Associations of ADHD Symptoms With Smoking and Alternative Tobacco Product Use Initiation During Adolescence

Nicholas I. Goldenson, BA; Rubin Khoddam, MA; Matthew D. Stone, BA; Adam M. Leventhal, PHD


J Pediatr Psychol. 2018;43(6):613-624. 

In This Article

Abstract and Introduction


Objective: Recently, use of alternative tobacco products, such as electronic cigarettes (e-cigarettes) and hookah (water-pipe tobacco), has increased among adolescents. It is unknown whether attention-deficit hyperactivity disorder (ADHD) symptoms are associated with initiation of alternative tobacco product use.

Methods: Ninth grade high school students who never used any tobacco product at baseline (N = 1,921) participated in a longitudinal survey from 2014 to 2015. Overall symptomatology and inattention (IN) and hyperactivity-impulsivity (HI) ADHD subtypes were assessed at baseline. Past 6-month e-cigarette, hookah, and combustible cigarette use (yes/no) were reported at three semi-annual follow-ups. Repeated measures logistic regression models assessed the association of baseline ADHD symptoms with likelihood of tobacco product initiation across follow-ups.

Results: For ADHD main effect estimates, unadjusted odds of reporting e-cigarette, hookah, and combustible cigarette use pooled across follow-up time points were 45%, 33%, and 37% greater, respectively, with each increase in one SD-unit of baseline ADHD symptoms in baseline never-users of tobacco products. ADHD was not associated with hookah or combustible cigarette use after adjusting for other risk factors. After adjustment, e-cigarette use initiation remained associated with overall ADHD (odds ratio, OR [95%confidence interval, 95% CI] = 1.22 [1.04, 1.42]) and HI (OR [95% CI] = 1.26 [1.09, 1.47]) symptoms, but not IN symptoms (OR [95% CI] = 1.13 [0.97, 1.32]). ADHD × Time interactions were not significant, suggesting ADHD increased odds of e-cigarette use initiation but did not alter the shape of use trajectory across follow-up among initiators.

Conclusions: Understanding the psychosocial mechanisms underlying the pathway from ADHD to e-cigarette use may advance tobacco product use etiologic theory and prevention practice in the current era in which e-cigarette use is popular among youth.


There is a well-documented association between attention-deficit hyperactivity disorder (ADHD) symptoms and combustible cigarette smoking among adolescents (McClernon & Kollins, 2008; Milberger, Biederman, Faraone, Chen, & Jones, 1997; Tercyak, Lerman, & Audrain, 2002; Wilens et al., 2008). National estimates suggest that low levels of ADHD symptomology are present in nearly 40% of adolescents (Kollins, McClernon, & Fuemmeler, 2005), and subclinical levels of ADHD symptoms have been shown to impact smoking among youth who do not meet DSM criteria for an ADHD diagnosis (Kollins, McClernon, & Fuemmeler, 2005; Wilens et al., 2008). ADHD symptoms are distributed on a continuum throughout the population (Levy, Hay, McStephen, Wood, & Waldman, 1997), with two distinct symptom dimensions: (1) inattention (IN; i.e., impaired levels of concentration and distractibility); and (2) hyperactivity-impulsivity (HI; i.e., poor inhibitory control and motor activity restlessness). Increased severity of both ADHD symptom dimensions has been shown to increase smoking risk throughout adolescence and the lifespan (i.e., likelihood of smoking initiation at earlier ages and progression to greater cigarette dependence; Fuemmeler, Kollins, & McClernon, 2007; Rodriguez, Tercyak, & Audrain-McGovern, 2008).

While the prevalence of combustible cigarette smoking among U.S. adolescents has declined in recent years, use of alternative tobacco products such as electronic cigarettes (e-cigarettes) and hookah (water-pipe tobacco) have markedly increased (Johnston et al., 2016). In 2015, approximately 16% and 7% of U.S. 10th graders reported using e-cigarettes and hookah, respectively, within the past 30 days (Johnston et al., 2016). In addition, poly-product use (i.e., use of two or more tobacco products) has risen, with 13.0% of high school students in 2015 reporting use of two or more tobacco products in the past 30 days (Singh et al., 2016). These trends are concerning, given evidence that the adolescent brain is particularly vulnerable to nicotine (Dwyer, McQuown, & Leslie, 2009), and that initiation of smoking at younger ages is associated with increased nicotine dependence later in life (Breslau, Fenn, & Peterson, 1993; Breslau & Peterson, 1996; Riggs, Chou, Li, & Pentz, 2007).

There is little extant research on associations between ADHD symptoms and initiation of alternative tobacco products, and there are several reasons to question whether the well-established link between ADHD and combustible cigarette smoking initiation found in previous years will extend to alternative tobacco products that are popular among today's youth. As a result of effective public health programs, combustible cigarettes are difficult to obtain by youth, banned in public areas, widely perceived to be hazardous to health, socially undesirable, and have other deterrents that dissuade most youth from smoking (Cuijpers, 2002; U.S. Department of Health and Human Services, 2014). In contrast, alternative tobacco products may be a popular entry point for youth tobacco product use because of perceptions that e-cigarettes and hookah are healthier and offer other unique benefits relative to combustible cigarettes (Amrock, Lee, & Weitzman, 2016; Kong, Morean, Cavallo, Camenga, & Krishnan-Sarin, 2015).

Before first use, messages generated from marketing and peers can lead to positive perceptions about e-cigarettes and hookah that are not present with combustible cigarettes. While cigarettes are available only in standard tobacco or menthol flavors, e-cigarettes and hookah can be purchased in youth-friendly flavors (e.g., candy, strawberry; Zhu et al., 2014) that have a wider appeal to youth and may produce less odor, making use easier to conceal from parents and other authority figures. Additionally, the water filtration of tobacco smoke in hookah and the emission of noncombusted aerosol in e-cigarettes may be perceived by youth to produce a smoother hit and be less harmful to health, and the individualized design of hookah pipes and e-cigarette devices may garner appeal to a wider audience of youth than do combustible cigarettes.

These key differences between alternative (hookah and e-cigarettes) and traditional (combustible cigarette) tobacco products may be much less salient for youth with ADHD-related characteristics, such as impulsivity and poor decision-making skills. For instance, concern over the potential health hazards of combustible cigarettes may be less of a deterrent, and the ability to conceal use from authority figures may be less appealing among youth with ADHD symptoms, given that they tend to be impulsive and less fearful of negative consequences (Matthys, Vanderschuren, & Schutter, 2013). Thus, youth with elevated ADHD symptoms (or other risk factors) may represent a disproportionate percentage of the population of teens willing to initiate use of combustible cigarettes. For e-cigarettes and hookah, however, youth with low or no ADHD symptoms may be drawn to uptake of these alternative products in addition to adolescents with elevated ADHD symptoms or other risk factors. For these reasons, ADHD may be a more robust risk factor for uptake of combustible cigarettes than uptake of alternative tobacco products.

Recent evidence offers indirect empirical support for this hypothesis. Cross-sectional data suggest that youth who use alternative tobacco products exhibit fewer psychosocial risk factors (e.g., sensation seeking) and mental health problems other than ADHD (e.g., substance use, anxiety, depression) than adolescents who smoke combustible cigarettes (Wills, 2017; Leventhal et al., 2016). Comparisons between youth poly-product users (e.g., use of e-cigarettes and combustible cigarettes) and youth who use a single product have found that poly-product users exhibit greater levels of some mental and behavioral health outcomes (e.g., marijuana use) but not others (e.g., anxiety and depression; Leventhal et al., 2016). It is unknown whether ADHD differentially confers risk to initiate use of alternative versus traditional tobacco products or whether ADHD is associated with poly-tobacco product use. Thus, studying the initiation of tobacco product use is critical for developing primary prevention programs that deter use before exposure to nicotine and disrupt the known behavioral sequelae that follow tobacco product initiation (e.g., development of tobacco dependence, use of other substances, neurocognitive dysregulation; Mathers, Toumbourou, Catalano, Williams, & Patton, 2006).

This prospective study investigated associations between ADHD symptomology and the initiation of e-cigarettes, hookah, and combustible cigarette use across an 18-month period among high school students who never used any tobacco product by 9th grade. Based on previous literature, we hypothesized that ADHD symptoms, including both the HI and IN symptom dimensions, would be associated with the initiation of alternative tobacco products (e-cigarettes and hookah) and combustible cigarettes. Given the reasoning above and extant data, we expected that the associations of ADHD symptoms with uptake of combustible cigarettes would be stronger than associations with alternative tobacco products. We also predicted that ADHD would associate with poly-tobacco product use initiation during the follow-up. In addition to investigating associations with use initiation during the follow-up period, we also studied whether persistence of use across time during the follow-up period differed as a function of baseline ADHD level.