Tobacco use and addiction most often begin during youth and young adulthood (1,2).
Youth use of tobacco in any form is unsafe (1). To determine the prevalence and trends
of current (past 30-day) use of nine tobacco products (cigarettes, cigars, smokeless
tobacco, e-cigarettes, hookahs, tobacco pipes, snus, dissolvable tobacco, and bidis)
among U.S. middle (grades 6–8) and high school (grades 9–12) students, CDC and the
Food and Drug Administration (FDA) analyzed data from the 2011–2014 National Youth
Tobacco Surveys (NYTS). In 2014, e-cigarettes were the most commonly used tobacco
product among middle (3.9%) and high (13.4%) school students. Between 2011 and 2014,
statistically significant increases were observed among these students for current
use of both e-cigarettes and hookahs (p<0.05), while decreases were observed for current
use of more traditional products, such as cigarettes and cigars, resulting in no change
in overall tobacco use. Consequently, 4.6 million middle and high school students
continue to be exposed to harmful tobacco product constituents, including nicotine.
Nicotine exposure during adolescence, a critical window for brain development, might
have lasting adverse consequences for brain development (1), causes addiction (3),
and might lead to sustained tobacco use. For this reason, comprehensive and sustained
strategies are needed to prevent and reduce the use of all tobacco products among
youths in the United States.
NYTS is a cross-sectional, school-based, self-administered, pencil-and-paper questionnaire
administered to U.S. middle and high school students. Information is collected on
tobacco control outcome indicators to monitor the impact of comprehensive tobacco
control policies and strategies (4) and inform FDA’s regulatory actions (5). A three-stage
cluster sampling procedure was used to generate a nationally representative sample
of U.S. students who attend public and private schools in grades 6–12. This report
includes data from 4 years of NYTS (2011–2014), using an updated definition of current
tobacco use that excludes kreteks (sometimes referred to as clove cigarettes).* Of
258 schools selected for the 2014 NYTS, 207 (80.2%) participated, with a sample of
22,007 (91.4%) among 24,084 eligible students; the overall response rate was 73.3%.
Sample sizes and overall response rates for 2011, 2012, and 2013 were 18,866 (72.7%),
24,658 (73.6%), and 18,406 (67.8%), respectively. Participants were asked about current
(past 30-day) use of cigarettes, cigars (defined as cigars, cigarillos, or little
cigars), smokeless tobacco (defined as chewing tobacco, snuff, or dip), e-cigarettes,†
hookahs,§ tobacco pipes (pipes),¶ snus, dissolvable tobacco (dissolvables), and bidis.
Current use for each product was defined as using a product on ≥1 day during the past
30 days. Tobacco use was categorized as “any tobacco product use,” defined as use
of one or more tobacco products and “≥2 tobacco product use,” defined as use of two
or more tobacco products. Data were weighted to account for the complex survey design
and adjusted for nonresponse; national prevalence estimates with 95% confidence intervals
and population estimates rounded down to the nearest 10,000 were computed. Estimates
for current use in 2014 are presented for any tobacco use, use of ≥2 tobacco products,
and use of each tobacco product, by selected demographics for each school level (high
and middle). Orthogonal polynomials were used with logistic regression analysis to
examine trends from 2011 to 2014 in any tobacco use, use of ≥2 tobacco products, and
use of each tobacco product by school level, controlling for grade, race/ethnicity,
and sex and simultaneously assessing for linear and nonlinear trends.** A p-value
<0.05 was considered statistically significant. SAS-Callable SUDAAN was used for analysis.
In 2014, a total of 24.6% of high school students reported current use of a tobacco
product, including 12.7% who reported current use of ≥2 tobacco products. Among all
high school students, e-cigarettes (13.4%) were the most common tobacco products used,
followed by hookahs (9.4%), cigarettes (9.2%), cigars (8.2%), smokeless tobacco (5.5%),
snus (1.9%), pipes (1.5%), bidis (0.9%), and dissolvables (0.6%) (Table). Among high
school non-Hispanic whites, Hispanics,†† and persons of non-Hispanic other races,
e-cigarettes were the most used product, whereas among non-Hispanic blacks, cigars
were used most commonly. Current use of any tobacco and ≥2 tobacco products among
middle school students was 7.7% and 3.1%, respectively. E-cigarettes (3.9%) were the
tobacco product used most commonly by middle school students, followed by hookahs
(2.5%), cigarettes (2.5%), cigars (1.9%), smokeless tobacco (1.6%), pipes (0.6%),
bidis (0.5%), snus (0.5%), and dissolvables (0.3%).
From 2011 to 2014, statistically significant nonlinear increases were observed among
high school students for current e-cigarette (1.5% to 13.4%) and hookah (4.1% to 9.4%)
use (Figure 1). Statistically significant linear decreases were observed for current
cigarette (15.8% to 9.2%) and snus (2.9% to 1.9%) use. Statistically significant nonlinear
decreases were observed for current cigar (11.6% to 8.2%), pipe (4.0% to 1.5%), and
bidi (2.0% to 0.9%) use. Current use of any tobacco product (24.2% to 24.6%) and use
of ≥2 tobacco products (12.5% to 12.7%) did not change significantly from 2011 to
2014. Among middle school students, similar trends were observed during 2011–2014
(Figure 2). A statistically significant linear decrease was observed only in middle
school students currently using ≥2 tobacco products (3.8% to 3.1%).
In 2014, an estimated 4.6 million middle and high school students currently used any
tobacco product, of which an estimated 2.2 million students currently used ≥2 tobacco
products. Of current tobacco users, 2.4 million used e-cigarettes and 1.6 million
used hookahs. The largest increase in current e-cigarette use occurred from 2013 to
2014. Current e-cigarette use tripled from 2013 (660,000 [4.5%]) to 2014 (2 million
[13.4%]) among high school students (Figure 1); and among middle school students,
prevalence increased by a similar magnitude, from 1.1% (120,000) to 3.9% (450,000)
(Figure 2). From 2013 to 2014, substantial increases also were observed for current
hookah use, with prevalence almost doubling for high school students from 5.2% (770,000)
to 9.4% (1.3 million) and for middle school students from 1.1% (120,000) to 2.5% (280,000)
over this period.
Discussion
From 2011 to 2014, substantial increases were observed in current e-cigarette and
hookah use among middle and high school students, resulting in an overall estimated
total of 2.4 million e-cigarette youth users and an estimated 1.6 million hookah youth
users in 2014. Statistically significant decreases occurred in the use of cigarettes,
cigars, tobacco pipes, bidis, and snus. The increases in current use of e-cigarettes
and hookahs offset the decreases in current use of other tobacco products, resulting
in no change in overall current tobacco use among middle and high school students.
In 2014, one in four high school students and one in 13 middle school students used
one or more tobacco products in the last 30 days. In 2014, for the first time in NYTS,
current e-cigarette use surpassed current use of every other tobacco product, including
cigarettes.
These findings are subject to at least three limitations. First, data were collected
only from youths who attended either public or private schools and might not be generalizable
to all middle and high school-aged youth. Second, current tobacco use was estimated
by including students who reported using at least one of the nine tobacco products
asked in the survey but might have had missing responses to any of the other eight
tobacco products; missing responses were considered as nonuse, which might have resulted
in underestimated results. Finally, changes between 2013 and 2014 in the wording and
placement of questions about the use of e-cigarettes, hookahs, and tobacco pipes might
have had an impact on reported use of these products. Despite these limitations, overall
prevalence estimates are similar to the findings of other nationally representative
youth surveys (6,7).
Tobacco prevention and control strategies, including increasing tobacco product prices,
adopting comprehensive smoke-free laws, and implementation of national public education
media campaigns, might have influenced the reduction of cigarette smoking in youths
(2). However, the lack of decline in overall tobacco use from 2011 to 2014 is concerning
and indicates that an estimated 4.6 million youths continue to be exposed to harmful
constituents, including nicotine, present in tobacco products (Table). Youth use of
tobacco in any form, whether it be combustible, noncombustible, or electronic, is
unsafe (1); regardless of mode of delivery, nicotine exposure during adolescence,
a critical time for brain development, might have lasting adverse consequences for
brain development (1), causes addiction (3), and might lead to sustained use of tobacco
products. Rapid changes in use of traditional and emerging tobacco products among
youths underscore the importance of enhanced surveillance of all tobacco use.
What is already known on this topic?
Tobacco use and addiction most often begins during youth and young adulthood. Youth
use of tobacco in any form is unsafe and might have lasting adverse consequences on
their developing brains.
What is added by this report?
In 2014, an estimated 4.6 million youths, including 3.7 million high school and 900,000
middle school students, reported current use (use on one or more days in the past
30 days) of any tobacco product. From 2011 to 2014, statistically significant increases
were observed in e-cigarette and hookah use among high school and middle school students,
while statistically significant decreases were observed in the use of cigarettes,
cigars, tobacco pipes, bidis, and snus. The increases in current use of e-cigarettes
and hookahs offset the decreases in other tobacco products, resulting in no change
in overall current tobacco use among youths.
What are the implications for public health practice?
In 2014, nearly one in four high school students and one in 13 middle school students
reported current use of any tobacco product. Because the use of emerging tobacco products
(e-cigarettes and hookahs) is on the rise among middle and high school students, it
is critical that comprehensive tobacco control and prevention strategies for youths
should address all tobacco products and not just cigarettes.
Sustained efforts to implement proven tobacco control policies and strategies are
necessary to prevent youth use of all tobacco products. In April 2014, FDA issued
a proposed rule to deem all products made or derived from tobacco subject to FDA jurisdiction,
and the agency is reviewing public comments on the proposed rule (8). Regulation of
the manufacturing, distribution, and marketing of tobacco products coupled with full
implementation of comprehensive tobacco control and prevention strategies at CDC-recommended
funding levels could reduce youth tobacco use and initiation (1,2,9). Because use
of emerging tobacco products (e-cigarettes and hookahs) is increasing among middle
and high school students, it is critical that comprehensive tobacco control and prevention
strategies for youths should address all tobacco products and not just cigarettes.