Analysis Reveals Increasing Addiction and Intensity of E-Cigarette Use by U.S. Adolescents

Among adolescents who were currently using any tobacco product, the proportion who initiated use with e-cigarettes increased over time, becoming the dominant first product in 2017. Percentages do not add up to 100% because some users initiated with more than 1 tobacco product at the same age. SLT indicates smokeless tobacco.
  • Among U.S. middle and high school students, e-cigarette initiation age dropped, and intensity of use and addiction increased between 2014 and 2021
  • By 2019 more e-cigarette users were using their first tobacco product within 5 minutes of waking—an indicator of addiction—than for cigarettes and all other tobacco products combined

A new analysis published in JAMA Network Open by investigators at Massachusetts General Hospital (MGH) in collaboration with a retired UCSF professor reveals ongoing and worsening adolescent e-cigarette addiction in the United States.

In the analysis of data from the annual National Youth Tobacco Survey, a nationally-representative survey of middle and high school students in grades 6–12, researchers found that e-cigarette prevalence among youth peaked in 2019 then declined, but e-cigarette initiation age dropped between 2014 and 2021,and intensity of use and addiction increased after the introduction of protonated nicotine products

Protonated nicotine is created by adding acid to the e-cigarette liquid, which makes the nicotine easier to inhale. Since Juul pioneered protonated nicotine, it has been widely adopted by other e-cigarette companies.

Age at first use of e-cigarettes fell by 1.9 months per year, while age at first use of cigarettes, cigars, and smokeless tobacco did not change significantly. By 2017, e-cigarettes became the most common first tobacco product used.

E-cigarette nicotine addiction, measured as the odds of use within 5 minutes of waking, an indicator of addiction, increased over time. By 2019 more youth e-cigarette users were using their first tobacco product within 5 minutes of waking than for cigarettes and all other products combined. The percent of sole e-cigarette users who used e-cigarettes within 5 minutes of waking was around 1% through 2017, but then it increased every year, reaching 10.3% youth using their first e-cigarette within 5 minutes of waking by 2021.

Median e-cigarette use also increased from 3–5 days per month in 2014–2018 to 6–9 days per month in 2019–2020 and 10–19 days per month in 2021.

The recently released 2022 National Youth Tobacco Survey data show that 2.55 million adolescents use e-cigarettes and 27.6% of adolescents use e-cigarettes daily. The comparable numbers reported in this paper for 2021 were 2.1 million and 24.7%.

“The increasing intensity of use of modern e-cigarettes highlights the clinical need to address youth addiction to these new high nicotine products over the course of many clinical encounters,” says senior author Jonathan P. Winickoff, MD, MPH, a pediatrician at MGH and a professor of pediatrics at Harvard Medical School. First author Stanton A. Glantz, PhD, a retired UCSF professor of medicine, adds, “In addition, stronger regulation including state and local comprehensive bans on the sale of flavored tobacco products such as voting YES on Proposition 31 on California’s November ballot, should be implemented.”

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