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. 2022 Mar 11;71(5):1-29.
doi: 10.15585/mmwr.ss7105a1.

Tobacco Product Use and Associated Factors Among Middle and High School Students - National Youth Tobacco Survey, United States, 2021

Andrea S Gentzke, Teresa W Wang, Monica Cornelius, Eunice Park-Lee, Chunfeng Ren, Michael D Sawdey, Karen A Cullen, Caitlin Loretan, Ahmed Jamal, David M Homa

Tobacco Product Use and Associated Factors Among Middle and High School Students - National Youth Tobacco Survey, United States, 2021

Andrea S Gentzke et al. MMWR Surveill Summ. .

Abstract

Problem/condition: Commercial tobacco use is the leading cause of preventable disease, disability, and death in the United States. Most tobacco product use begins during adolescence. In recent years, tobacco products have evolved to include various combusted, smokeless, and electronic products.

Period covered: 2021.

Description of system: The National Youth Tobacco Survey (NYTS) is an annual, cross-sectional, school-based, self-administered survey of U.S. middle school (grades 6-8) and high school (grades 9-12) students. A three-stage cluster sampling procedure is used to generate a nationally representative sample of U.S. students attending public and private schools. NYTS is the only nationally representative survey of U.S. middle and high school students that focuses exclusively on tobacco use patterns and associated factors. NYTS provides data to support the design, implementation, and evaluation of comprehensive youth tobacco use prevention and control programs and to guide tobacco regulatory activities. Since 2019, NYTS has been administered electronically via tablet computers. Because of emergency COVID-19 protocols that were in place across the United States during the 2021 NYTS fielding window (January 18-May 21, 2021), the 2021 survey was administered using a web URL to allow participation by eligible students learning under varying instructional models (in-person, distance/virtual, and hybrid). In total, 50.8% of student respondents reported completing the survey in a school building or classroom and 49.2% at home or some other place. CDC and the Food and Drug Administration (FDA) analyzed data from the 2021 NYTS to assess tobacco product use patterns and associated factors among U.S. middle and high school students. Overall, 20,413 students (out of 25,149 sampled students; student response rate: 81.2%) completed the questionnaire from 279 schools (out of 508 sampled schools; school response rate: 54.9%). The overall response rate, defined as the product of the student and school response rates, was 44.6%. The sample was weighted to represent approximately 11.97 million middle school students and 15.44 million high school students. Students with missing information about grade level were excluded from the school-level analyses (n = 135).

Results: In 2021, an estimated 34.0% of high school students (5.22 million) and 11.3% of middle school students (1.34 million) reported ever using a tobacco product (i.e., electronic cigarettes [e-cigarettes], cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco, heated tobacco products, nicotine pouches, and bidis [small brown cigarettes wrapped in a leaf]). Current (past 30-day) use of a tobacco product was 13.4% for high school students (2.06 million) and 4.0% for middle school students (470,000). E-cigarettes were the most commonly currently used tobacco product, cited by 11.3% of high school students (1.72 million) and 2.8% of middle school students (320,000), followed by cigarettes, cigars, smokeless tobacco, hookahs, nicotine pouches, heated tobacco products, and pipe tobacco. Current use of any tobacco product was reported by 14.2% of students identifying as lesbian, gay, or bisexual (LGB) (versus 7.9% of heterosexual); 18.9% of students identifying as transgender (versus 8.2% of not transgender); and 14.2% of students reporting severe psychological distress (versus 5.5% with no distress). Among students who currently used each respective tobacco product, frequent use (on ≥20 days of the past 30 days) ranged from 17.2% for nicotine pouches to 39.4% for e-cigarettes. Among current users of any tobacco product, 79.1% reported using a flavored tobacco product; by product, e-cigarettes were the most commonly used flavored tobacco product. Among current users of any tobacco product, the most commonly reported source of access was from a friend (32.8%). Among students who currently used e-cigarettes, 53.7% used a disposable device, 28.7% used a prefilled/refillable pod or cartridge device, 9.0% used a tank or mod system (a system that can be customized by the user), and 8.6% did not know the device type. Among students who had ever used e-cigarettes, the most common reason for first trying them was "a friend used them" (57.8%); among current e-cigarette users, the most commonly cited reason for current use was "I am feeling anxious, stressed, or depressed" (43.4%). Among all middle and high school students, 75.2% reported past-year recognition of any antitobacco public education campaign ads. Exposure to marketing or advertising for any tobacco product was reported by 75.7% of students who had contact with an assessed potential source of tobacco product advertisements or promotions (going to a convenience store, supermarket, or gas station; using the Internet; watching television or streaming services or going to the movies; or reading newspapers or magazines). Among students who reported using social media, 73.5% had ever seen e-cigarette-related content. Among all students, perceiving "no" or "little" harm from intermittent tobacco product use was highest for e-cigarettes (16.6%) and lowest for cigarettes (9.6%). Among students who currently used any tobacco product, 27.2% had experienced cravings during the past 30 days; 19.5% reported wanting to use a tobacco product within 30 minutes of waking. Moreover, 65.3% of students who currently used tobacco products were seriously thinking about quitting the use of all products, and 60.2% had stopped using all products for ≥1 day because they were trying to quit during the past 12 months.

Interpretation: In 2021, approximately one in 10 U.S. middle and high school students (9.3%) had used a tobacco product during the preceding 30 days. By school level, this represented more than one in eight high school students (13.4%) and approximately one in 25 middle school students (4.0%). E-cigarettes were the most commonly used tobacco product in 2021. Tobacco product use was higher among certain subpopulations, such as those identifying as LGB or transgender, or those reporting psychological distress. Importantly, approximately two thirds of students who currently used tobacco products were seriously thinking about quitting. However, factors that might continue to promote tobacco product use among U.S. youths, such as the availability of flavors, access to tobacco products, exposure to tobacco product marketing, and misperceptions about harm from tobacco product use, remained prevalent in 2021.

Public health action: The continued monitoring of all forms of youth tobacco product use and associated factors through surveillance efforts including NYTS is important to the development of public health policy and action at national, state, and local levels. The 2021 NYTS was successfully administered during the COVID-19 pandemic using a web URL to allow participation by eligible students learning under varying instructional models. As a result of these modifications to the fielding procedures, any comparison of results between 2021 NYTS findings with previous years, including the direct attribution of any potential changes in tobacco product use, is not possible. Parents, educators, youth advocates, and health care providers can help protect youths from the harms of tobacco products, including e-cigarettes. In addition, the comprehensive and sustained implementation of evidence-based tobacco control strategies, combined with FDA's regulation of tobacco products, is important for reducing all forms of tobacco product use among U.S. youths.

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Conflict of interest statement

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Figures

FIGURE 1
FIGURE 1
Percentage of middle and high school students who reported current (past 30-day) use of select tobacco products,* any tobacco product,† any combustible tobacco product,§ or two or more tobacco product types, by school level** and overall — National Youth Tobacco Survey, United States, 2021 Abbreviation: e-cigarettes = electronic cigarettes. * Past 30-day use of e-cigarettes was determined by asking, “During the past 30 days, on how many days did you use e-cigarettes?” Past 30-day use of cigarettes was determined by asking, “During the past 30 days, on how many days did you smoke cigarettes?” Past 30-day use of cigars was determined by asking, “During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?” Smokeless tobacco was defined as use of chewing tobacco, snuff, dip, snus, or dissolvable tobacco products. Past 30-day use of smokeless tobacco was determined by asking, “During the past 30 days, on how many days did you use [chewing tobacco, snuff, or dip /snus/dissolvable tobacco products]?” Responses from these questions were combined to derive overall smokeless tobacco use. Past 30-day use of hookahs was determined by asking, “During the past 30 days, on how many days did you smoke tobacco in a hookah or water pipe?” Past 30-day use of nicotine pouches was determined by asking, “During the past 30 days, on how many days did you use nicotine pouches?” Past 30-day use of heated tobacco products was determined by asking, “During the past 30 days, on how many days did you use heated tobacco products?” Past 30-day use of pipe tobacco (not hookahs) was determined by asking, “In the past 30 days, on how many days did you smoke pipes filled with tobacco?” Because of missing data on the past 30-day use questions, denominators for each tobacco product might be different. For each product, current use was defined as self-reported use on ≥1 day during the past 30 days. † Any tobacco product use was defined as use of any tobacco product (e-cigarettes, cigarettes, cigars [cigars, cigarillos, or little cigars], smokeless tobacco [chewing tobacco, snuff, dip, snus, or dissolvable tobacco products], hookahs, pipe tobacco, heated tobacco products, nicotine pouches, or bidis [small brown cigarettes wrapped in a leaf]) on ≥1 day during the past 30 days. § Any combustible tobacco product use was defined as use of cigarettes, cigars (cigars, cigarillos, or little cigars), hookahs, pipe tobacco, or bidis on ≥1 day during the past 30 days. Defined as use of two or more tobacco products (e-cigarettes, cigarettes, cigars [cigars, cigarillos, or little cigars], smokeless tobacco [chewing tobacco, snuff, dip, snus, or dissolvable tobacco products], hookahs, pipe tobacco, heated tobacco products, nicotine pouches, or bidis) on ≥1 day during the past 30 days. ** Overall estimates were reported among 20,413 U.S. middle and high school students. School level was determined by self-reported grade level: high school (grades 9–12; n = 10,515) and middle school (grades 6–8; n = 9,763).
FIGURE 2
FIGURE 2
Flavor types* used among middle and high school students who reported current (past 30-day) use of flavored tobacco products, by product†,§,¶ — National Youth Tobacco Survey, United States, 2021 Abbreviation: e-cigarettes = electronic cigarettes. * For each respective tobacco product excluding cigarettes (e-cigarettes, cigars [cigars, cigarillos, or little cigars], smokeless tobacco [chewing tobacco, snuff, or dip; snus; dissolvable tobacco products], hookahs, pipe tobacco, heated tobacco products, nicotine pouches), current (past 30-day) users were asked, “Were any of the [tobacco product] that you used in the past 30 days flavored to taste like menthol, mint, clove or spice, alcohol (wine, cognac), candy, fruit, chocolate, or any other flavor?” (response options were “yes,” “no,” or “don’t know”). Those who responded yes were then asked, “What flavors were the [tobacco product] that you have used in the past 30 days? (Select one or more).” Response options were menthol, mint, clove or spice, alcoholic drinks (such as wine, cognac, margarita, or other cocktails), candy, desserts, or other sweets, fruit, chocolate, and some other flavor not listed here (write-in responses). Write-in responses were examined and recoded to a prespecified response option where applicable. † For cigarettes, flavored use refers to menthol cigarette use only. All other flavor types for cigarettes are not applicable. Menthol cigarette use is omitted from this figure. § For smokeless tobacco, flavor types were assessed separately among flavored chewing tobacco, snuff, or dip; snus; and dissolvable tobacco product users. Flavor types were then assessed as a composite among current users of chewing, snuff, dip, snus or dissolvable tobacco products. Data are not shown as they were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%: smokeless tobacco: clove or spice; hookahs: some other flavor, alcoholic drinks, chocolate, clove or spice; heated tobacco products: mint, some other flavor, alcoholic drinks, chocolate, clove or spice; nicotine pouches: fruit; candy, desserts, or sweets; some other flavor; alcoholic drinks; chocolate; or clove or spice. All estimates of flavor types used for pipe tobacco were statistically unreliable and are omitted from this figure.
FIGURE 3
FIGURE 3
E-cigarette device types* reported among middle and high school students who reported current (past 30-day) use of e-cigarettes, overall and by school level — National Youth Tobacco Survey, United States, 2021 Abbreviation: e-cigarettes = electronic cigarettes. * Device type among current e-cigarette users was assessed by the question, “Which of the following best describes the type of e-cigarette you have used in the past 30 days? If you have used more than one type, please think about the one you use most often. Response options included the following: “a disposable e-cigarette (for example, Puff Bar or Stig),” “an e-cigarette that uses pre-filled or refillable pods or cartridges (for example, Juul, Smok, or Suorin),” “an e-cigarette with a tank that you refill with liquids (including mod systems that can be customized by the user),” and “I don’t know the type.” † Past 30-day use of e-cigarettes was determined by asking, “During the past 30 days, on how many days did you use e-cigarettes?” Those indicating use on ≥1 day of the past 30 days were considered current user of the respective product.
FIGURE 4
FIGURE 4
Harm perceptions of intermittent use* of select tobacco products among middle and high school students — National Youth Tobacco Survey, United States, 2021 Abbreviation: e-cigarettes = electronic cigarettes. * Assessed by the questions, “How much do you think people harm themselves when they [use e-cigarettes; smoke cigarettes; smoke cigars, cigarillos, or little cigars; use chewing tobacco, snuff, dip, snus, or dissolvable tobacco products; or smoke tobacco in a hookah or water pipe] some days but not every day?” Response options included “no harm,” “little harm,” “some harm,” and “a lot of harm” for each of the five tobacco products assessed. Harm perceptions of intermittent use of other tobacco products were not assessed in the 2021 National Youth Tobacco Survey.
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References

    1. US Department of Health and Human Services. The health consequences of smoking: 50 years of progress. a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 2014. https://www.ncbi.nlm.nih.gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdf
    1. US Department of Health and Human Services. Preventing tobacco use among youth and young adults: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2012. https://www.ncbi.nlm.nih.gov/books/NBK99237/pdf/Bookshelf_NBK99237.pdf
    1. US Department of Health and Human Services. E-cigarette use among youth and young adults: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2016. https://www.cdc.gov/tobacco/data_statistics/sgr/e-cigarettes/pdfs/2016_s...
    1. CDC. National Youth Tobacco Survey. Atlanta, GA: US Department of Health and Human Services, CDC; 2020. https://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm
    1. Market Data Retrieval. National education database master extract. Shelton, CT: Market Data Retrieval; 2019.