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

Background Concerns have been raised that e-cigarettes have created a new generation of people addicted to nicotine. This study aimed to examine 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. Methods Repeat cross-sectional analyses of a nationally-representative sample of 107,968 US high-school students (14-18y) participating in the 2014-2023 National Youth Tobacco Surveys. Nicotine 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 (i) strong past-30-day cravings to use tobacco and (ii) wanting to use nicotine products within 30 minutes of waking. Results Past-30-day use of any nicotine product decreased from 24.5% [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, 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. Use of cigarettes fell considerably across the period (from 9.0% [7.9-10.3%] to 1.8% [1.4-2.4%]); this was the product category consistently associated with the highest levels of dependence. The proportion using only e-cigarettes increased rapidly between 2017 and 2019 (from 5.4% [4.2-6.8%] to 17.0% [15.3-18.7%]) then fell to 6.7% [5.6-7.9%] by 2023; symptoms of nicotine dependence within this group increased non-linearly over time with increases through to 2022 before possible declines in 2023. Conclusions The 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.