Changing patterns of nicotine product use and nicotine dependence among United States high-school students: The National Youth Tobacco Survey, 2014-2023

Background and aimConcerns have been raised that e-cigarettes have created a new generation of people addicted to nicotine. This study aimed to measure changes in the proportion of US high-school students reporting symptoms of nicotine dependence over the past decade, in the context of changing patterns of nicotine product use.DesignRepeat cross-sectional analyses of the 2014-2023 National Youth Tobacco Surveys.SettingUnited States of America.Participants107 968 high-school students (14-18y).MeasurementsNicotine product use was categorised based on self-reported past-30-day use of cigarettes, other combustible tobacco, smokeless/non-combustible products and e-cigarettes. Nicotine dependence was operationalised as (a) strong past-30-day cravings to use tobacco and (b) wanting to use nicotine products within 30 minutes of waking.FindingsPast-30-day use of any nicotine product decreased from 24.5% (95% confidence interval = 22.5%-26.6%) to 19.6% (16.8%-22.4%) between 2014 and 2017, increased sharply, reaching 31.4% (29.0%-33.7%) in 2019 (driven by an increase in e-cigarette use), then fell to the lowest level at 12.5% (10.9%-14.1%) by 2023. The proportion who reported symptoms of nicotine dependence was substantially lower, but followed a similar pattern of changes over time. For example, the proportion reporting strong cravings decreased from 7.8% (6.6%-9.0%) to 5.5% (4.3%-6.7%) between 2014 and 2017, increased to 7.9% (6.8%-9.0%) between 2017 and 2018 and remained stable up to 2020, then fell to the lowest level at 2.5% (1.9%-3.1%) by 2023. While dependence symptoms were consistently highest among cigarette users, they were increasingly prevalent among those using only e-cigarettes after 2017.ConclusionsThe sharp rise in the prevalence of nicotine product use (in particular, e-cigarettes) among US high-school students in the late 2010s was short-lived and was not accompanied by a sustained increase in the overall population burden of nicotine dependence. By 2023, both nicotine product use and nicotine dependence had reached historic lows. However, dependence symptoms increased over time among those using e-cigarettes only.