Clinical Context

In the United States, use of tobacco products is the leading cause of preventable disease, disability, and death. Approximately 88% of adults who smoke cigarettes daily report first trying cigarette smoking before 18 years of age. Although recent research suggests decreases in current cigarette smoking among US high school students, there is now available an increasing variety of electronic vapor products (eg, e-cigarettes) with growing popularity among youths.

A Centers for Disease Control and Prevention (CDC) report used data from the 2019 Youth Risk Behavior Survey to evaluate use of cigarettes and electronic vapor products among US high school students.

Study Synopsis and Perspective

Use of electronic vapor products, or vaping, more than doubled among US high school students from 2017 to 2019 (going from 13.2% in 2017 to 32.7% in 2019), a report from the CDC has found. Current cigarette smoking decreased from 8.8% to 6.0% during that time, as did cigar smoking (from 8.0% to 5.7%) and smokeless tobacco use (from 5.5% to 3.8%).

Current use of any tobacco product increased from 19.5% in 2017 to 36.5% in 2019.

"The dramatic increase in electronic vapor product use among high school students has led to increases in overall tobacco product use among U.S. youths, erasing gains made in previous years and leading the U.S. Surgeon General to declare youth e-cigarette use an epidemic in the United States," the authors write.

"The new youth tobacco use data released today from CDC's 2019 Youth Risk Behavior Survey confirm that our nation is facing multiple public health crises simultaneously: the COVID-19 pandemic, continued racial health equity disparities, and a youth vaping crisis," Harold Wimmer, president and chief executive office of the American Lung Association, said in a statement about the findings.

"The dramatic increase in youth vaping led to a near doubling of overall tobacco product use among high school students from 19.5% in 2017 to 36.5% in 2019," he added.

MeLisa R. Creamer, PhD, from the Office on Smoking and Health in the CDC's National Center for Chronic Disease Prevention and Health Promotion, and colleagues report their findings in an article published online August 20 in the Morbidity and Mortality Weekly Report.

The researchers analyzed data from the 1991 to 2019 cycles of the CDC's biennial national Youth Risk Behavior Survey. The findings, the authors say, are in line with those from other national surveillance systems, including the National Youth Tobacco Survey and Monitoring the Future.

Frequent use (20 or more days during the previous 30 days) of electronic vapor products also increased among current electronic vapor product users (from 25.1% to 32.6%), but frequent cigarette smoking fell and frequent use of smokeless tobacco or cigars remained the same among users of those products.

The use of 2 or more tobacco products did not change from 2017 to 2019. "Multiple tobacco product use is associated with substance use disorders and might increase nicotine exposure and risk for nicotine dependence," the authors explain.

Differences by Demographic Group

Among current vapers, the usual source of obtaining these products differed by age. Those aged 17 years or younger most often said they borrowed them from someone else (42.8%). Among those aged 18 or older, 56.4% said they purchased them in a store.

Federal legislation raised the minimum age for tobacco product sales from 18 to 21 years nationwide on December 20, 2019.

Students aged 17 years or younger were more likely to get tobacco products on the internet, give someone else money to purchase them, borrow them from someone else, get them from someone who could buy them legally, or get them another way.

Male students were more likely to report that they use cigarettes, cigars, smokeless tobacco, and 2 or more tobacco products when compared with female students. The prevalence of tobacco product use was higher among those in 12th grade than among those in 9th grade.

White and Hispanic students had a higher prevalence of current use of electronic vapor products, cigarettes, any tobacco product, and at least 2 tobacco products when compared with Black students. White students were more likely than Hispanic students to say they used electronic vapor products and any tobacco product.

Youth aged 18 years or older were more likely than students aged 16 or 17 and those aged 15 years or younger to say they currently used cigars. Prevalence rose in each age group for all other individual products, any tobacco product, and multiple tobacco products.

Students who were heterosexual, lesbian, gay, or bisexual were more likely than those who were "not sure" about their sexual identity to report using electronic vapor products. Those who were lesbian, gay, or bisexual were more likely than heterosexual students to currently use cigarettes, cigars, tobacco products, and multiple tobacco products. Any tobacco product use was more common among lesbian, gay, or bisexual students when compared with students unsure of their sexual identity.

Flavored Tobacco Products Driving Much of Increase

Flavored tobacco products, including flavored vaping devices, are responsible for the sharp rise in e-cigarette use. From 2016 through 2017, sales of JUUL, "the most commonly sold e-cigarette in the United States since December 2017," rose approximately 600% (from 2.2 million unit sales to 16.2 million unit sales), the authors write.

By December 2018, three quarters (76%) of the $322.1 million in total e-cigarettes sales during that month in the United States were JUUL products. Several factors likely explain the appeal of these products to youths, including exposure through advertising, the availability of desirable flavors, curiosity, and being around friends and other individuals socially who use the products.

"We need look no further for the cause of this spike than the rise of JUUL and now Puff Flow and Vuse, and the continued sale and proliferation of flavored tobacco products, including flavored vaping devices," Dr Wimmer said.

"The tobacco industry has long used flavored tobacco products as starter products for kids and continues with flavored e-cigarettes today. And these data show that e-cigarette companies, many of which are owned by major tobacco companies, have successfully used Big Tobacco's playbook to hook another generation of America's kids," he continued.

Even infrequent use of tobacco products, and cigarette smoking in particular, is predictive of developing a daily smoking habit, and infrequent use has been associated with nicotine dependence.

"Flavors are known to lure and hook kids to a lifetime of tobacco addiction, and we see this reflected in the continued spike of the amount of youth vaping," Dr Wimmer explained. "To protect kids, the American Lung Association has long called for menthol cigarettes and all flavored tobacco products, including e-cigarettes, to be removed from the marketplace.

"The Food and Drug Administration (FDA) has a unique opportunity to reverse this spike in youth use by denying any flavored tobacco product permission to remain on the market when it reviews the applications due to the agency on September 9. In the meantime, our states and communities must act to fill the void left by FDA's failure to take action by passing state and local laws to prohibit the sale of all flavored tobacco products."

Limitations of the study include changes in the wording of questions in 2017 that make it impossible to compare data from previous years and "long-term trend analyses for prevalence of smokeless tobacco use, any tobacco product use, and use of two or more tobacco products," the authors explain.

The question about how students obtained tobacco products only allowed students to select a single response, but students may have several sources for obtaining the products, and the full scope of their access is unclear.

The findings are part of a larger report on youth risk behavior.

The authors have disclosed no relevant financial relationships.

Morb Mortal Wkly Rep. Published online August 20, 2020.

Survey Highlights

• From 2017 to 2019, the prevalence of vaping and overall tobacco use doubled among US youth, whereas use of cigarettes and cigars decreased.
• Implementation of evidence-based tobacco control strategies and FDA regulatory efforts are needed to prevent and reduce all forms of tobacco product use among youths.
• Members of the health care team should be aware that, regardless of frequency or number of products, use of any tobacco product among youth is unsafe; even infrequent use predicts progression to daily smoking and has been linked to symptoms of nicotine dependence.
• This analysis of data from US high school students completing the 2019 Youth Risk Behavior Survey examined ever use of cigarettes and electronic vapor products, current use (≥1 day during the 30 days before the survey) of tobacco products, frequent use (≥20 days during the preceding 30 days) among current users of tobacco products, trends in use over time, and usual source of electronic vapor products among current users.
• In 2019, 50.1% of US high school students had ever used electronic vapor products and 24.1% had ever tried cigarette smoking.
• The proportion of students reporting current tobacco use was 32.7% for electronic vapor products, 6.0% for cigarettes, 5.7% for cigars, and 3.8% for smokeless tobacco.
• 36.5% of students were current users of any tobacco product; 8.2% currently used at least 2 products.
• Frequent use was reported by 32.6% of students for electronic vapor products, 28.5% for smokeless tobacco, 22.2% for cigarettes, and 18.4% for cigars.
• The most commonly reported source among current electronic vapor product users aged 17 years or younger was borrowing them from someone else (42.8%); other common sources were via the Internet, giving someone else money to purchase them, or getting them from someone who could buy them legally.
• In contrast, 56.4% of current electronic vapor product users aged 18 years or older reported in-store purchase.
• There were significant decreases in current cigarette smoking, from 27.5% in 1991 to 8.8% in 2017 and 6.0% in 2019; cigar smoking, from 22.0% in 1997 to 8% in 2017 to 5.7% in 2019; and smokeless tobacco use, from 5.5% in 2017 to 3.8% in 2019.
• In contrast, current electronic vapor product use increased significantly, from 13.2% in 2017 to 32.7% in 2019, as did current use of any tobacco product, from 19.5% in 2017 to 36.5% in 2019.
• Students in in 12th grade had higher prevalence of tobacco product use than those in 9th grade.
• Current cigar use was more prevalent in students aged 18 years or older than in those aged 16 to 17 years and those aged 15 years or younger.
• For all other individual products, any tobacco product, and multiple tobacco products, prevalence of use increased with increasing age.
• Males were more likely than females to report use of cigarettes, cigars, smokeless tobacco, and 2 or more tobacco products.
• Compared with Blacks, Whites and Hispanics had a higher prevalence of current use of electronic vapor products, cigarettes, any tobacco product, and 2 or more tobacco products.
• Compared with Hispanics, Whites were more likely to report use of electronic vapor products and any tobacco product.
• Use of electronic vapor products was more likely among students who were heterosexual, lesbian, gay, or bisexual than among those who were unsure of their sexual identity.
• Compared with heterosexual students, those who were lesbian, gay, or bisexual were more likely to report current use of cigarettes, cigars, any tobacco product, and multiple products.
• Compared with students unsure of their sexual identity, lesbian, gay, or bisexual students were more likely to report use of any tobacco product.
• On the basis of their findings, the investigators concluded that the increased prevalence of electronic vapor product use among high school students is concerning, despite decreases in current cigarette smoking, cigar smoking, and smokeless tobacco use.
• During 2017 to 2019, frequent use of electronic vapor products increased, whereas frequent use of other tobacco products decreased or remained stable.
• Regardless of frequency or number of products, use of any tobacco product among youth is unsafe.
• Even infrequent use of tobacco products, particularly cigarettes, predicts progression to daily smoking and has been linked to symptoms of nicotine dependence.
• Multiple tobacco product use, reported by 8.2% of high school students, is associated with substance use disorders and might increase nicotine exposure and risk for nicotine dependence.
• Among US youths, the dramatic increase in electronic vapor product use has resulted in increases in overall tobacco product use, erasing gains made in previous years and leading the Surgeon General to declare youth e-cigarette use an epidemic in the United States.
• Factors encouraging tobacco product use among youths include media exposure to tobacco product advertising and imagery, social interactions with individuals who use the products, curiosity, and especially the availability of flavored tobacco products.
• Sales of flavored JUUL, the most commonly sold e-cigarette in the United States since December 2017, increased 7-fold from 2016 through 2017, from 2.2 million to 16.2 million unit sales.
• In December 2018, JUUL products accounted for 76% of the $322.1 million total US e-cigarette sales.
• An expert consulted by Medscape highlighted the continued sale and proliferation of flavored tobacco products as being largely responsible for the current vaping crisis among youths, noting that the tobacco industry has long used flavored tobacco products as starter products for adolescents.
• The American Lung Association has therefore called for a ban on marketing menthol cigarettes, flavored e-cigarettes, and all flavored tobacco products.
• To guide and assess public health policy at the local, state, tribal, and national levels, the investigators recommend continued surveillance for all tobacco product use in this age group.
• Implementation of evidence-based tobacco control strategies and FDA regulatory efforts are needed to prevent and reduce all forms of tobacco product use among youths.
• Useful strategies may include increased price of tobacco products, comprehensive smoke-free policies, advertising and promotion restrictions, national antitobacco public education media campaigns, restricting youth access to flavored tobacco products, and increasing the minimum age of purchase for tobacco products from ages 18 to 21 years, which federal legislation did nationwide on December 20, 2019.
• The National Cancer Institute and the Truth Initiative also offer resources to help youth stop using tobacco products.
• Study limitations include changes in question wording for smokeless tobacco use from 2017, precluding comparison of 2017 with 2019 and long-term trend analyses; question regarding source of electronic vapor products requiring selection of only single response; and questions related to electronic vapor products and cigars not specifically excluding the possibility of marijuana use in either product.

Clinical Implications

• From 2017 to 2019, the prevalence of vaping and overall tobacco use doubled among US youth, whereas use of cigarettes and cigars decreased.
• Implementation of evidence-based tobacco control strategies and FDA regulatory efforts are needed to prevent and reduce all forms of tobacco product use among youths.
• Implications for the Healthcare Team: Regardless of frequency or number of products, use of any tobacco product among youth is unsafe; even infrequent use predicts progression to daily smoking and has been linked to symptoms of nicotine dependence. Members of the healthcare team should assess teenage patients for vaping and tobacco use and provide cessation related resources when appropriate.

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