Racial/Ethnic Disparities in Tobacco Product Use Among Middle and High School Students — United States, 2014–2017

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During the past few decades, wide disparities in tobacco product use have been documented among the largest racial/ethnic groups in the United States (1,2); however, little is known about tobacco product use among youths from racial/ethnic groups other than whites, blacks, and Hispanics. Surveillance reports typically aggregate these racial/ethnic minorities into a single category because of small sample sizes (3). To assess tobacco product use among U.S. middle and high school students from seven racial/ethnic groups (non-Hispanic whites [whites], non-Hispanic blacks [blacks], Hispanics, non-Hispanic Asians [Asians], non-Hispanic American Indian/Alaska natives [AI/ANs], non-Hispanic Native Hawaiians/Other Pacific Islanders [NHOPIs], and non-Hispanic multiracial persons [multiracial]), CDC analyzed pooled data from the 2014–2017 National Youth Tobacco Surveys (NYTS). Prevalence of ever (≥1 time in lifetime) and current (≥1 time in past 30 days) use of seven tobacco products (cigarettes, cigars, smokeless tobacco, electronic cigarettes [e-cigarettes], hookahs, pipes, and bidis) was assessed; any tobacco product use was defined as use of one or more tobacco products, including hand-rolled cigarettes. During 2014–2017, ever-use of any tobacco product among U.S. middle and high school students was as follows: NHOPIs (45.1%), AI/ANs (43.8%), multiracial persons (38.2%), Hispanics (35.1%), blacks (32.3%), whites (32.0%), and Asians (16.3%). Current use of any tobacco product was as follows: NHOPIs (23.4%), AI/ANs (20.6%), multiracial persons (16.5%), whites (15.3%), Hispanics (14.6%), blacks (11.5%), and Asians (5.0%). Among black middle and high school students, cigars were the most common product currently used, whereas e-cigarettes were the most commonly used product for all other racial/ethnic groups. Comprehensive and sustained implementation of evidence-based, population-level tobacco control interventions could reduce prevalence and disparities in tobacco product use among U.S. youths.

NYTS is a cross-sectional, voluntary, school-based, paper-and-pencil questionnaire administered to U.S. middle (grades 6–8) and high (grades 9–12) school students. A three-stage cluster sampling procedure was used to generate a nationally representative sample of U.S. students attending public and private schools.* For these analyses, data were pooled across four cycles of NYTS (2014–2017) to allow sufficient sample size to assess tobacco product use among each of the racial/ethnic groups. Averaged annual sample size and response rate were 19,566 and 69.1%, respectively.^†

Participants were asked about ever^§ and current^¶ use of seven tobacco product types: cigarettes, cigars (cigars, cigarillos, and little cigars), smokeless tobacco products (chewing tobacco, snuff, dip, snus, and dissolvable tobacco), e-cigarettes, hookahs, pipes, and bidis. Use of hand-rolled cigarettes was also assessed in the survey, but is not reported separately as a distinct tobacco product type because the majority (88.7%) of persons who reported smoking hand-rolled cigarettes also smoked regular cigarettes. Any tobacco product use was defined as use of ≥1 tobacco product types, including hand-rolled cigarettes.

Data were weighted to adjust for differential nonresponse and to yield nationally representative estimates. Pooled sample sizes for each racial/ethnic group during 2014–2017 included 32,358 whites, 11,664 blacks, 21,337 Hispanics, 3,321 Asians, 1,213 AI/ANs, 456 NHOPIs, and 4,106 multiracial persons. Prevalence was calculated overall and by race/ethnicity; within each racial/ethnic group, prevalence was further stratified by sex and school level (middle or high school). Comparisons between and within each racial/ethnic group were performed with chi-squared tests, with statistical significance defined as p<0.05. Estimates with relative standard errors ≥30% were suppressed. Differences in any tobacco product use across groups were assessed using Poisson regression models adjusted for sex and school level. Adjusted prevalence ratios (aPRs) with 95% confidence intervals (CIs) were calculated, with the group with the lowest prevalence (Asians) serving as the referent group.

Corresponding author: Satomi Odani, lpu7@cdc.gov, 770-488-5493.

¹Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

References

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Abbreviations: AI/AN = American Indians/Alaska Natives; CI = confidence interval; HS = high school; MS = middle school; NHOPI = Native Hawaiian/Other Pacific Islander.
* Respondents were asked whether they had ever used/smoked the respective tobacco products, or asked “Which of the following tobacco products have you ever tried, even just one time?,” depending on the type of products and survey years. Those who provided an affirmative response or specified their product(s) from the product list provided were classified as ever tobacco product users.
^† All racial/ethnic groups assessed are non-Hispanic unless otherwise specified.
^§ Data were pooled across four cycles of National Youth Tobacco Surveys (2014–2017) to increase precision of estimates among racial/ethnic minorities. Pooled sample sizes for each racial/ethnic group during 2014–2017 were 32,358 whites; 11,664 blacks; 21,337 Hispanics; 3,321 Asians; 1,213 AI/ANs; 456 NHOPIs; and 4,106 multiracial persons.
^¶ Any tobacco product use was defined as use of one or more tobacco product types, including hand-rolled cigarettes. Smokers of hand-rolled cigarettes are not reported separately because the vast majority (88.7%) of these persons reported ever smoking regular cigarettes.
** Chewing tobacco/snuff/dip/snus/dissolvable tobacco.
^†† Prevalence significantly different (p<0.05) within demographic subgroups (male versus female; MS versus HS).
^§§ Estimates not presented because relative standard error ≥30%.

Abbreviations: AI/AN = American Indians/Alaska Natives; CI = confidence interval; HS = high school; MS = middle school; NHOPI = Native Hawaiian/Other Pacific Islander.
* Respondents were asked on how many days in the past 30 days they used/smoked the respective tobacco products, or asked “In the past 30 days, which of the following products have you used on at least one day?,” depending on the type of products and survey years. Those who answered ≥1 day or specified their product(s) from the product list provided were classified as current tobacco product users.
^† All racial/ethnic groups assessed are non-Hispanic, unless otherwise specified.
^§ Data were pooled across four cycles of National Youth Tobacco Surveys (2014–2017) to increase precision of estimates among racial/ethnic minorities. Pooled sample sizes for each racial/ethnic group during 2014–2017 were 32,358 whites; 11,664 blacks; 21,337 Hispanics; 3,321 Asians; 1,213 AI/ANs; 456 NHOPIs; and 4,106 multiracial persons.
^¶ Any tobacco product use was defined as use of one or more tobacco product types, including hand-rolled cigarettes. Smokers of hand-rolled cigarettes are not reported separately because the vast majority (88.7%) of these individuals reported ever smoking regular cigarettes.
** Chewing tobacco/snuff/dip/snus/dissolvable tobacco.
^†† Prevalence significantly different within demographic subgroups (male versus female; MS versus HS) (p<0.05).
^§§ Estimates not presented because relative standard error ≥30%.

FIGURE. Adjusted prevalence ratios* of current use of any tobacco product^† among middle and high school students — National Youth Tobacco Survey, United States, 2014–2017^§,¶

Abbreviations: AI/AN = American Indians/Alaska Natives; NHOPI = Native Hawaiian/Other Pacific Islander.

* Adjusted prevalence ratios and 95% confidence intervals (presented as whiskers) were obtained using Poisson regression models adjusted for sex and school level, with the group with the lowest prevalence of current use of any tobacco product (Asians, 5.0%) serving as the referent. Among other racial and ethnic groups, prevalence was NHOPIs 23.4%; AI/ANs 20.6%; multiracial 16.5%; whites 15.3%; Hispanics 14.6%; and blacks 11.5%.

^† Current (≥1 time in the past 30 days) use of any tobacco product was defined as current use of one or more tobacco product types, including cigarettes, cigars (including cigarillos and little cigars), smokeless tobacco (including chewing tobacco, snuff, dip, snus, and dissolvable tobacco), electronic cigarettes, hookahs, pipes, bidis, and hand-rolled cigarettes.

^§ Data were pooled across four cycles of NYTS (2014–2017) to increase precision of estimates among racial and ethnic minorities. Pooled sample sizes for each racial/ethnic group during 2014–2017 were 32,358 whites; 11,664 blacks; 21,337 Hispanics; 3,321 Asians; 1,213 AI/ANs; 456 NHOPIs; and 4,106 multiracial.

^¶ All racial/ethnic groups assessed are non-Hispanic, unless otherwise specified.