Vital Signs: Tobacco Product Use Among Middle and High School Students - United States, 2011-2018

Abstract

Introduction: Tobacco use is the leading cause of preventable disease and death in the United States; nearly all tobacco product use begins during youth and young adulthood.

Methods: CDC, the Food and Drug Administration, and the National Cancer Institute analyzed data from the 2011-2018 National Youth Tobacco Surveys to estimate tobacco product use among U.S. middle and high school students. Prevalence estimates of current (past 30-day) use of seven tobacco products were assessed; differences over time were analyzed using multivariable regression (2011-2018) or t-test (2017-2018).

Results: In 2018, current use of any tobacco product was reported by 27.1% of high school students (4.04 million) and 7.2% of middle school students (840,000); electronic cigarettes (e-cigarettes) were the most commonly used product among high school (20.8%; 3.05 million) and middle school (4.9%; 570,000) students. Use of any tobacco product overall did not change significantly during 2011-2018 among either school level. During 2017-2018, current use of any tobacco product increased 38.3% (from 19.6% to 27.1%) among high school students and 28.6% (from 5.6% to 7.2%) among middle school students; e-cigarette use increased 77.8% (from 11.7% to 20.8%) among high school students and 48.5% (from 3.3% to 4.9%) among middle school students.

Conclusions and implications for public health practice: A considerable increase in e-cigarette use among U.S. youths, coupled with no change in use of other tobacco products during 2017-2018, has erased recent progress in reducing overall tobacco product use among youths. The sustained implementation of comprehensive tobacco control strategies, in coordination with Food and Drug Administration regulation of tobacco products, can prevent and reduce the use of all forms of tobacco products among U.S. youths.

FIGURE 1

Frequent use of selected tobacco products† among U.S. middle and high school students who currently used each tobacco product — National Youth Tobacco Survey, 2017–2018 Abbreviation: e-cigarettes = electronic cigarettes. * Frequent tobacco product use defined as use of each respective tobacco product on ≥20 of the past 30 days. ^† Frequency of use during the past 30 days was not available for pipe tobacco in the 2017 or 2018 surveys. ^§ Among youths who currently report using each respective tobacco product, defined as a response other than "0 days" to each of the following questions: E-cigarettes: "During the past 30 days, on how many days did you use e-cigarettes?"; Cigarettes: "During the past 30 days, on how many days did you smoke cigarettes?"; Cigars: "During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?"; Smokeless tobacco: “During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip?"; Hookahs: "During the past 30 days, on how many days did you smoke tobacco in a hookah or waterpipe?" For all questions, answer choices included, “0 days, 1 or 2 days, 3 to 5 days, 6 to 9 days, 10 to 19 days, 20 to 29 days, and All 30 days." ^¶ During 2017–2018, a significant increase in frequent use of e-cigarettes was observed only among high school students (p<0.05). No significant changes were observed for any other tobacco product during 2017–2018 among middle or high school students

FIGURE 2

Estimated percentage of high school students who currently use any tobacco product, any combustible tobacco product, ≥2 tobacco product types, and selected tobacco products — National Youth Tobacco Survey, 2011–2018^,, Abbreviation: e-cigarettes = electronic cigarettes. * Any tobacco product use was defined as use of e-cigarettes, cigarettes, cigars, hookahs, smokeless tobacco, pipe tobacco and/or bidis (small brown cigarettes wrapped in a leaf) on ≥1 day in the past 30 days. ^† Any combustible tobacco product use was defined as use of cigarettes, cigars, hookahs, pipe tobacco, and/or bidis on ≥1 day in the past 30 days. ^§ Use of ≥2 tobacco product types was defined as use of ≥2 of the following tobacco products: e-cigarettes, cigarettes, cigars, hookahs, smokeless tobacco, pipe tobacco, and/or bidis on ≥1 day in the past 30 days. ^¶ During 2017–2018, current use of any tobacco product, ≥2 types of tobacco products, and e-cigarettes significantly increased (p<0.05). ** During 2011–2018, current use of combustible tobacco products, ≥2 types of tobacco products, cigars, smokeless tobacco, and pipe tobacco exhibited linear decreases (p<0.05). Current use of cigarettes exhibited a nonlinear decrease (p<0.05). Current use of hookahs exhibited a nonlinear change (p<0.05). Current use of e-cigarettes exhibited a nonlinear increase (p<0.05). No significant trend in use of any tobacco product overall was observed. ^†† Beginning in 2015, the definition of smokeless tobacco included chewing tobacco/snuff/dip, snus, and dissolvable tobacco to better reflect this class of tobacco products. Thus, estimates for individual smokeless tobacco products (chewing tobacco/snuff/dip, snus, and dissolvable tobacco) are not reported. This definition was applied across all years (2011–2018) for comparability purposes.

FIGURE 3

Estimated percentage of middle school students who currently use any tobacco product, any combustible tobacco product, ≥2 tobacco product types, and selected tobacco products — National Youth Tobacco Survey, 2011–2018^,, Abbreviation: e-cigarettes = electronic cigarettes. * Any tobacco product use was defined as use of e-cigarettes, cigarettes, cigars, hookahs, smokeless tobacco, pipe tobacco and/or bidis (small brown cigarettes wrapped in a leaf) ≥1 day in the past 30 days. ^† Any combustible tobacco product use was defined as use of cigarettes, cigars, hookahs, pipe tobacco, and/or bidis on ≥1 day in the past 30 days. ^§ Use of ≥2 tobacco product types was defined as use of ≥2 of the following tobacco products: e-cigarettes, cigarettes, cigars, hookahs, smokeless tobacco, pipe tobacco, and/or bidis on ≥1 day in the past 30 days. ^¶ During 2017–2018, current use of any tobacco product and e-cigarettes significantly increased (p<0.05). ** During 2011–2018, current use of combustible tobacco products, ≥2 tobacco products, cigarettes, cigars, smokeless tobacco, and pipe tobacco exhibited significant linear decreases (p<0.05). Use of e-cigarettes exhibited a significant nonlinear increase (p<0.05), and use of hookahs exhibited a nonlinear change (p<0.05). No significant trend in use of any tobacco product overall was observed. ^†† Beginning in 2015, the definition of smokeless tobacco included chewing tobacco/snuff/dip, snus, and dissolvable tobacco to better reflect this class of tobacco products. Thus, estimates for individual smokeless tobacco products (chewing tobacco/snuff/dip, snus, and dissolvable tobacco) are not reported. This definition was applied across all years (2011–2018) for comparability purposes.