Association of Daily E-Cigarette Use Duration With Anxiety in Adolescents: A Comparison With Cigarette-Only and Dual Use

Objective This study examined whether duration of daily e-cigarette use was associated with anxiety symptoms among Korean adolescents, with comparisons across cigarette-only, e-cigarette-only, and dual-use groups. The study also evaluated whether negative health perception showed indirect effects in the association between duration of daily use and anxiety.Methods Data were drawn from the 2024 Korea Youth Risk Behavior Survey, a nationally representative sample of 54,653 middle and high school students. Primary analyses were restricted to 992 current users classified as cigarette-only, e-cigarette-only, or dual users. Anxiety symptoms were assessed using the Generalized Anxiety Disorder-7 (GAD-7). Multiple linear regression models were used to examine associations between daily use duration and anxiety, and structural equation modeling (SEM) was conducted to estimate indirect effects involving negative health perception.Results Longer duration of daily e-cigarette use and dual use was significantly associated with higher GAD-7 anxiety scores, whereas duration of cigarette-only use was not. SEM findings showed statistically significant indirect effects involving negative health perception, with the smallest standardized indirect effect observed among e-cigarette-only users. Although statistically significant, the indirect effects were small in magnitude.Conclusion Among Korean adolescents, longer duration of daily e-cigarette use and dual use were associated with higher anxiety scores. Negative health perception also showed small but statistically significant indirect effects in these associations. These findings should be interpreted cautiously given the cross-sectional design and modest effect sizes, but they suggest that adolescent e-cigarette use may warrant attention in relation to anxiety symptoms and perceptions of health risk.