Tobacco Use Among Middle and High School Students — United States, 2011–2015

Tobacco use is the leading cause of preventable disease and death in the United States; if current smoking rates continue, 5.6 million Americans aged <18 years who are alive today are projected to die prematurely from smoking-related disease (1). Tobacco use and addiction mostly begin during youth and young adulthood (1,2). CDC and the Food and Drug Administration (FDA) analyzed data from the 2011–2015 National Youth Tobacco Surveys (NYTS) to determine the prevalence and trends of current (past 30-day) use of seven tobacco product types (cigarettes, cigars, smokeless tobacco, electronic cigarettes [e-cigarettes], hookahs [water pipes used to smoke tobacco], pipe tobacco, and bidis [small imported cigarettes wrapped in a tendu leaf]) among U.S. middle (grades 6–8) and high (grades 9–12) school students. In 2015, e-cigarettes were the most commonly used tobacco product among middle (5.3%) and high (16.0%) school students. During 2011–2015, significant increases in current use of e-cigarettes and hookahs occurred among middle and high school students, whereas current use of conventional tobacco products, such as cigarettes and cigars decreased, resulting in no change in overall tobacco product use. During 2014–2015, current use of e-cigarettes increased among middle school students, whereas current use of hookahs decreased among high school students; in contrast, no change was observed in use of hookahs among middle school students, use of e-cigarettes among high school students, or use of cigarettes, cigars, smokeless tobacco, pipe tobacco, or bidis among middle and high school students. In 2015, an estimated 4.7 million middle and high school students were current tobacco product users, and, therefore, continue to be exposed to harmful tobacco product constituents, including nicotine. Nicotine exposure during adolescence, a critical period for brain development, can cause addiction, might harm brain development, and could lead to sustained tobacco product use among youths (1,3). Comprehensive and sustained strategies are warranted to prevent and reduce the use of all tobacco products among U.S. youths.

The NYTS is a cross-sectional, school-based, self-administered, pencil-and-paper questionnaire administered to U.S. middle school 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 to inform the FDA’s regulatory actions (5). A three-stage cluster sampling procedure was used to generate a nationally representative sample of U.S. students attending public and private schools in grades 6–12. This report uses data from 5 years of NYTS (2011–2015). Sample sizes and overall response rates for 2011, 2012, 2013, 2014, and 2015 were 18,866 (72.7%), 24,658 (73.6%), 18,406 (67.8%), 22,007 (73.3%), and 17,711 (63.4%), respectively.

Participants were asked about current (past 30-day) use of cigarettes, cigars, smokeless tobacco,* e-cigarettes,^† hookahs,^§ pipe tobacco,^¶ and bidis. Current use for each product was defined as use on ≥1 day during the past 30 days. Current tobacco use was categorized as “any tobacco product use,” defined as use of one or more tobacco products in the past 30 days; and “≥2 tobacco product use,” defined as use of two or more tobacco products in the past 30 days.** Kreteks (sometimes referred to as clove cigarettes) are no longer legally sold in the United States, and were excluded from the definition of current any tobacco product use, consistent with other recent reports.^†† 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 2015 are presented for any tobacco product use, use of ≥2 tobacco products, and use of each tobacco product, by selected demographics for each school level (high and middle). Results were assessed for the presence of linear and quadratic trends to determine the overall trend present, adjusting for race/ethnicity, sex, and grade; p-value <0.05 was used to determine statistical significance.^§§ T-tests were performed to examine differences between estimates from 2014 and 2015; p-values <0.05 were considered statistically significant.

In 2015, 25.3% of high school students reported current use of any tobacco product, including 13.0% who reported current use of ≥2 tobacco products. Among all high school students, e-cigarettes (16.0%) were the most commonly used tobacco product, followed by cigarettes (9.3%), cigars (8.6%), hookahs (7.2%), smokeless tobacco (6.0%), pipe tobacco (1.0%), and bidis (0.6%) (Table). Males reported higher use of any tobacco, ≥2 tobacco products, e-cigarettes, cigarettes, cigars, smokeless tobacco, and bidis than did females. Among non-Hispanic white and Hispanic high school students, e-cigarettes were the most commonly used tobacco product, whereas among non-Hispanic black high school students, cigars were most commonly used. Cigarette use was higher among non-Hispanic whites than among non-Hispanic blacks; and smokeless tobacco use was higher among non-Hispanic whites than other races.

Among middle school students, current use of any tobacco product and ≥2 tobacco products was 7.4% and 3.3%, respectively (Table). E-cigarettes (5.3%) were the most commonly used tobacco product by middle school students, followed by cigarettes (2.3%), hookahs (2.0%), smokeless tobacco (1.8%), cigars (1.6%), pipe tobacco (0.4%), and bidis (0.2%). As was the case among high school students, male middle school students reported higher use of any tobacco product than did females. Hispanic middle school students reported higher use of any tobacco product, use of ≥2 tobacco products, and use of e-cigarettes compared with that of other races/ethnicities.

During 2014–2015, current use of hookahs declined among high school students. Use of all other tobacco products, including e-cigarettes, cigarettes, cigars, and smokeless tobacco remained unchanged during this time period among high school students. Among middle school students, e-cigarette use increased from 3.9% in 2014 to 5.3% in 2015. Use of other tobacco products, including cigarettes, cigars, hookahs, and smokeless tobacco remained unchanged.

During 2011–2015, among all high school students, significant nonlinear increases were observed for current use of e-cigarettes (1.5% to 16.0%) and hookahs (4.1% to 7.2%) (Figure 1). Significant linear decreases were observed for current use of cigarettes (15.8% to 9.3%) and smokeless tobacco (7.9% to 6.0%), and significant nonlinear decreases were observed for current use of cigars (11.6% to 8.6%), pipe tobacco (4.0% to 1.0%), and bidis (2.0% to 0.6%). Current use of any tobacco product (24.2% to 25.3%) did not change significantly during 2011–2015. Among middle school students, significant linear increases were observed for current use of e-cigarettes (0.6% to 5.3%) and hookahs (1.0% to 2.0%) (Figure 2). Significant linear decreases were observed for current use of cigarettes (4.3% to 2.3%), cigars (3.5% to 1.6%), and smokeless tobacco (2.7% to 1.8%), and significant nonlinear decreases were observed for current use of pipe tobacco (2.2% to 0.4%) and bidis (1.7% to 0.2%). There was also a significant nonlinear change in the percentage of middle school students reporting current use of ≥2 tobacco products.

In 2015, an estimated 4.7 million middle and high school students were current users of any tobacco product, over 2.3 million of whom were current users of ≥2 tobacco products. Among middle and high school current tobacco users, 3.0 million used e-cigarettes, 1.6 million used cigarettes, 1.4 million used cigars, 1.2 million used hookahs, and 1.1 million used smokeless tobacco.

Corresponding contributor: Tushar Singh, TSingh@cdc.gov, 770-488-4252.

¹Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; ²Epidemic Intelligence Service, CDC; ³Center for Tobacco Products, Food and Drug Administration.

References

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TABLE. Estimated percentage of tobacco use in the past 30 days, by product,* school level, sex, and race/ethnicity — National Youth Tobacco Survey, United States, 2015

Abbreviation: CI = confidence interval.
* 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, and/or dissolvable tobacco. Past 30-day use of smokeless tobacco was determined by asking the following question for use of chewing tobacco/snuff/dip: “During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip?,” and the following question for use of snus and dissolvable tobacco: “In the past 30 days, which of the following products have you used on at least one day?,” and combining responses together to derive use. Past 30-day use of electronic cigarettes was determined by asking, “During the past 30 days, on how many days did use electronic cigarettes or e–cigarettes?”; past 30-day use of hookahs, pipe tobacco (not hookah), and bidis, were determined by asking, “In the past 30 days, which of the following products have you used on at least one day?”
^† Estimated total number of users is rounded down to the nearest 10,000.
^§ Data are statistically unreliable because sample size <50 or relative standard error >0.3.
^¶ Any tobacco product use is past 30-day use of cigarettes, cigars, smokeless tobacco, electronic cigarettes, hookahs, pipe tobacco, and/or bidis on ≥1 day in the past 30 days.
** ≥2 tobacco product use is past 30-day use of two or more of cigarettes, cigars, smokeless tobacco, electronic cigarettes, hookahs, pipe tobacco, and/or bidis on ≥1 day in the past 30 days.

FIGURE 1. Estimated percentage of high school students who currently use any tobacco products,* =2 tobacco products,^† and select tobacco products^§ — National Youth Tobacco Survey 2011–2015

* Any tobacco product use is defined as past 30-day use of cigarettes, cigars, smokeless tobacco, electronic cigarettes (e-cigarettes), hookahs, pipe tobacco, and/or bidis.

^† =2 tobacco product use is defined as past 30-day use of two or more of the following product types: cigarettes, cigars, smokeless tobacco, e-cigarettes, hookahs, pipe tobacco, and/or bidis.

^§ E-cigarettes and hookahs demonstrated a nonlinear increase (p<0.05). Cigarettes and smokeless tobacco demonstrated a linear decrease (p<0.05). Cigars, pipe tobacco, and bidis demonstrated a nonlinear decrease (p<0.05).

FIGURE 2. Estimated percentage of middle school students who currently use any tobacco products,* =2 tobacco products,^†,§ and select tobacco products^¶ in the past 30 days — National Youth Tobacco Survey, 2011–2015

* Any tobacco use is defined as past 30-day use of cigarettes, cigars, smokeless tobacco, electronic cigarettes (e-cigarettes), hookahs, pipe tobacco, and/or bidis.

^† =2 tobacco product use is defined as past 30-day use of two or more of the following product types: cigarettes, cigars, smokeless tobacco, e-cigarettes, hookahs, pipe tobacco, and/or bidis.

^§ =2 tobacco product use demonstrated a nonlinear change (p<0.05).

^¶ E-cigarettes and hookahs demonstrated a linear increase (p<0.05). Cigarettes, cigars, and smokeless tobacco demonstrated a linear decrease (p<0.05). Pipe tobacco and bidis demonstrated a nonlinear decrease (p<0.05).