was classified as none, one to two, or three to four. All youth participants completed the Global Appraisal of Individual Needs (GAIN) assessment.    

Study findings

About 50.4% of study participants were between 12 and 14 years of age, whereas 49.6% were between 15 and 17 years of age. Of the 13,572 youths included in the study cohort, 51.3% were male. Approximately 14% of study participants received an ADHD diagnosis, 57.9% of whom were prescribed pharmacotherapy for ADHD at wave one.

Multivariable logistic regression analyses indicated that U.S. youths with asymptomatic ADHD, regardless of those who were prescribed ADHD pharmacotherapies, were at a similar risk of initiating tobacco use as compared to controls over the subsequent nine years.

Comparatively, all subgroups with individuals having three or more ADHD symptoms, regardless of lifetime ADHD diagnosis or pharmacotherapy, were significantly more likely to initiate e-cigarette use, smoke cigarettes, other tobacco use, or dual-use in the subsequent nine years as compared to youths with asymptomatic ADHD or population controls.

Youths with highly symptomatic ADHD receiving pharmacotherapy were more likely to be tobacco and nicotine users as compared to those with fewer ADHD symptoms prescribed medication and those without ADHD symptoms.

Conclusions

The current study established a robust association between ADHD symptoms and newer forms of nicotine and tobacco use. This finding emphasizes the importance of early ADHD diagnosis and effective management strategies to reduce the risk of future nicotine and tobacco use among U.S. youths.

While more research is needed to determine the degree to which ADHD symptom reduction lowers risk behaviors…greater symptom reduction through treatment results in improved functional outcomes.”