Children and adolescents with attention-deficit/hyperactivity disorder (ADHD) are at increased risk for the initiation of substance use and subsequent substance use disorders. There is a large body of research supporting an association between ADHD and tobacco use. According to a recent meta-analysis, youths with ADHD were more than twice as likely to report nicotine use by middle adolescence compared to their peers without ADHD. Early tobacco use in adolescents, particularly those with ADHD, is a strong predictor for later development of substance use disorders. Thus, recognizing early tobacco initiation in youths with ADHD can help clinicians identify at-risk youths and initiate timely interventions to prevent progression to more severe substance use problems.
In a recent study, researchers, including Timothy Wilens, MD, Chief of the Division of Child and Adolescent Psychiatry and the Co-Director of the Center for Addiction Medicine at Mass General Hospital, analyzed data from a national study in order to examine whether youths with asymptomatic ADHD differ from youths with symptomatic ADHD in terms of their risk for nicotine and tobacco use.
Study Design
This cohort study included a nationally representative sample of US youths (N = 13,651) between the ages of 12 and 17 years and their parents (N = 13,588) in the Population Assessment of Tobacco and Health (PATH) Study. Participants were surveyed via questionnaires at wave 1 (September 2013 to December 2014) and followed up over 6 additional waves in subsequent years (October 2014 to April 2023).
At each wave, youths reported their lifetime and past-year use of nine nicotine or tobacco products, including cigarettes and e-cigarettes. Parents provided information on ADHD diagnosis and treatment. Youths also completed the Global Appraisal of Individual Needs (GAIN) assessment, which included validated ADHD symptom screeners from the PhenX Toolkit. Of the 13,572 participants analyzed, 51.3% were male, and 14.1% had an ADHD diagnosis.
Time in years and history of ADHD diagnosis, symptom severity, and pharmacotherapy at wave 1 were used to construct nine mutually exclusive subgroups of US youths, including youths with ADHD diagnosis and pharmacotherapy, ADHD diagnosis without pharmacotherapy, and population controls without ADHD diagnosis. Within each of these three subgroups, ADHD symptom severity was categorized as none, 1 to 2, or 3 to 4 symptoms.
How Do Youth with Asymptomatic and Symptomatic ADHD Differ?
When the researchers compared youth with asymptomatic ADHD (with or without pharmacotherapy) to youth without ADHD, they did not observe any significant differences between the use of e-cigarettes, cigarette smoking, other tobacco products, or dual use.
In contrast, when the researchers focused on youth with symptomatic ADHD — having 3 or more ADHD symptoms (with or without pharmacotherapy) — they observed that youths with symptomatic ADHD had significantly higher odds of e-cigarette use (adjusted odds ratio [AOR], 1.60; 95% CI, 1.34-2.04), cigarette smoking (AOR, 1.52; 95% CI, 1.22-1.89), other tobacco use (AOR, 1.61; 95% CI, 1.27-2.02), and dual use (AOR, 1.72; 95% CI, 1.38-2.14) compared with youths with asymptomatic ADHD or population controls.
Among youths with ADHD, those with highly symptomatic ADHD were significantly more likely to initiate e-cigarette (AOR, 1.68; 95% CI, 1.16-2.44) and dual use (AOR, 1.82; 95% CI, 1.17-2.83) than youths without symptoms.
Clinical Implications
In this cohort study of 13 572 US youths, odds of e-cigarette use, cigarette smoking, other tobacco use, and dual use did not significantly differ between those with asymptomatic ADHD (with or without pharmacotherapy) and population controls. In contrast, all youths who had 3 or more ADHD symptoms (with or without pharmacotherapy) had significantly higher adjusted odds of using nicotine and tobacco products.
These findings emphasize that the risk of nicotine and tobacco use among youths is closely linked to the severity of ADHD symptoms, rather than simply to an ADHD diagnosis or treatment status. Youths with asymptomatic ADHD—regardless of whether they received pharmacotherapy—had similar odds of initiating e-cigarette, cigarette, or other tobacco use as their peers without ADHD. In contrast, those with three or more ADHD symptoms faced significantly higher odds of starting to use nicotine and tobacco products, indicating a clear dose-response relationship between symptom burden and substance use risk31.
Clinically, this underscores the importance of regular monitoring and targeted management of ADHD symptoms in children and adolescents. Effective treatment and reduction of core ADHD symptoms may help lower the risk of later nicotine and tobacco use. Early identification and intervention for youths exhibiting multiple inattentive or hyperactive/impulsive symptoms—regardless of formal diagnosis—are crucial, as these individuals represent a high-risk group that may otherwise go unrecognized.
Healthcare professionals should use validated screening tools to assess ADHD symptoms and provide evidence-based interventions, including pharmacologic and psychosocial treatments, to minimize symptom severity. Educating families about the risks associated with persistent ADHD symptoms and the potential protective effect of symptom control may further support prevention efforts. Ultimately, prioritizing symptom reduction could help mitigate the progression to nicotine and tobacco use among at-risk youths.
Read More
McCabe SE, Pasman E, Wilens T, Boyd CJ, Veliz P, McCabe V, Chen B, Dickinson K, Evans-Polce RJ. Attention-Deficit/Hyperactivity Disorder Symptoms and Later E-Cigarette and Tobacco Use in US Youths. JAMA Netw Open. 2025 Feb 3;8(2):e2458834.
