Temporal Trends in Tobacco Product Use Among US Middle and High School Students: National Youth Tobacco Survey, 2011-2020

Abstract

Objectives: Despite significant declines in cigarette smoking during the past decade, other tobacco products gained popularity among middle and high school students. This study examined temporal trends in exclusive and concurrent use of tobacco products among middle and high school students in the United States from 2011 through 2020.

Methods: We used multiple annual datasets from the National Youth Tobacco Survey from 2011 through 2020 (N = 193 350) to examine trends of current (past 30 days) exclusive, dual, and poly use of tobacco products (ie, cigarettes, electronic cigarettes [e-cigarettes], cigars, hookahs, and smokeless tobacco). We used joinpoint regression models to calculate log-linear trends in annual percentage change (APC).

Results: During 2011-2020, exclusive use of any tobacco product decreased significantly, except for e-cigarettes, which increased significantly at an APC of 226.8% during 2011-2014 and 14.6% during 2014-2020. This increase was more pronounced among high school students (APC = 336.6% [2011-2014] and 15.7% [2014-2020]) than among middle school students (APC = 10.4% [2014-2020]) and among male students (APC = 252.8% [2011-2014] and 14.8% [2014-2020]) than among female students (APC = 13.6% [2014-2020]). During 2011-2020, we also found upward trends in dual use of e-cigarettes and cigarettes (APC = 17.3%). Poly use of e-cigarettes, cigarettes, and any other tobacco products increased significantly at an APC of 57.1% during 2011-2014.

Conclusions: The emergence of new tobacco products such as e-cigarettes in the US market has shifted the landscape of tobacco use among adolescents in the last decade toward poly product use, in which e-cigarettes are a prominent component. Our findings underscore the increasing complexity of tobacco use among adolescents in the United States and the need for strong policies and regulations adapted to evolving trends in cigarette and noncigarette tobacco products.

Keywords: tobacco; trends; youth.

Figure 1.

Categories used to define current tobacco use among middle and high school students in the United States, National Youth Tobacco Survey, 2011-2020. In the poly use category, “other” refers to cigars, hookahs, smokeless, pipes, bidis, roll-your-own, HTPs, and kreteks. Abbreviations: e-cigarettes, electronic cigarettes; HTP, heated tobacco product. Data source: Centers for Disease Control and Prevention.

Figure 2.

Prevalence of any current tobacco use among middle and high school students overall from 2011 through 2020, National Youth Tobacco Survey. Linear trend: exclusive (49.7% to 63.9%; P = .002); dual (24.7% to 19.5%; P = .007); poly (25.6% to 16.6%; P = .06). Significance determined by joinpoint regression; P < .05 considered significant. Abbreviation: APC, annual percentage change. Data source: Centers for Disease Control and Prevention.

Figure 3.

Prevalence of current exclusive tobacco use among middle and high school students overall from 2011 through 2020, National Youth Tobacco Survey. Linear trend: cigarette (43.0% to 3.6%; P < .001); cigar (24.0% to 6.8%; P = .01); electronic cigarette (e-cigarette) (1.7% to 79.3%; P < .001); hookahs (5.7% to 4.6%; P = .06); smokeless (19.6% to 3.9%; P < .001); other (6.0% to 1.7%; P = .13). Significance determined by joinpoint regression; P < .05 considered significant. Abbreviation: APC, annual percentage change. Data source: Centers for Disease Control and Prevention.

Figure 4.

Prevalence of current dual tobacco use among middle and high school students overall from 2011 through 2020, National Youth Tobacco Survey. Linear trend: cigarette + electronic cigarette (e-cigarette) (3.4% to 27.8%; P < .001); cigarette + hookahs (6.0% to 0.3%; P < .001); cigarette + cigar (38.7% to 3.9%; P < .001); cigarette + smokeless tobacco (21.6% to 2.5%; P = .01); cigarette + other (5.5% to 0.4%; P = .09); e-cigarette + hookah (0.2% to 13.4%; P = .06); e-cigarette + cigar (0.4% to 20.8%; P < .001); e-cigarette + smokeless tobacco (1.1% to 17.1%; P = .003); e-cigarette + other (0.1% to 3.7%; P = .001); 2 tobacco products not including cigarette or e-cigarette (23.1% to 10.0%; P = .04). Significance determined by joinpoint regression; P < .05 considered significant. Abbreviation: APC, annual percentage change. Data source: Centers for Disease Control and Prevention.

Figure 5.

Prevalence of current poly tobacco use among middle and high school students overall from 2011 through 2020, National Youth Tobacco Survey. Linear trend: cigarette + electronic cigarette (e-cigarette) + ≥1 other tobacco product (13.9% to 62.1%; P = .01); cigarette + ≥2 other tobacco products not including e-cigarette (72.6% to 7.5%; P = .002); e-cigarette + ≥2 other tobacco products not including cigarette (1.8% to 24.8%; P = .01); ≥3 tobacco products not including cigarette or e-cigarette (11.7% to 5.6%; P = .18). Significance determined by joinpoint regression; P < .05 considered significant. Abbreviation: APC, annual percentage change. Data source: Centers for Disease Control and Prevention.