DOI: 10.1542/peds.2023-062424 ISSN: 0031-4005

Biomarker Assessment of Nicotine Exposure Among Adolescent E-Cigarette Users: 2018–2019

Hongying Daisy Dai, Tzeyu Michaud, Nicolas Guenzel, Mathuri Morgan, Samuel M. Cohen
  • Pediatrics, Perinatology and Child Health


Despite the increasing prevalence of vaping e-cigarettes among adolescents, there remains a lack of population-level assessments regarding the objective measurement of nicotine exposure.


This study analyzed a nationally representative sample of adolescents aged 13 to 17 years from Wave 5 of the Population Assessment of Tobacco and Health Study conducted between 2018 and 2019. Urinary nicotine metabolites, including cotinine and trans-3′-hydroxycotinine (3-HC), were assessed among exclusive nonnicotine e-cigarette users (n = 56), exclusive nicotine e-cigarette users (n = 200), and nonusers (n = 1059). We further examined nicotine exposure by past 30-day vaping frequency (ie, occasional [1–5 days], intermittent [6–19 days], and frequent [20+ days]) and flavor types among nicotine e-cigarette users. Multivariable linear regressions tested pairwise group effects, and biomarkers were normalized by the log transformation.


Compared with nonusers, both nonnicotine and nicotine e-cigarette users exhibited higher levels of cotinine and 3-HC. Nicotine e-cigarette users had mean cotinine concentrations (61.3; 95% confidence interval, 23.8–158.0, ng/mg creatinine) approximately 146 times higher (P < .0001) than nonusers (0.4; 0.3–0.5), whereas nonnicotine users (4.9; 1.0–23.2) exhibited cotinine concentrations ∼12 times higher (P = .02). Among nicotine e-cigarette users, the levels of cotinine and 3-HC increased by vaping frequency, with cotinine increasing from 10.1 (2.5–40.1) among occasional users to 73.6 (31.8–170.6) among intermittent users and 949.1 (482.5–1866.9) among frequent users. Nicotine exposure was not significantly different by flavor type.


E-cigarette use poses health-related risks resulting from nicotine exposure among adolescents. Comprehensive regulations of e-cigarette products and marketing, vaping prevention, cessation, and public policies are needed to prevent youth from developing nicotine addiction.

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