Associations of Nicotine Use with Reduced Wellbeing and Increased Problem Behaviors Among German Adolescents

Among US-adolescents, nicotine use, especially dual use of e-cigarettes and cigarettes is associated with poor mental health outcomes. This study examines associations between different nicotine use profiles and wellbeing and problem behaviors among German adolescents.

A school-based survey was conducted in secondary schools between November 2024 and February 2025 in 116 schools from 14 out of 16 federal German states. Symptoms of internalizing and externalizing behavioral problems were assessed using the Strengths and Difficulties Questionnaire. Wellbeing was assessed with the WHO-5 Well-Being Index. Nicotine use (past 30-day use) was categorized into four groups: monthly use of e-cigarettes only, monthly use of combustible cigarettes only, monthly dual use, and nonuse.

A total of 25,128 adolescents with a mean age of 13 years with 52% being female participated. Compared with individuals who did not report e-cigarette and/or cigarette use, adolescents engaging in monthly dual use had the highest odds, with an adjusted OR of 2.11 (95% CI: 1.80-2.47) for reduced wellbeing and 3.65 (95% CI: 2.95-4.52) for externalizing behavioral problems. Regarding internalizing behavioral problems, individuals reporting cigarette use (OR = 2.23, 95% CI: 1.60-3.10) and dual use (OR = 1.90, 95% CI: 1.58-2.27) had the highest odds, with no significant difference between them.

German adolescents who use nicotine, especially dual use of e-cigarettes and cigarettes, are at an increased risk for internalizing and externalizing behavioral problems and have lower overall well-being. Due to design limitations, we are unable to draw causal conclusions.