A recent longitudinal study found that U.S. youths with greater attention-deficit/hyperactivity disorder symptom severity had a significantly higher risk of initiating nicotine and tobacco use over a 9-year period. The findings suggested that ADHD symptoms—rather than a formal diagnosis alone—may be key predictors of tobacco use risk.

In a study, published in JAMA Network Open, investigators analyzed data from 13,572 U.S. youths aged 12 to 17 years at baseline who participated in the Population Assessment of Tobacco and Health (PATH) Study, tracking their tobacco use from 2013 to 2023. The participants were grouped by attention-deficit/hyperactivity disorder (ADHD) diagnosis (with or without pharmacotherapy) and symptom severity. Those with three or more ADHD symptoms had an increased risk of nicotine use, regardless of diagnosis or medication status.

Among the key findings were:

• E-cigarette use: adjusted odds ratio [OR] = 1.60 (95% confidence interval [CI] = 1.34–2.04)
• Cigarette smoking: adjusted OR = 1.52 (95% CI = 1.22–1.89)
• Other tobacco use: adjusted OR = 1.61 (95% CI = 1.27–2.02)
• Dual use (e-cigarettes and cigarettes/tobacco): adjusted OR = 1.72 (95% CI = 1.38–2.14).

Among youths with ADHD, those with higher symptom severity had an even greater likelihood of e-cigarette (adjusted OR = 1.68) and dual use (adjusted OR = 1.82) compared with those with asymptomatic ADHD.

ADHD pharmacotherapy alone did not significantly impact nicotine use risk. Youths who were treated but had no symptoms had no higher risk of tobacco use compared with controls. However, those with persistent symptoms remained at elevated risk, regardless of treatment status.

"Youths who had three or more ADHD symptoms (with or without pharmacotherapy) had [a] significantly higher [risk] of using nicotine and tobacco products," said lead study author Sean Esteban McCabe, PhD, of the University of Michigan School of Nursing, and colleagues. "These findings highlight the importance of early diagnosis and effective treatment of ADHD to mitigate symptoms and reduce the risk of later nicotine and tobacco use," they added. 

Given the strong association between higher ADHD symptom severity and tobacco use, the investigators emphasized the need for:

• Early screening and intervention for ADHD symptoms
• Clinician monitoring of ADHD symptoms over time
• Targeted prevention efforts to reduce nicotine and tobacco exposure among high-risk youth populations.

The 9-year cohort study provided strong evidence linking ADHD symptom severity—not just diagnosis—to increased tobacco use risk in U.S. youths, reinforcing the importance of early intervention and sustained symptom management.

No conflicts of interest were disclosed.