For decades, boys and men were more likely than their female peers to use nicotine. But a new study from MUSC shows that among U.S. adolescents, that pattern has reversed for vaping.
Girls have been vaping at higher rates than boys since 2021, with the gap becoming particularly pronounced among older teenagers, according to the study published in JAMA Pediatrics .
The findings offer the first look at how smoking and vaping patterns have changed by age and gender across a full decade – from the rapid rise of e-cigarettes in the late 2010s through the shifting patterns of youth nicotine use seen today.
Benjamin Toll, Ph.D. , director of the MUSC Health Tobacco Treatment Program and co-director of the Lung Cancer Screening Program at MUSC Hollings Cancer Center , said the latest numbers should serve as a warning that the youth vaping problem has not gone away.
"We have to understand why, and we need to mobilize our public health efforts," Toll said. "We need both prevention and intervention for these young people who are vaping at alarmingly high rates."
A decade of changing nicotine use
Previous research has captured pieces of the changing youth vaping landscape, but the new study is the first to examine smoking and vaping trends by age and gender across a full decade, from 2014 through 2024. That wider view allowed researchers to follow the evolution of youth vaping – from historically higher rates among boys, through the dramatic surge in use in 2018 and 2019 to the more recent emergence of higher rates among girls.
To get that broader view, the researchers analyzed data from the Population Assessment of Tobacco and Health, or PATH, Study , a large, nationally representative study of tobacco use in the U.S. Their analysis included adolescents ages 12 to 17 and the 2014 to 2024 data.
The study focused on "current established" smoking and vaping – meaning these were not adolescents who had simply tried a cigarette or e-cigarette at some point. Participants had to report having used the product regularly and within the past 30 days.
"That makes this a pretty conservative estimate of use," said lead author Brandon Sanford, Ph.D. "These aren't youth who simply tried vaping once or twice. We're talking about adolescents who are regularly using e-cigarettes now."
Historically, nicotine use has been more common among males. The researchers found that this pattern had held for vaping from 2014 through 2018. Vaping was also consistently more common among older teens ages 15 to 17 than younger adolescents ages 12 to 14.
Then came a dramatic surge in youth vaping in 2018 and 2019, when rates climbed sharply among both boys and girls, and the longstanding gender gap largely disappeared. The surge coincided with the growing popularity of a new generation of e-cigarettes, including products like JUUL, which used nicotine salts and came in small, pod-based devices that made vaping more appealing, easier to use and more discreet.
Rates then dropped by 2021 – but what came next differed by age and gender.
Among younger adolescents ages 12 to 14, vaping rates remained relatively low and fluctuated from year to year. Girls generally had higher rates than boys after 2021, although vaping among girls declined in the latest data.
Naomi Brownstein, Ph.D. , co-first author and a biostatistician at MUSC, cautioned against viewing the recent decline as evidence that the problem has disappeared.
"Even though the rate dropped from 2023 to 2024, it's still high," Brownstein said. "There are still a lot of middle school girls vaping."
Among older teens ages 15 to 17, the shift was much more pronounced. Regular vaping among girls consistently climbed from 4.9% in 2021 to 7.8% in 2024, approaching the peak seen during the 2018-2019 youth vaping surge. By comparison, 4.6% of boys the same age were regular users in 2024.
While the difference between boys and girls is striking, the researchers stressed that vaping among boys remains a public health concern as well.
"We have to sound the alarm bells for girls," Toll said. "But we also need to make sure that we're addressing the boys, too."
Cigarette smoking approaches historic lows
Against those vaping trends, the decade-long data also reveal an encouraging shift: Traditional cigarette smoking among adolescents has fallen dramatically. By the final wave of data, fewer than half of 1% of both boys and girls were established smokers.
Toll described the decline in cigarette smoking as a "massive public health win."
Sanford added that the changing patterns suggest that vaping may be displacing at least some cigarette smoking among young people. But this shift also means that public health efforts must contend with a different form of nicotine use.
E-cigarettes do expose users to fewer known toxicants and carcinogens than combustible cigarettes, which is part of why they may have a role in helping adults who smoke to transition away from cigarettes.
But that does not make them harmless, particularly for young people who otherwise might not use nicotine. Because e-cigarettes are relatively new, researchers do not yet know their long-term health effects. And for adolescents, regular vaping can lead to nicotine addiction at a time when the brain is still developing.
E-cigarettes can also make patterns of nicotine use harder to track. Unlike cigarettes, which have a natural stopping point, e-cigarette cartridges offer hundreds or thousands of puffs, allowing users to vape repeatedly throughout the day. The devices are also easy to conceal, making it harder for users and those around them to recognize how much they are vaping.
Sanford described seeing that challenge firsthand with his patients. When he asks how much they vape, he said, many struggle to give a clear answer because they cannot keep track of individual vaping sessions or how long a device lasts.
Why are girls vaping more?
The study shows a clear shift in who is vaping – but it was not designed to determine what is driving that change. And because the study is observational, Brownstein emphasized that the researchers can only point to associations – not conclude that any one factor caused the increased use among girls.
"There are certainly factors associated with these rates we're seeing that are quite fascinating," Brownstein said. "There's a lot more work that we could delve into."
Sanford said understanding what drives use is one of the most important next questions.
"We would love to look into some of the whys," he said. "Are there shifts in motivation to use, marketing, social influences or perceptions?"
Answering those questions could ultimately help researchers to develop more targeted ways to prevent and treat youth vaping, including prevention messages and cessation programs tailored to the factors influencing use among girls and youth more generally.
The findings also have implications beyond researchers and public health officials. Toll said pediatricians, parents, coaches and others who regularly interact with teenagers should be aware that youth vaping remains a problem.
"There may be some complacency with people thinking we've gotten through the JUUL crisis. I want pediatricians to pay attention to possible vaping, especially for their female patients."
For the research team, the changing trends point to where more attention may be needed.
"I think it says a lot about where we ought to be putting our resources," Sanford emphasized, "in terms of prevention efforts, treatment development and public health policy."
