Trends in and Risk Factors for Nicotine Consumption in Childhood and Adolescence

Smoking is harmful to all aspects of health and leads to nicotine dependence. Discouraging adolescents from consuming nicotine is an important factor in preventing addiction.

Methods

Our study is based on eight waves of the Prevention Radar, a questionnaire study carried out in school classes 5–10 (www.praeventionsradar.de). The convenience sample included 117 281 data sets from 76 278 students. All secondary schools in 14 German states receive one written invitation to participate every year. School classes are registered for participation by using the study homepage. A mean of 85% of registered classes participate in the survey. 34% of students have repeatedly participated in one of the data collections.

The primary endpoint of the study was the monthly prevalence of the consumption of different nicotine products and the consumption of at least 2 nicotine products (polyuse). The sample was divided into children (9–13 years) and adolescents (14–17 years). The prevalence estimates are based on logistic regression models. We used weighting factors to adjust the data to the distribution of the baseline total of students as regards age, sex, and type of school.

To analyze risk factors we used the data from school/academic year 2023/24 and calculated logistic regressions into which all factors of influence were integrated simultaneously. We used validated questionnaires to capture the personality trait sensation seeking (openness to risk), behavioral problems, perceived education style, wellbeing, loneliness, and cyberbullying. Furthermore, we determined the influence of sex, the school type attended, and friends’ nicotine consumption. We determined the degree of regional socioeconomic deprivation at the level of the 107 participating schools on the basis of data from the Robert Koch-Institute (1).

Results

66 795 children and 49 405 adolescents participated in the study. The mean age in the children’s sample was 11.8 years (standard deviation [SD]=1.04 years) and in the adolescents’ sample, 14.8 years (SD=0.81).

Trends in nicotine consumption

In childhood, nicotine consumption did not change and was between 3% and 4%. During adolescence, nicotine consumption declined from school year 2016/17 to school year 2021/22 and rose subsequently. In school year 2023/24, nicotine consumption in adolescents was 1.6% (95 confidence interval: [15.8; 17.4]) (Figure). Over the entire observation period, nicotine consumption in adolescents fell by 2.8 percentage points and shisha consumption by 7.5 percentage points. Since school year 2021/22, e-cigarette consumption and polyuse increased. In 2023/24, polyuse increased in 1.7% of children [1.4; 1.9] and 8.3% of adolescents [7.6; 8.9]. E-cigarettes were the most commonly consumed nicotine product in both age groups (children: 2.9%, [2.6; 3.2]; adolescents: 13.9% [13.2; 14.7]).

Figure.

Prevalence estimates with 95% confidence intervals of monthly nicotine consumption from 2016 to 2024 separated by *¹childhood (9–13 years) and *²adolescence (14–17 years). Any nicotine consumption, consumption of cigarettes, e-cigarettes, shisha, and polyuse (a minimum of 2 of the 3 nicotine products) are shown separately.

Analysis of risk factors

Attending high school and a sense of wellbeing (the latter in adolescents only) were protective factors. Risk factors were friends’ nicotine consumption, individual openness to risk, behavioral problems, experience of stress, residence in rural districts with greater socioeconomic deprivation (adolescents only), and an education style experienced as relaxed (adolescents only) (Table).

Table. Protective factors and risk factors of monthly nicotine consumption in 2023/2024, separated by age.

Factors of influence	Odds ratios [95% CI]
	Children*1	Adolescents*2
Nicotine consumption of friends	21.66 [15.92; 29.48]	9.54 [8.20; 11.09]
Sensation seeking	3.56 [2.64; 4.80]	3.53 [3.04; 4.09]
Socioeconomic deprivation	1.31 [1.00; 1.73]	1.24 [1.07; 1.44]
Behavioral problems	2.29 [1.59; 3.30]	1.91 [1.55; 2.35]
Stress	1.72 [1.24; 2.38]	1.46 [1.22; 1.73]
Affected by cyberbullying	1.00 [0.71; 1.41]	1.02 [0.82; 1.27]
Boys	0.77 [0.58; 1.03]	0.90 [0.77; 1.06]
Wellbeing	0.76 [0.56; 1.03]	0.78 [0.66; 0.92]
Heightened perception/experience of loneliness	0.87 [0.64; 1.20]	0.98 [0.83; 1.16]
Relaxed upbringing	0.85 [0.64; 1.13]	1.23 [1.06; 1.43]
High school attendance	0.42 [0.32; 0.54]	0.58 [0.50; 0.67]

^*1 Children aged 9–13 years; ^*2 adolescents aged 14–17 years

Discussion

Trends towards e-cigarettes and polyuse are becoming clear. Different factors probably facilitated these trends. E-cigarettes were allowed to be advertised for longer (till the end of 2023) than tobacco products. Social media present consumption of e-cigarettes by “influencers” in an unregulated way as a positive behavior (2). The flavors, which make the consumption of e-cigarettes easier and have a consumption-promoting effect, were not prohibited in Germany, and neither were the popular disposable e-cigarettes (3).

Cohort studies have shown that consuming e-cigarettes can encourage adolescents to smoke conventional cigarettes (4). The “gateway” effect may have facilitated the trend towards polyuse.

Analyzing risk factors showed that adolescents experiencing a sense of wellbeing experiment less with nicotine products. Environmental factors such as living in regions with socioeconomic deprivation, attending schools that are not high schools, and the immediate friendship group constituted risk factors, as did a personality that is more open to risk, increased experience of stress, or general behavioral problems.

The results are based on questionnaire data that may be subject to response biases. An ecologic error is possible since socioeconomic deprivation was not recorded at the individual level but at school level.

Stringent preventive measures seem necessary in order to lower the wide spread of nicotine consumption in adolescents. In addition to high product prices, measures supporting an image change should be implemented via school based information and education and mass media campaigns. Nicotine products are advertised at the point of sale, on the internet, but also by the product design of e-cigarettes (which is attractive to the targeted consumer group), which in their many colors resemble digital devices.

Adolescents have to be educated about the health risks of consuming e-cigarettes, such as the threat of nicotine dependence and subsequent/future cardiovascular and pulmonary disorders (5). According to our analysis of risk factors, preventive behavioral measures that enable life competencies so as to handle psychologically stressful situations effectively seem as sensible as strengthening parents’ educational practices.

The finding that regional socioeconomic deprivation is positively associated with the prevalence of smoking implies that improving regional living conditions may have a preventive effect as regards nicotine consumption among adolescents.