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30 Jul 2021

Kaplan B et al. Tob Induc Dis 2021; 19: 44

The use of e-cigarettes has increased markedly in the US in recent years. However, while it is well documented that adolescents with ADHD smoke more cigarettes than those without ADHD, there is little information on the use of e-cigarettes in this population. Therefore, this study aimed to compare the use of cigarettes and e-cigarettes among adolescents with and without ADHD.

The study used data from the publically available Population Assessment of Tobacco Health (PATH) study (wave 3, 2015–2016) – a longitudinal, cross-sectional, US study (Hyland et al, 2017; Kasza et al, 2020). Study data on tobacco/cigarette usage was collected from adolescents through self-interviews, and information on ADHD diagnosis was collected from parents* through personal interviews. Current use of any tobacco product was defined as use within the past 30 days, with product types categorised as cigarettes, e-cigarettes or other products (cigar, hookah, smokeless, snus, kretek). Statistical analyses were used to compare the association between tobacco usage and ADHD status, with data presented for relative risk ratio (RRR) adjusted by age, sex and race/ethnicity.

Assessment was based on data from 11,807 adolescents (51.4% male) aged 12–17 years (12–14 years, n=5996, 50.4%; 15–17 years, n=5805, 49.6%). Parents reported that 1240/11,807 adolescents (10.8%) had received a diagnosis of ADHD from a health professional.

Tobacco/cigarette use in adolescents with/without ADHD

Overall, 9.7% of adolescents with ADHD and 5.7% of adolescents without ADHD were tobacco/cigarette users. All categories of tobacco/cigarette products showed higher usage in adolescents with ADHD compared with those without ADHD (all p<0.001): cigarettes only (1.6% vs 1.1%; RRR 1.79, 95% confidence interval 1.02–3.21), e-cigarettes only (3.0% vs 2.1%; RRR 1.41, 1.01–2.21), both cigarettes and e-cigarettes (1.7% vs 0.7%; RRR 3.40, 1.69–6.84), cigarettes and other products (1.0% vs 0.7%; RRR 1.75, 0.92–3.35), e-cigarettes and other products (0.8% vs 0.6%; RRR 1.48, 0.58–3.77), cigarettes, e-cigarettes and other products (= poly-use; 1.6% vs 0.5%; RRR 3.37, 1.86–6.11).

Initiating and quitting cigarette usage

The proportion of adolescents reporting regular use of cigarettes/e-cigarettes before the age of 14 years was similar in the two groups: 62.1%/51.1% with ADHD and 54.3%/42.1% without ADHD (all p>0.5). The proportion of adolescents trying to quit cigarettes/e-cigarettes in the last 12 months was also similar between groups: 37.5%/28.8% with ADHD and 40.7%/28.3% without ADHD (all p>0.05).

Prevalence of ADHD among tobacco/cigarette users

The prevalence of ADHD in tobacco/cigarette users (13.7% in cigarette users, 14.3% in e-cigarette only users, 23.7% in dual cigarette and e-cigarette users, and 26.7% in poly-users) was significantly higher compared with non-users (10.1%; p<0.001).

The study had several limitations. Firstly, being cross-sectional it did not explore the causal association between ADHD and e-cigarette use. It also relied upon parent self-reports of ADHD diagnosis, and adolescent self-reports of tobacco usage, and did not include those with clinically non-significant ADHD symptoms. In addition, it was not possible to control for the health insurance status of the participants, and internalising/externalising issues (which may relate to e-cigarette use) were not explored. Finally, information on initiation age and quit rates for tobacco use were based on data from only a limited number of participants.

The authors suggested that the use of e-cigarettes (as well as dual cigarette/e-cigarette use, and poly-use) was significantly associated with parent-reported ADHD diagnosis among adolescents. They recommended that healthcare providers should screen for e-cigarette use among those with ADHD and suggested that better education about e-cigarettes may help to curb their use.

Read more about the association between e-cigarette use and ADHD in US adolescents here


*Parents were asked, “In the past 12 months, has your child been told by a doctor, nurse or other health professional that he/she has ADHD?” and if the answer was no, they were then asked, “Has your child ever been told by a doctor, nurse or other health professional that he/she has ADHD or attention deficit disorder (ADD)?”

Disclaimer: The views expressed here are the views of the author(s) and not those of Takeda.

Hyland A, Ambrose BK, Conway KP, et al. Design and methods of the Population Assessment of Tobacco and Health (PATH) Study. Tob Control 2017; 26: 371-378.

Kaplan B, Marcell AV, Kaplan T, Cohen JE. Association between e-cigarette use and parents’ report of attention deficit hyperactivity disorder among US youth. Tob Induc Dis 2021; 19: 44.

Kasza KA, Edwards KC, Tang Z, et al. Correlates of tobacco product initiation among youth and adults in the USA: findings from the PATH Study Waves 1–3 (2013–2016). Tob Control 2020; 29: s191-s202.

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