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Characteristic Sex Race and ethnicity Total
Female Male White, non-Hispanic Black, non-Hispanic Hispanic Other, non-Hispanic
% (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) Estimated no. of users§
Overall
Any tobacco product 24.5 (22.2–27.1) 23.8 (21.7–26.1) 26.7 (23.7–29.9) 21.9 (19.2–24.9) 22.4 (20.7–24.2) 16.1 (11.6–21.8) 24.1 (22.1–26.3) 6,600,000
E-cigarettes 20.1 (17.9–22.5) 18.8 (16.8–21.0) 23.1 (20.3–26.2) 12.6 (10.4–15.2) 17.6 (15.8–19.5) 12.7 (8.9–17.7) 19.4 (17.5–21.5) 5,300,000
Cigarettes 8.0 (6.9–9.1) 8.3 (7.3–9.4) 9.3 (8.1–10.8) 6.2 (4.8–8.0) 7.1 (6.0–8.4) 5.9 (3.5–10.0) 8.1 (7.2–9.1) 2,180,000
Cigars 3.7 (3.2–4.3) 6.6 (5.6–7.9) 5.9 (4.7–7.3) 6.8 (5.5–8.4) 4.1 (3.4–4.9) 1.9 (1.1–3.4) 5.2 (4.5–6.0) 1,400,000
Smokeless tobacco 2.2 (1.6–2.8) 5.0 (4.1–6.2) 4.8 (3.9–5.8) 1.8 (1.2–2.7) 2.3 (1.7–3.0) —** 3.6 (2.9–4.5) 960,000
Hookahs 3.1 (2.5–3.8) 2.5 (2.0–3.0) 2.1 (1.6–2.7) 5.0 (4.0–6.3) 3.2 (2.3–4.3) 2.8 (2.3–3.3) 740,000
Nicotine pouches 1.2 (0.9–1.7) 2.6 (2.0–3.2) 2.6 (2.1–3.3) 0.7 (0.4–1.3) 1.3 (0.9–1.9) 1.9 (1.5–2.4) 490,000
Heated tobacco products 1.8 (1.5–2.2) 1.7 (1.5–2.0) 1.7 (1.4–2.1) 1.7 (1.1–2.5) 2.1 (1.5–2.9) 1.8 (1.5–2.0) 440,000
Pipe tobacco 0.9 (0.6–1.2) 1.2 (0.9–1.6) 1.3 (1.0–1.6) 0.9 (0.7–1.3) 1.0 (0.8–1.3) 270,000
Any combustible tobacco product†† 11.3 (10.1–12.5) 12.4 (11.1–13.8) 12.6 (10.9–14.4) 14.0 (11.8–16.4) 10.4 (9.3–11.6) 8.3 (5.5–12.4) 11.9 (10.8–13.0) 3,200,000
Two or more tobacco products§§ 9.1 (8.0–10.3) 10.9 (9.5–12.4) 11.8 (10.1–13.7) 8.5 (6.8–10.5) 8.5 (7.3–9.9) 6.3 (4.2–9.4) 10.0 (8.9–11.3) 2,740,000
High school (grades 9–12)
Any tobacco product 35.2 (32.4–38.1) 33.0 (30.3–35.8) 37.8 (34.7–41.1) 27.7 (25.1–30.6) 29.7 (27.2–32.4) 27.9 (22.5–34.0) 34.0 (31.6–36.5) 5,220,000
E-cigarettes 30.2 (27.4–33.1) 27.7 (25.0–30.6) 33.8 (30.7–37.1) 16.9 (14.5–19.7) 25.0 (22.4–27.9) 23.0 (17.6–29.5) 28.9 (26.4–31.4) 4,430,000
Cigarettes 10.8 (9.3–12.5) 11.5 (9.9–13.3) 13.0 (11.3–14.9) 6.4 (4.7–8.5) 9.5 (7.6–11.9) 9.6 (5.6–15.8) 11.2 (9.9–12.6) 1,680,000
Cigars 4.9 (4.2–5.8) 10.0 (8.6–11.7) 8.7 (7.3–10.4) 8.7 (7.0–10.6) 5.4 (4.3–6.8) 7.6 (6.6–8.8) 1,140,000
Smokeless tobacco 2.4 (1.8–3.3) 6.8 (5.5–8.4) 6.6 (5.4–7.9) 1.7 (1.0–2.9) 2.2 (1.5–3.2) 4.7 (3.8–5.9) 700,000
Hookahs 4.2 (3.4–5.3) 3.5 (2.8–4.3) 2.9 (2.3–3.8) 6.8 (5.3–8.7) 4.0 (3.0–5.3) 5.1 (2.9–8.9) 3.8 (3.2–4.6) 570,000
Nicotine pouches 1.7 (1.3–2.4) 4.1 (3.3–5.1) 4.1 (3.3–5.1) 1.5 (1.0–2.2) 3.0 (2.4–3.6) 420,000
Heated tobacco products 2.5 (1.9–3.1) 2.1 (1.8–2.5) 2.3 (1.9–2.8) 2.1 (1.2–3.7) 2.4 (1.6–3.4) 2.3 (2.0–2.6) 310,000
Pipe tobacco 1.1 (0.7–1.8) 1.7 (1.2–2.4) 1.8 (1.3–2.4) 1.1 (0.7–1.8) 1.4 (1.1–1.9) 210,000
Any combustible tobacco product 15.4 (13.6–17.2) 17.6 (15.9–19.5) 17.8 (15.9–19.8) 17.4 (15.0–20.1) 13.5 (11.3–16.2) 14.1 (9.8–19.9) 16.6 (15.1–18.1) 2,500,000
Two or more tobacco products 12.8 (11.4–14.4) 16.2 (14.3–18.4) 17.2 (15.2–19.4) 10.8 (8.8–13.4) 11.6 (9.5–14.1) 10.9 (7.6–15.5) 14.6 (13.1–16.3) 2,240,000
Middle school (grades 6–8)
Any tobacco product 11.1 (9.3–13.2) 11.5 (9.9–13.4) 10.3 (8.7–12.1) 14.0 (10.9–17.8) 13.2 (10.5–16.5) 6.0 (3.7–9.6) 11.3 (9.8–13.0) 1,340,000
E-cigarettes 7.5 (6.2–9.1) 7.0 (5.8–8.5) 7.5 (6.3–9.0) 7.0 (4.9–9.8) 8.4 (6.5–10.8) 3.8 (2.2–6.6) 7.3 (6.2–8.6) 860,000
Cigarettes 4.2 (3.2–5.6) 3.9 (3.1–5.0) 3.8 (2.9–5.1) 5.7 (3.8–8.4) 4.1 (2.8–5.8) 4.1 (3.2–5.1) 480,000
Cigars 2.0 (1.5–2.7) 2.2 (1.7–2.7) 1.7 (1.2–2.3) 4.3 (3.2–5.8) 2.5 (1.6–3.8) 2.1 (1.7–2.6) 240,000
Smokeless tobacco 1.8 (1.2–2.6) 2.5 (1.8–3.6) 2.1 (1.5–2.8) 1.9 (1.1–3.3) 2.3 (1.5–3.5) 2.2 (1.6–3.0) 250,000
Hookahs 1.5 (1.0–2.3) 1.1 (0.7–1.5) 0.6 (0.4–1.0) 2.7 (1.8–3.9) 2.1 (1.2–3.7) 1.3 (0.9–1.8) 150,000
Nicotine pouches 0.6 (0.3–1.1) 0.5 (0.3–0.8) 0.4 (0.3–0.7) 0.6 (0.4–0.8) 60,000
Heated tobacco products 1.0 (0.7–1.4) 1.2 (0.9–1.8) 0.8 (0.5–1.3) 1.7 (1.0–3.0) 1.1 (0.9–1.5) 120,000
Pipe tobacco 0.5 (0.3–0.8) 0.4 (0.2–0.6) 0.7 (0.4–1.2) 0.5 (0.3–0.7) 50,000
Any combustible tobacco product 6.0 (4.9–7.4) 5.4 (4.5–6.5) 4.7 (3.8–5.9) 9.2 (6.7–12.5) 6.5 (5.0–8.6) 5.7 (4.8–6.8) 670,000
Two or more tobacco products 4.3 (3.3–5.7) 3.7 (2.8–4.9) 3.6 (2.7–4.9) 5.4 (3.6–8.1) 4.7 (3.4–6.5) 4.0 (3.2–5.1) 480,000

Table 1. Percentage of middle and high school students who reported ever using tobacco products, by product,* overall and by school level, sex, and race and ethnicity — National Youth Tobacco Survey, United States, 2021

Abbreviation: e-cigarettes = electronic cigarettes.
*Ever use of e-cigarettes was determined by asking, "Have you ever used an e-cigarette, even once or twice?" Ever use of cigarettes was determined by asking, "Have you ever smoked a cigarette, even one or two puffs?" Ever use of cigars was determined by asking, "Have you ever smoked a cigar, cigarillo, or little cigar, even one or two puffs?" Smokeless tobacco was defined as use of chewing tobacco, snuff, or dip, snus, or dissolvable tobacco products. Ever use of smokeless tobacco was determined by asking the following questions: for chewing tobacco, snuff, and dip: "Have you ever used chewing tobacco, snuff, or dip, even just a small amount?"; for snus: "Have you ever used snus, even just one time?"; and for dissolvable tobacco products: "Have you ever used dissolvable tobacco products, even just one time?" Responses from these questions were combined to derive overall smokeless tobacco use. Ever use of hookahs was determined by asking, "Have you ever smoked tobacco in a hookah or water pipe, even one or two puffs?" Ever use of nicotine pouches was determined by asking, "Have you ever used a "nicotine pouch," even just one time?" Ever use of heated tobacco products was determined by asking, "Have you ever used a heated tobacco product, even just one time?" Ever use of pipe tobacco (not hookahs) was determined by asking, "Have you ever smoked pipes filled with tobacco (not hookah or water pipe), even just one time?" Because of missing data on the ever use questions, denominators for each tobacco product might be different. For each question, response options were "yes" or "no."
†Hispanic persons could be of any race.
§Estimated weighted total number of ever tobacco product users was rounded down to the nearest 10,000 persons. Overall estimates were reported among 20,413 U.S. middle and high school students. School level was determined by self-reported grade level: high school (grades 9–12; n = 10,515) and middle school (grades 6–8; n = 9,763). Overall estimates might not directly total to sums of corresponding subgroup estimates because of rounding or inclusion of students who did not self-report sex, race and ethnicity, or grade level.
¶Any tobacco product use was defined as ever use of any tobacco product (e-cigarettes, cigarettes, cigars [cigars, cigarillos, or little cigars], smokeless tobacco [chewing tobacco, snuff, or dip, snus, or dissolvable tobacco products], hookahs, pipe tobacco, heated tobacco products, nicotine pouches, or bidis [small brown cigarettes wrapped in a leaf]), even just one time.
**Data were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%.
††Any combustible tobacco product use was defined as ever use of cigarettes, cigars (cigars, cigarillos, or little cigars), hookahs, pipe tobacco, or bidis, even just one time.
§§Defined as ever use of two or more tobacco products (e-cigarettes, cigarettes, cigars [cigars, cigarillos, or little cigars], smokeless tobacco [chewing tobacco, snuff, or dip, snus, or dissolvable tobacco products], hookahs, pipe tobacco, heated tobacco products, nicotine pouches, or bidis), even just one time.

 

Characteristic Sex Race and ethnicity Total
Female Male White, non-Hispanic Black, non-Hispanic Hispanic Other, non-Hispanic
% (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) Estimated no. of users§
Overall
Any tobacco product 9.6 (8.4–11.0) 9.0 (7.9–10.3) 11.0 (9.5–12.8) 8.2 (6.5–10.2) 7.4 (6.4–8.7) 5.4 (3.6–8.1) 9.3 (8.3–10.5) 2,550,000
E-cigarettes 8.0 (6.8–9.4) 7.1 (6.1–8.3) 9.6 (8.2–11.4) 4.3 (3.1–6.0) 6.0 (4.9–7.2) 4.1 (2.7–6.2) 7.6 (6.6–8.7) 2,060,000
Cigarettes 1.5 (1.2–1.9) 1.5 (1.2–2.0) 1.8 (1.4–2.2) 1.0 (0.6–1.6) 1.5 (1.1–2.0) —** 1.5 (1.3–1.8) 410,000
Cigars 1.1 (0.8–1.4) 1.8 (1.5–2.1) 1.4 (1.1–1.8) 3.1 (2.4–4.1) 0.9 (0.7–1.2) 1.4 (1.2–1.7) 380,000
Smokeless tobacco 0.5 (0.3–0.7) 1.3 (1.0–1.8) 1.1 (0.8–1.5) 0.7 (0.5–1.0) 0.9 (0.7–1.2) 240,000
Hookahs 0.9 (0.6–1.4) 0.8 (0.6–1.0) 0.5 (0.4–0.7) 2.2 (1.4–3.4) 1.0 (0.6–1.5) 0.8 (0.7–1.1) 220,000
Nicotine pouches 0.5 (0.3–0.7) 1.0 (0.7–1.4) 0.9 (0.6–1.3) 0.7 (0.4–1.0) 0.8 (0.6–1.0) 200,000
Heated tobacco products 0.6 (0.4–0.8) 0.7 (0.5–1.0) 0.6 (0.5–0.9) 0.7 (0.4–1.3) 0.7 (0.4–1.1) 0.7 (0.5–0.8) 170,000
Pipe tobacco 0.3 (0.2–0.5) 0.3 (0.2–0.6) 0.4 (0.2–0.6) 0.3 (0.2–0.6) 0.3 (0.2–0.5) 80,000
Any combustible tobacco product†† 3.1 (2.6–3.8) 3.2 (2.8–3.7) 3.1 (2.6–3.7) 5.2 (4.1–6.6) 2.8 (2.3–3.4) 3.2 (2.8–3.6) 860,000
Two or more tobacco products§§ 2.4 (1.9–2.9) 3.0 (2.5–3.7) 3.1 (2.6–3.8) 3.0 (2.2–4.0) 2.2 (1.7–2.9) 2.7 (2.3–3.2) 740,000
High school (grades 9–12)
Any tobacco product 13.8 (11.9–16.0) 13.0 (11.2–15.1) 16.2 (14.1–18.6) 11.0 (8.7–13.9) 9.1 (7.4–11.1) 9.3 (6.3–13.6) 13.4 (11.8–15.2) 2,060,000
E-cigarettes 11.9 (10.0–14.0) 10.7 (9.1–12.6) 14.5 (12.4–16.8) 5.9 (4.2–8.2) 7.6 (6.0–9.6) 7.4 (4.9–10.9) 11.3 (9.7–13.0) 1,720,000
Cigarettes 1.8 (1.3–2.3) 2.0 (1.5–2.7) 2.2 (1.8–2.8) 1.6 (1.2–2.3) 1.9 (1.5–2.4) 280,000
Cigars 1.5 (1.1–2.1) 2.6 (2.1–3.3) 2.1 (1.6–2.6) 4.4 (3.3–5.9) 1.2 (0.8–1.6) 2.1 (1.7–2.6) 310,000
Smokeless tobacco 1.7 (1.2–2.4) 1.5 (1.0–2.1) 1.2 (0.8–1.6) 170,000
Hookahs 1.3 (0.8–2.0) 1.2 (0.9–1.5) 0.8 (0.5–1.1) 3.2 (1.9–5.2) 1.3 (0.8–2.3) 1.2 (0.9–1.6) 180,000
Nicotine pouches 0.6 (0.3–1.0) 1.6 (1.1–2.3) 1.4 (0.9–2.2) 1.1 (0.8–1.6) 160,000
Heated tobacco products 0.7 (0.5–1.2) 0.9 (0.6–1.4) 0.9 (0.6–1.3) 0.8 (0.6–1.1) 120,000
Pipe tobacco 0.5 (0.3–0.9) 0.4 (0.3–0.7) 60,000
Any combustible tobacco product 4.2 (3.3–5.2) 4.6 (3.8–5.4) 4.3 (3.5–5.1) 7.3 (5.5–9.6) 3.5 (2.7–4.5) 4.4 (3.8–5.1) 660,000
Two or more tobacco products 3.1 (2.4–4.0) 4.5 (3.6–5.6) 4.4 (3.7–5.4) 4.0 (2.8–5.7) 2.6 (2.0–3.5) 3.8 (3.2–4.6) 580,000
Middle school (grades 6–8)
Any tobacco product 4.4 (3.5–5.5) 3.6 (2.9–4.5) 3.4 (2.7–4.4) 4.5 (3.4–5.9) 5.3 (3.9–7.1) 2.2 (1.2–3.8) 4.0 (3.3–4.8) 470,000
E-cigarettes 3.2 (2.4–4.2) 2.3 (1.9–3.0) 2.6 (1.9–3.5) 2.3 (1.4–4.0) 3.9 (2.9–5.3) 2.8 (2.2–3.4) 320,000
Cigarettes 1.2 (0.8–1.8) 0.9 (0.6–1.4) 1.0 (0.7–1.5) 1.1 (0.6–1.9) 1.2 (0.7–1.9) 1.0 (0.8–1.4) 120,000
Cigars 0.5 (0.3–0.9) 0.6 (0.4–0.9) 0.5 (0.3–0.7) 1.4 (0.8–2.3) 0.6 (0.4–1.1) 0.6 (0.4–0.8) 60,000
Smokeless tobacco 0.8 (0.5–1.2) 0.5 (0.3–0.9) 0.6 (0.4–0.9) 60,000
Hookahs 0.4 (0.2–0.6) 40,000
Nicotine pouches 0.2 (0.1–0.3) 0.3 (0.2–0.5) 30,000
Heated tobacco products 0.4 (0.2–0.7) 0.4 (0.3–0.7) 0.4 (0.3–0.6) 40,000
Pipe tobacco 0.2 (0.1–0.3) 20,000
Any combustible tobacco product 1.9 (1.3–2.7) 1.4 (1.0–1.9) 1.4 (1.0–1.9) 2.4 (1.7–3.3) 1.9 (1.3–2.8) 1.6 (1.3–2.1) 190,000
Two or more tobacco products 1.5 (0.9–2.3) 1.1 (0.8–1.5) 1.2 (0.8–1.8) 1.6 (1.0–2.5) 1.6 (1.0–2.7) 1.3 (0.9–1.7) 150,000

Table 2. Percentage of middle and high school students who reported current (past 30-day) tobacco product use, by product,* overall and by school level, sex, and race and ethnicity — National Youth Tobacco Survey, United States, 2021

Abbreviation: e-cigarettes = electronic cigarettes.
*Past 30-day use of e-cigarettes was determined by asking, "During the past 30 days, on how many days did you use e-cigarettes?" 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, or dip, snus, or dissolvable tobacco products. Past 30-day use of smokeless tobacco was determined by asking, "During the past 30 days, on how many days did you use [chewing tobacco, snuff, or dip, snus, or dissolvable tobacco products]?" Responses from these questions were combined to derive overall smokeless tobacco use. Past 30-day use of hookahs was determined by asking, "During the past 30 days, on how many days did you smoke tobacco in a hookah or water pipe?" Past 30-day use of nicotine pouches was determined by asking, "During the past 30 days, on how many days did you use nicotine pouches?" Past 30-day use of heated tobacco products was determined by asking, "During the past 30 days, on how many days did you use heated tobacco products?" Past 30-day use of pipe tobacco (not hookahs) was determined by asking, "In the past 30 days, on how many days did you smoke pipes filled with tobacco?" Because of missing data on the past 30-day use questions, denominators for each tobacco product might be different. For each product, current use was defined as self-reported use on ≥1 day during the past 30 days.
†Hispanic persons could be of any race.
§Estimated weighted total number of current tobacco product users was rounded down to the nearest 10,000 persons. Overall estimates were reported among 20,413 U.S. middle and high school students. School level was determined by self-reported grade level: high school (grades 9–12; n = 10,515) and middle school (grades 6–8; n = 9,763). Overall estimates might not directly total to sums of corresponding subgroup estimates because of rounding or inclusion of students who did not self-report sex, race and ethnicity, or grade level.
¶Any tobacco product use was defined as use of any tobacco product (e-cigarettes, cigarettes, cigars [cigars, cigarillos, or little cigars], smokeless tobacco [chewing tobacco, snuff, or dip, snus, or dissolvable tobacco products], hookahs, pipe tobacco, heated tobacco products, nicotine pouches, or bidis [small brown cigarettes wrapped in a leaf]) on ≥1 day during the past 30 days.
**Data were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%.
††Any combustible tobacco product use was defined as use of cigarettes, cigars (cigars, cigarillos, or little cigars), hookahs, pipe tobacco, or bidis on ≥1 day during the past 30 days.
§§Defined as use of two or more tobacco products (e-cigarettes, cigarettes, cigars [cigars, cigarillos, or little cigars], smokeless tobacco [chewing tobacco, snuff, or dip, snus, or dissolvable tobacco products], hookahs, pipe tobacco, heated tobacco products, nicotine pouches, or bidis) on ≥1 day during the past 30 days.

 

Characteristic Ever use, any tobacco product Current use, any tobacco product
% (95% CI) Estimated no. of users % (95% CI) Estimated no. of users
Overall§
Sexual identity
Heterosexual 22.8 (20.7–25.0) 4,210,000 7.9 (7.0–9.0) 1,460,000
Gay, lesbian, or bisexual 35.4 (32.4–38.4) 1,220,000 14.2 (11.9–17.0) 490,000
Not sure 14.4 (11.8–17.5) 340,000 5.5 (4.2–7.3) 130,000
Transgender
No, not transgender 23.4 (21.3–25.7) 5,210,000 8.2 (7.3–9.3) 1,830,000
Yes, transgender 37.9 (31.3–45.0) 160,000 18.9 (13.8–25.4) 80,000
Not sure 26.4 (20.7–33.1) 180,000 9.1 (6.1–13.5) 60,000
I don't know what this question is asking 18.4 (14.7–22.8) 180,000 9.7 (6.9–13.4) 90,000
Psychological distress (PHQ-4 scale)
None 16.6 (14.7–18.8) 2,070,000 5.5 (4.7–6.3) 680,000
Mild 27.3 (25.0–29.7) 1,340,000 9.6 (8.3–11.1) 470,000
Moderate 29.3 (25.7–33.2) 910,000 11.2 (8.8–14.1) 340,000
Severe 37.8 (33.9–41.8) 1,110,000 14.2 (11.9–16.8) 410,000
Family affluence scale**
Low 24.4 (22.4–26.6) 1,490,000 9.2 (7.8–10.8) 560,000
Medium 22.3 (20.2–24.6) 2,400,000 7.7 (6.7–8.8) 820,000
High 24.0 (20.9–27.5) 1,760,000 8.8 (7.5–10.3) 640,000
Grades in school
Mostly As 18.3 (15.9–21.0) 1,980,000 5.5 (4.6–6.7) 590,000
Mostly Bs 25.7 (23.3–28.3) 1,770,000 9.6 (8.2–11.1) 650,000
Mostly Cs 31.3 (28.3–34.4) 910,000 13.2 (11.0–15.8) 380,000
Mostly Ds 36.7 (32.1–41.6) 360,000 15.6 (12.6–19.2) 150,000
Mostly Fs 41.7 (36.8–46.8) 350,000 17.3 (13.4–22.0) 140,000
Speak language other than English (home)
Yes 20.5 (18.4–22.8) 1,440,000 6.4 (5.5–7.3) 440,000
No 24.5 (22.1–27.1) 4,310,000 9.2 (8.1–10.5) 1,620,000
High school (grades 9–12)
Sexual identity
Heterosexual 31.6 (29.2–34.1) 3,420,000 11.4 (10.1–12.9) 1,230,000
Gay, lesbian, or bisexual 43.8 (40.1–47.6) 910,000 17.4 (14.2–21.1) 360,000
Not sure 26.8 (22.5–31.7) 240,000 10.2 (7.3–13.9) 90,000
Transgender
No, not transgender 32.7 (30.3–35.2) 4,190,000 11.7 (10.3–13.2) 1,490,000
Yes, transgender 45.6 (36.7–54.8) 110,000 24.5 (17.2–33.6) 60,000
Not sure 38.4 (29.3–48.3) 120,000 12.3 (6.8–21.4) 30,000
I don't know what this question is asking 30.9 (24.0–38.9) 140,000 17.9 (12.1–25.5) 80,000
Psychological distress (PHQ-4 scale)
None 25.4 (22.9–28.0) 1,680,000 8.3 (7.2–9.6) 550,000
Mild 37.1 (33.9–40.3) 1,100,000 13.6 (11.5–16.0) 400,000
Moderate 37.5 (32.6–42.6) 710,000 15.2 (11.7–19.5) 290,000
Severe 46.5 (42.5–50.5) 840,000 17.6 (14.5–21.2) 310,000
Family affluence scale
Low 33.2 (30.5–36.0) 1,170,000 12.7 (10.4–15.4) 440,000
Medium 31.4 (28.5–34.5) 1,930,000 11.2 (9.6–13.0) 680,000
High 34.9 (31.7–38.3) 1,400,000 12.8 (11.0–14.9) 510,000
Grades in school
Mostly As 27.8 (24.6–31.2) 1,680,000 8.5 (7.1–10.2) 510,000
Mostly Bs 35.4 (32.6–38.2) 1,420,000 13.7 (11.8–15.8) 550,000
Mostly Cs 40.7 (36.8–44.7) 710,000 17.9 (14.8–21.5) 310,000
Mostly Ds 42.6 (35.2–50.4) 250,000 18.4 (13.1–25.2) 100,000
Mostly Fs 48.3 (41.8–54.9) 260,000 19.6 (14.4–26.0) 100,000
Speak language other than English (home)
Yes 28.5 (25.7–31.4) 1,070,000 8.4 (6.7–10.4) 310,000
No 34.5 (32.0–37.1) 3,480,000 13.5 (11.9–15.2) 1,350,000
Middle school (grades 6–8)
Sexual identity
Heterosexual 10.0 (8.7–11.6) 760,000 3.0 (2.4–3.6) 220,000
Gay, lesbian, or bisexual 22.5 (18.8–26.6) 300,000 9.5 (7.1–12.5) 120,000
Not sure 6.8 (4.6–9.9) 100,000 2.6 (1.6–4.0) 30,000
Transgender
No, not transgender 10.6 (9.2–12.2) 990,000 3.5 (2.9–4.3) 330,000
Yes, transgender 27.8 (19.0–38.7) 50,000 ††
Not sure 16.7 (11.6–23.4) 60,000 6.5 (3.7–11.0) 20,000
I don't know what this question is asking 7.4 (5.0–10.9) 40,000 2.3 (1.4–3.9) 10,000
Psychological distress (PHQ-4 scale)
None 6.3 (5.3–7.5) 360,000 2.1 (1.6–2.7) 120,000
Mild 12.2 (10.0–14.8) 230,000 3.4 (2.5–4.5) 60,000
Moderate 16.4 (13.1–20.2) 190,000 4.9 (3.3–7.1) 50,000
Severe 24.1 (19.6–29.3) 270,000 8.8 (6.3–12.1) 90,000
Family affluence scale
Low 12.3 (10.4–14.5) 310,000 4.4 (3.6–5.4) 110,000
Medium 10.0 (8.3–11.9) 450,000 3.0 (2.2–4.0) 130,000
High 10.8 (8.8–13.1) 350,000 3.8 (2.9–4.9) 120,000
Grades in school
Mostly As 6.0 (4.8–7.3) 280,000 1.7 (1.2–2.4) 70,000
Mostly Bs 12.2 (10.0–14.9) 340,000 3.7 (2.7–5.0) 100,000
Mostly Cs 17.0 (13.9–20.7) 190,000 6.1 (4.5–8.3) 70,000
Mostly Ds 27.9 (21.4–35.5) 110,000 11.2 (7.6–16.1) 40,000
Mostly Fs 30.4 (22.0–40.4) 90,000 13.3 (9.1–19.1) 40,000
Speak language other than English (home)
Yes 11.1 (8.8–13.9) 350,000 3.8 (2.8–5.2) 120,000
No 10.9 (9.2–12.9) 810,000 3.6 (2.8–4.5) 260,000

Table 3. Percentage of middle and high school students who reported ever use or current (past 30-day) use of any tobacco product,* overall and by selected demographic characteristics and social determinant indicators — National Youth Tobacco Survey, United States, 2021

Abbreviations: e-cigarettes = electronic cigarettes; PHQ-4 = four-item Patient Health Questionnaire.
*Any tobacco product includes e-cigarettes, cigarettes, cigars (cigars, cigarillos, or little cigars), smokeless tobacco (chewing tobacco, snuff, or dip; snus; dissolvable tobacco products), hookahs, pipe tobacco, bidis (small brown cigarettes wrapped in a leaf), heated tobacco products and nicotine pouches. Ever use of any tobacco product was defined as self-reported ever use of any tobacco product, even just one time. Current use of any tobacco product was defined as self-reported use of any tobacco product on ≥1 day during the past 30 days.
Estimated weighted total numbers of ever and current tobacco product users were rounded down to the nearest 10,000 persons. Overall estimates might not directly total to sums of corresponding subgroup estimates by school level because of rounding or inclusion of students who did not self-report grade level.
§Overall estimates were reported among 20,413 U.S. middle and high school students. School level was determined by self-reported grade level: high school (grades 9–12; n = 10,515) and middle school (grades 6–8; n = 9,763).
A composite scale made up of four questions to assess psychological distress: "During the past two weeks, how often have you been bothered by any of the following problems?": 1) little interest or pleasure in doing things; 2) feeling down, depressed, or hopeless; 3) feeling nervous, anxious, or on edge; 4) not being able or stop or control worrying. Response options were provided with a numeric value [not at all = 0; several days = 1; more than half of the days = 2; and nearly every day = 3]. Responses were summed (range: 0–12) and categorized as none (0–2), mild (3–5), moderate (6–8) and severe (9–12). The PHQ–4 scale was reported among respondents who had complete data on all four questions (n = 17,355).
**A composite scale made up of four questions. Numeric values were assigned to each response and summed across responses: 1) "Does your family own a vehicle (such as a car, van, or truck)?" [no = 0; yes, one = 1; yes, two or more = 2]; 2) "Do you have your own bedroom?" [no = 0; yes = 1]; 3) "How many computers (including laptops and tablets, not including game consoles and smartphones) does your family own?" [none = 0; one= 1; two = 2; more than two = 3]; and 4) "During the past 12 months, how many times did you travel on vacation with your family?" [not at all = 0; once = 1; twice = 2; more than twice = 3]. Summed responses (range: 0–9) were categorized into approximate tertiles based on the weighted distribution of scores in this sample: low (0–5), medium (6–7), and high (8–9). The family affluence scale was reported among respondents who had complete data on all four questions (n = 17,878).
††Data were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%.

 

Characteristic 1–5 days 6–19 days 20–30 days
% (95% CI) Estimated no. of users§ % (95% CI) Estimated no. of users§ % (95% CI) Estimated no. of users§
Overall
E-cigarettes 44.5 (40.7–48.3) 910,000 16.2 (13.8–18.8) 330,000 39.4 (35.4–43.5) 810,000
Cigarettes 66.5 (57.8–74.3) 270,000 14.6 (10.4–20.1) 60,000 18.9 (13.6–25.7) 70,000
Cigars 67.1 (60.0–73.5) 250,000 12.2 (8.3–17.7) 40,000 20.7 (15.3–27.4) 80,000
Chewing tobacco, snuff, or dip 50.5 (40.1–60.9) 100,000 20.0 (13.8–28.0) 30,000 29.5 (22.4–37.9) 50,000
Snus 57.3 (41.7–71.6) 50,000 26.1 (15.5–40.6) 20,000
Hookahs 66.2 (57.1–74.3) 140,000 13.9 (9.0–20.9) 30,000 19.9 (14.0–27.5) 40,000
Pipe tobacco 65.3 (45.8–80.7) 50,000
Heated tobacco products 54.3 (42.9–65.3) 90,000 23.6 (15.3–34.7) 40,000 22.1 (13.7–33.5) 30,000
Nicotine pouches 63.5 (53.5–72.5) 120,000 19.3 (11.7–30.1) 30,000 17.2 (11.3–25.3) 30,000
High school (grades 9–12)
E-cigarettes 40.2 (36.0–44.5) 690,000 16.3 (13.5–19.5) 280,000 43.6 (39.0–48.2) 750,000
Cigarettes 66.9 (56.5–75.9) 190,000 13.3 (8.7–19.7) 30,000 19.9 (13.8–27.6) 50,000
Cigars 67.3 (59.0–74.6) 210,000 12.0 (7.7–18.3) 30,000 20.7 (14.6–28.5) 60,000
Chewing tobacco, snuff, or dip 47.6 (34.8–60.6) 60,000 22.2 (14.2–33.0) 30,000 30.3 (21.8–40.2) 40,000
Snus
Hookahs 68.2 (57.5–77.3) 120,000 14.7 (9.3–22.6) 20,000 17.0 (11.0–25.5) 30,000
Pipe tobacco
Heated tobacco products 55.6 (41.7–68.7) 60,000 19.7 (12.2–30.3) 20,000 24.7 (13.6–40.6) 30,000
Nicotine pouches 64.1 (52.1–74.6) 100,000 21.0 (12.2–33.5) 30,000 15.0 (9.1–23.7) 20,000
Middle school (grades 6–8)
E-cigarettes 66.7 (60.0–72.8) 210,000 16.1 (11.3–22.6) 50,000 17.2 (12.8–22.6) 50,000
Cigarettes 68.0 (56.1–77.9) 80,000 14.8 (8.2–25.1) 10,000 17.2 (9.3–29.8) 20,000
Cigars 66.7 (51.3–79.1) 40,000 20.1 (10.8–34.4) 10,000
Chewing tobacco, snuff, or dip 57.6 (43.2–70.7) 30,000 28.0 (16.0–44.3) 10,000
Snus
Hookahs
Pipe tobacco
Heated tobacco products 51.0 (30.1–71.5) 20,000
Nicotine pouches

Table 4. Frequency of use* among middle and high school students currently (past 30-day) using each tobacco product,† overall and by school level — National Youth Tobacco Survey, United States, 2021

Abbreviation: e-cigarettes = electronic cigarettes.
*Frequency of current use of e-cigarettes; cigarettes; cigars (cigars, cigarillos, or little cigars); chewing tobacco, snuff, or dip; snus; dissolvable tobacco products; pipe tobacco; hookahs; heated tobacco products; and nicotine pouches was determined by asking respondents on how many days they smoked or used each respective tobacco product during the past 30 days. Respondents could enter a valid response of 0–30 days. Responses were recoded as 1–5 days, 6–19 days, and 20–30 days.
Estimates of frequency of use of dissolvable tobacco products are statistically unreliable (overall and by school level) and are omitted from the table.
§Estimated weighted total number of users was rounded down to the nearest 10,000 persons. Overall estimates might not directly total to sums of corresponding subgroup estimates because of rounding or inclusion of students who did not self-report grade level.
Data were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%.

 

Characteristic Tobacco product
Any tobacco§ % (95% CI) E-cigarettes % (95% CI) Cigarettes % (95% CI) Cigars % (95% CI) Smokeless tobacco** % (95% CI) Hookahs % (95% CI) Pipe tobacco % (95% CI) Heated tobacco products % (95% CI) Nicotine pouches % (95% CI)
Overall
Flavored tobacco product use among all students†† 7.2 (6.2–8.2) 6.2 (5.3–7.3) 0.6 (0.4–0.8) 0.6 (0.5–0.8) 0.6 (0.5–0.9) 0.4 (0.3–0.5) 0.1 (0.1–0.2) 0.3 (0.2–0.4) 0.5 (0.3–0.7)
Current use
Estimated weighted no. of flavored tobacco product users§§ 1,950,000 1,680,000 150,000 160,000 170,000 100,000 30,000 70,000 120,000
Flavored tobacco product use among current tobacco users¶¶ 79.1 (76.0–81.9) 84.7 (81.4–87.5) 38.8 (32.3–45.7) 44.4 (36.9–52.1) 70.1 (60.8–77.9) 46.6 (38.3–55.2) 34.4 (20.1–52.1) 44.0 (34.0–54.5) 61.6 (49.7–72.2)
School level
High school (grades 9–12) 80.2 (76.8–83.3) 85.8 (82.3–88.7) 41.1 (33.2–49.5) 41.1 (32.9–49.7) 72.1 (60.3–81.5) 42.9 (33.1–53.3) —*** 41.0 (27.8–55.7) 63.9 (50.1–75.7)
Middle school (grades 6–8) 74.6 (67.5–80.6) 79.2 (69.1–86.6) 34.8 (24.9–46.3) 59.9 (46.5–72.0) 65.5 (50.9–77.6) 51.5 (35.2–67.4)
Sex
Female 84.3 (80.2–87.7) 88.8 (85.1–91.6) 41.8 (32.5–51.8) 55.8 (43.3–67.6) 61.9 (44.3–76.8) 52.2 (39.5–64.6) 55.1 (37.6–71.4)
Male 74.1 (70.0–77.8) 80.5 (75.7–84.6) 37.0 (28.5–46.4) 38.2 (29.9–47.3) 72.6 (61.0–81.8) 40.4 (29.5–52.4) 35.5 (21.1–53.1) 60.3 (45.0–73.8)
Race and ethnicity
White, non-Hispanic 82.9 (79.4–85.9) 86.5 (82.5–89.7) 38.2 (29.4–47.7) 43.6 (34.8–52.8) 75.7 (62.9–85.2) 36.0 (21.6–53.4) 37.7 (23.8–54.0) 65.2 (48.7–78.7)
Black, non-Hispanic 66.2 (58.8–72.8) 76.3 (61.8–86.6) 46.3 (33.6–59.4) 50.4 (36.0–64.8)
Hispanic††† 76.4 (71.2–80.9) 83.6 (78.0–88.0) 28.6 (19.4–40.1) 45.3 (29.0–62.7)
Other, non-Hispanic 79.4 (67.1–87.9) 86.6 (72.3–94.2)

Table 5. Flavored tobacco product* use among middle and high school students overall and among those who reported current (past 30-day) use† of each tobacco product, by school level, sex, and race and ethnicity — National Youth Tobacco Survey, United States, 2021

Abbreviation: e-cigarettes = electronic cigarettes.
*For each respective tobacco product excluding cigarettes, current (past 30-day) users were asked, "Were any of the [tobacco product] that you used in the past 30 days flavored to taste like menthol, mint, clove or spice, alcohol (wine, cognac), candy, fruit, chocolate, or any other flavor?" Response options were "yes," "no," or "don't know." Those who responded yes were considered flavored tobacco product users.
Reported among respective current (past 30-day) users for each product. Past 30-day use of e-cigarettes was determined by asking, "During the past 30 days, on how many days did you use e-cigarettes?" 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?" Past 30-day use of smokeless tobacco was determined by asking the following question for use of chewing tobacco, snuff, and dip: "During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip?" Past 30-day use of snus was determined by asking the following question for use of snus: "During the past 30 days, on how many days did you use snus?" Past 30-day use of dissolvable tobacco products was determined by asking the following question for use of dissolvable tobacco products: "During the past 30 days, on how many days did you use dissolvable tobacco products?" Past 30-day use of pipe tobacco was determined by asking the following question for use of pipe tobacco: "During the past 30 days, on how many days did you smoke pipes filled with tobacco?" Past 30-day use of hookahs was determined by asking, "During the past 30 days, on how many days did you smoke tobacco in a hookah or water pipe?" Past 30-day use of heated tobacco products was determined by asking the following question for use of heated tobacco products: "During the past 30 days, on how many days did you use heated tobacco products?" Past 30-day use of nicotine pouches was determined by asking the following question for use of heated tobacco products: "During the past 30 days, on how many days did you use nicotine pouches?"
§Any tobacco use includes use of e-cigarettes, cigarettes, cigars (cigars, cigarillos, or little cigars), smokeless tobacco (chewing tobacco, snuff, or dip; snus; dissolvable tobacco products), hookahs, pipe tobacco, bidis (small brown cigarettes wrapped in a leaf), heated tobacco products, and nicotine pouches on ≥1 day during the past 30 days.
Flavored cigarette use refers to menthol cigarette use. Current cigarette smokers were categorized as flavored (menthol) cigarette smokers: if they responded "yes" to the question, "Menthol cigarettes are cigarettes that taste like mint. During the past 30 days, were the cigarettes that you usually smoked menthol?"; or if they indicated "Kool" or "Newport" as a brand they usually smoked in the past 30 days. Usual brand was determined based on responses to two questions: 1) "During the past 30 days, what brands of cigarettes did you smoke? (Select one or more)" and 2) "During the past 30 days, what brand of cigarettes did you usually smoke? (Choose only one answer)." If "Kool" or "Newport" was the only brand selected for the first question, or if multiple brands were selected in the first question and "Kool" or "Newport" was selected for the second question, "Kool" or "Newport" was considered the respondent's usual brand. Those who selected "some other brand(s) not listed here" could provide a write-in response; write-in responses corresponding to an original response option were recoded. Those who reported "no" or "not sure" to the menthol question or those who did not report "Newport" or "Kool" as their usual brand were categorized as nonmenthol smokers; all other past 30-day cigarette smokers who did not provide any valid response were assigned as missing menthol smoking status.
**Flavored tobacco product use was assessed separately among current (past 30-day) users of chewing tobacco, snuff, or dip; snus; and dissolvable tobacco product users. Flavored use was then recoded as a composite among users of any current smokeless tobacco product combined.
††Calculated among all respondents regardless of tobacco product use status. Because of missing data, denominators for each tobacco product might be different: any tobacco (n = 20,167), e-cigarettes (n = 20,084), cigarettes (n = 19,936), cigars (n = 19,860), smokeless tobacco [chewing tobacco, snuff, or dip; snus; dissolvable tobacco products] (n = 19,778), hookahs (n = 19,697), pipe tobacco (n = 19,655), heated tobacco products (n = 19,501), and nicotine pouches (n = 19,500).
§§Estimated weighted total number of flavored tobacco product users was rounded down to the nearest 10,000 persons.
¶¶Calculated among current users of any tobacco (n =1,792), e-cigarettes (n = 1,383), cigarettes (n = 314), cigars (n = 299), smokeless tobacco (n = 210), hookahs (n = 168), pipe tobacco (n = 64), heated tobacco products (n = 133), and nicotine pouches (n = 137).
***Data were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%.
†††Hispanic persons could be of any race.

 

Characteristic Among ever e-cigarette users Among current e-cigarette users
% (95% CI) Estimated no. of users§ % (95% CI) Estimated no. of users§
Overall
A friend [used/uses] them 57.8 (55.0–60.4) 2,990,000 28.3 (25.4–31.5) 560,000
I [was/am] curious about them 47.6 (45.4–49.9) 2,460,000 10.3 (8.5–12.6) 200,000
I [was/am] feeling anxious, stressed, or depressed 25.1 (23.0–27.4) 1,300,000 43.4 (39.4–47.4) 860,000
To get a high or buzz from nicotine 23.3 (21.5–25.2) 1,200,000 42.8 (38.4–47.4) 850,000
A family member [used/uses] them 18.6 (16.5–20.9) 960,000 8.7 (7.0–10.8) 170,000
I [could/can] use them to do tricks 16.5 (14.5–18.7) 850,000 20.0 (17.5–22.7) 390,000
They [were/are] available in flavor, such as menthol, mint, candy, fruit, or chocolate 13.5 (12.0–15.0) 690,000 13.2 (11.1–15.6) 260,000
I [could/can] use them unnoticed at home or at school 10.8 (9.5–12.4) 560,000 13.0 (10.9–15.3) 250,000
They are less harmful than other forms of tobacco, such as cigarettes 8.3 (7.1–9.6) 420,000 10.3 (8.3–12.7) 200,000
They [were/are] easier to get that other tobacco products, such as cigarettes 4.8 (3.8–6.0) 240,000 6.0 (4.7–7.7) 120,000
I've seen people on TV, online, or in movies use them 4.5 (3.7–5.6) 230,000 2.9 (2.1–4.0) 50,000
To try to quit using other tobacco products, such as cigarettes 2.5 (1.9–3.4) 130,000 4.6 (3.5–6.1) 90,000
They cost less than other tobacco products, such as cigarettes 2.2 (1.6–2.9) 110,000 4.7 (3.4–6.6) 90,000
Some other reason 10.6 (9.2–12.1) 540,000 19.5 (16.9–22.5) 380,000
High school (grades 9–12)
A friend [used/uses] them 60.6 (57.7–63.4) 2,630,000 27.6 (24.6–30.8) 460,000
I [was/am] curious about them 47.2 (44.7–49.7) 2,050,000 9.0 (7.0–11.5) 150,000
I [was/am] feeling anxious, stressed, or depressed 24.5 (22.0–27.2) 1,060,000 43.2 (38.5–48.1) 720,000
To get a high or buzz from nicotine 24.9 (22.9–26.9) 1,080,000 45.3 (40.4–50.3) 750,000
A family member [used/uses] them 16.0 (13.9–18.4) 690,000 6.3 (4.8–8.3) 100,000
I [could/can] use them to do tricks 16.4 (14.2–18.8) 710,000 19.5 (16.9–22.5) 320,000
They [were/are] available in flavor, such as menthol, mint, candy, fruit, or chocolate 13.2 (11.7–14.8) 570,000 13.2 (11.1–15.7) 220,000
I [could/can] use them unnoticed at home or at school 11.2 (9.6–13.0) 480,000 13.9 (11.7–16.5) 230,000
They are less harmful than other forms of tobacco, such as cigarettes 8.3 (7.2–9.6) 360,000 10.3 (8.2–13.0) 170,000
They [were/are] easier to get that other tobacco products, such as cigarettes 4.5 (3.4–6.0) 190,000 5.5 (4.1–7.3) 90,000
I've seen people on TV, online, or in movies use them 4.4 (3.5–5.6) 190,000 2.5 (1.7–3.6) 40,000
To try to quit using other tobacco products, such as cigarettes 2.3 (1.6–3.3) 100,000 4.1 (2.9–5.9) 60,000
They cost less than other tobacco products, such as cigarettes 1.9 (1.3–2.7) 80,000 4.1 (2.8–6.1) 60,000
Some other reason 9.0 (7.6–10.7) 390,000 19.0 (16.1–22.4) 310,000
Middle school (grades 6–8)
A friend [used/uses] them 42.6 (37.8–47.7) 340,000 31.7 (24.1–40.4) 90,000
I [was/am] curious about them 49.4 (44.1–54.9) 400,000 17.8 (13.4–23.3) 50,000
I [was/am] feeling anxious, stressed, or depressed 28.1 (24.6–31.9) 230,000 45.0 (38.8–51.4) 140,000
To get a high or buzz from nicotine 14.5 (11.0–19.0) 110,000 29.2 (22.7–36.6) 90,000
A family member [used/uses] them 32.0 (28.2–36.1) 260,000 21.0 (15.9–27.2) 60,000
I [could/can] use them to do tricks 16.3 (12.9–20.4) 130,000 22.2 (15.3–31.1) 60,000
They [were/are] available in flavor, such as menthol, mint, candy, fruit, or chocolate 14.2 (10.8–18.5) 110,000 12.1 (7.8–18.1) 30,000
I [could/can] use them unnoticed at home or at school 8.3 (6.0–11.4) 60,000 8.1 (4.7–13.7) 20,000
They are less harmful than other forms of tobacco, such as cigarettes 7.7 (5.4–10.9) 60,000 10.0 (6.3–15.7) 30,000
They [were/are] easier to get that other tobacco products, such as cigarettes 6.0 (3.9–9.0) 40,000 7.8 (4.7–12.6) 20,000
I've seen people on TV, online, or in movies use them 4.9 (3.5–6.7) 30,000
To try to quit using other tobacco products, such 6.0 (3.4–10.5) 10,000
They cost less than other tobacco products, such as cigarettes 7.5 (4.3–12.9) 20,000
Some other reason 18.4 (15.1–22.3) 150,000 22.0 (14.9–31.1) 60,000

Table 6. Reasons for first e-cigarette use* among middle and high school students who reported ever using e-cigarettes, and reasons for current (past 30-day) e-cigarette use† among middle and high school students who reported currently using e-cigarettes, overall and by school level — National Youth Tobacco Survey, United States, 2021

Abbreviations: e-cigarettes = electronic cigarettes; TV = television.
*Responses to the question, "Why did you first use an e-cigarette? (Select one or more)" were assessed among students who reported "yes" to the question, "Have you ever used an e-cigarette, even once or twice?" Respondents indicating "some other reason" could specify through write-in option; write-ins were not examined in this report (n = 275).
Responses to the question, "Why did you currently use e-cigarettes? (Select one or more)" were assessed among students who reported using e-cigarettes on 1–30 days, from the question, "During the past 30 days, on how many days did you use e-cigarettes? Respondents indicating "some other reason" could specify through write-in option; write-ins were not examined in this report (n = 195).
§Estimated weighted total numbers of ever and current e-cigarette users were rounded down to the nearest 10,000 persons. Overall estimates might not directly total to sums of corresponding subgroup estimates because of rounding or inclusion of students who did not self-report grade level.
Data were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%.

 

Access to each tobacco product Tobacco product
Any tobacco§ % (95% CI) E-cigarettes % (95% CI) Cigarettes % (95% CI) Cigars % (95% CI) Smokeless tobacco % (95% CI) Hookahs % (95% CI) Pipe tobacco % (95% CI) Heated tobacco products % (95% CI) Nicotine pouch % (95% CI)
How did you get your [tobacco product]?
I got them from a friend 32.8 (29.7–36.0) 32.3 (28.7–36.2) 18.4 (13.5–24.7) 22.1 (16.2–29.2) 26.3 (18.5–35.9) 23.9 (16.8–33.0) —** 23.4 (12.8–39.0) 22.7 (14.9–33.0)
I bought them myself 31.3 (28.5–34.2) 31.1 (27.4–35.0) 22.0 (16.3–29.0) 29.8 (23.4–37.0) 24.1 (17.6–32.1) 18.3 (12.8–25.5) 14.6 (8.8–23.2)
I had someone else buy them for me 28.8 (26.0–31.8) 28.7 (25.7–31.8) 13.6 (9.4–19.1) 23.7 (17.7–31.1) 26.8 (19.8–35.3) 15.7 (9.9–24.2) 24.5 (14.8–37.7) 17.7 (11.2–27.0)
Someone offered them to me 26.3 (23.1–29.7) 21.7 (19.2–24.4) 16.4 (10.7–24.2) 22.8 (17.3–29.4) 27.8 (19.5–37.9) 26.5 (18.8–35.8) 32.0 (19.5–47.8) 23.7 (15.6–34.2) 24.6 (17.2–33.9)
I asked someone to give me some 19.4 (16.6–22.6) 16.3 (13.8–19.2) 20.2 (14.6–27.3) 14.3 (8.9–22.2) 23.6 (15.4–34.4) 22.1 (13.0–35.0) 22.8 (12.2–38.6) 13.3 (7.1–23.3)
I got them from a family member 14.5 (12.3–17.1) 10.2 (8.2–12.6) 17.5 (12.7–23.6) 16.7 (12.1–22.6) 20.5 (13.7–29.5) 19.5 (11.9–30.3) 15.8 (8.5–27.7)
I took them from a store or another person 6.0 (4.6–7.7) 3.3 (2.4–4.6) 12.2 (8.0–18.2) 6.5 (3.8–10.7) 9.2 (5.2–15.7)
I got them in some other way 21.3 (19.0–23.8) 15.7 (13.1–18.6) 21.8 (16.3–28.5) 22.7 (16.6–30.3) 23.5 (16.7–31.9) 24.6 (17.5–33.3) 23.4 (15.3–34.1) 27.5 (20.1–36.5) 20.6 (11.7–33.8)
Where did you buy your [tobacco product]?
I did not buy them 48.6 (45.9–51.4) 37.2 (34.2–40.3) 48.0 (40.9–55.2) 33.2 (26.1–41.1) 33.4 (24.2–44.0) 54.2 (45.7–62.5) 37.0 (25.0–50.8) 33.2 (24.2–43.5) 34.3 (24.3–46.0)
Bought them from another person (friend, family member, someone else) 22.5 (19.4–26.1) 21.5 (18.2–25.2) 14.7 (10.3–20.5) 13.4 (9.2–19.0) 21.0 (14.4–29.4) 23.6 (13.2–38.6) 24.2 (15.5–35.8) 13.9 (7.9–23.3)
A vape shop or tobacco shop 20.2 (16.8–24.0) 22.2 (18.3–26.6) 7.0 (4.1–11.7) 12.2 (8.2–17.8)
A gas station, convenience store 19.6 (16.9–22.7) 17.7 (14.4–21.5) 17.1 (12.1–23.6) 34.1 (26.2–42.9) 17.9 (11.2–27.3) 8.5 (4.7–15.0)
A drugstore 4.8 (3.5–6.5) 3.7 (2.6–5.4) 5.0 (2.8–8.8)
A grocery store 4.8 (3.6–6.4) 2.6 (1.6–4.0) 5.3 (3.0–9.1) 10.3 (5.8–17.7)
Through the mail 3.6 (2.4–5.4) 2.2 (1.3–3.8) 6.7 (3.7–11.9)
On the Internet 3.5 (2.5–4.8) 2.9 (1.9–4.5)
A mall or shopping center kiosk or stand 3.2 (2.1–4.9) 1.7 (1.0–2.8)
A vending machine 2.9 (2.1–4.2) 1.8 (1.2–2.8) 6.9 (3.7–12.2)
Through a delivery service 2.4 (1.6–3.5) 1.6 (0.9–2.5)
Some other place 15.8 (13.8–18.1) 12.3 (10.5–14.4) 17.9 (12.6–24.8) 14.5 (9.6–21.3) 22.2 (16.3–29.3) 18.9 (11.0–30.4) 19.8 (13.2–28.7) 21.5 (13.0–33.4)

Table 7. Access to tobacco products*,† among middle and high school students who reported current (past 30-day) use of each tobacco product — National Youth Tobacco Survey, United States, 2021

Abbreviation: e-cigarettes = electronic cigarettes.
*"During the past 30 days, how did you get your [e-cigarette devices, pods, cartridges, or e-liquid refills; cigarettes; cigars, cigarillos, or little cigars; chewing tobacco, snuff, or dip; hookahs; pipe tobacco; snus; dissolvable tobacco products; heated tobacco products; nicotine pouches]? (Select one or more)."
"During the past 30 days, where did you buy your [e-cigarette devices, pods, cartridges, or e-liquid refills; cigarettes; cigars, cigarillos, or little cigars; chewing tobacco, snuff, or dip; hookahs; pipe tobacco; snus; dissolvable tobacco products; heated tobacco products; nicotine pouches]
§Any tobacco use includes use of e-cigarettes, cigarettes, cigars (cigars, cigarillos, or little cigars), smokeless tobacco (chewing tobacco, snuff, or dip; snus; or dissolvable tobacco products), hookahs, pipe tobacco, bidis (small brown cigarettes wrapped in a leaf), heated tobacco products and nicotine pouches on ≥1 day during the past 30 days.
Access ("how did you get …" and "where did you buy …") during the past 30 days was assessed separately for smokeless tobacco products (chewing tobacco, snuff, or dip; snus; or dissolvable tobacco products). Access was then recoded as a smokeless composite among students who reported past 30-day use of one or more smokeless tobacco product.
**Data were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%.

 

Characteristic Sex Race and ethnicity Total
Male % (95% CI) Female % (95% CI) White, non-Hispanic % (95% CI) Black, non-Hispanic % (95% CI) Hispanic % (95% CI) Other, non-Hispanic % (95% CI)
% (95% CI) Estimated no.§
Overall
One or more 78.3 (76.5–79.9) 71.9 (70.3–73.5) 79.2 (77.6–80.8) 75.8 (73.2–78.3) 69.8 (67.7–71.7) 67.6 (62.4–72.3) 75.2 (73.7–76.6) 19,560,000
The Real Cost 65.0 (62.7–67.3) 56.5 (54.4–58.5) 66.5 (64.5–68.6) 54.9 (51.3–58.4) 55.0 (52.9–57.1) 54.8 (49.0–60.5) 60.9 (58.9–62.8) 15,830,000
Truth 41.7 (39.4–43.9) 37.7 (35.8–39.6) 43.9 (41.5–46.3) 38.2 (34.7–41.8) 35.9 (34.2–37.6) 29.9 (26.6–33.5) 39.7 (37.9–41.6) 10,200,000
Tips, Tips from Former Smokers 19.9 (18.6–21.2) 19.7 (18.5–21.1) 21.8 (20.4–23.2) 20.8 (18.3–23.5) 16.9 (15.7–18.2) 16.5 (12.9–20.9) 19.8 (18.7–20.9) 5,080,000
Fresh Empire 7.5 (5.5–10.1) 6.3 (5.5–7.3) 5.4 (4.1–7.0) 17.6 (13.9–21.9) 5.9 (5.1–6.9) 4.7 (3.1–7.0) 6.9 (5.7–8.4) 1,780,000
This Free Life 5.0 (4.4–5.6) 4.5 (3.9–5.3) 4.7 (3.9–5.5) 5.8 (4.6–7.2) 4.7 (3.9–5.6) 4.7 (3.2–6.8) 4.8 (4.3–5.3) 1,220,000
Some other advertisement 12.0 (11.0–13.0) 11.3 (10.4–12.3) 11.0 (10.0–12.0) 13.7 (11.9–15.6) 12.2 (11.2–13.3) 10.6 (8.5–13.1) 11.7 (11.0–12.4) 2,990,000
High school (grades 9–12)
One or more 82.4 (80.4–84.3) 76.1 (73.9–78.2) 84.1 (82.5–85.5) 78.0 (74.6–81.1) 71.3 (68.4–74.1) 74.0 (68.2–79.0) 79.4 (77.7–81.1) 11,570,000
The Real Cost 69.4 (66.6–72.1) 61.7 (59.2–64.2) 71.9 (69.5–74.2) 56.6 (52.4–60.6) 57.9 (55.4–60.3) 61.3 (52.6–69.3) 65.8 (63.4–68.0) 9,560,000
Truth 48.4 (45.7–51.0) 44.2 (41.8–46.7) 51.4 (49.1–53.7) 40.8 (36.3–45.5) 40.3 (37.5–43.1) 37.0 (30.7–43.8) 46.4 (44.1–48.7) 6,680,000
Tips, Tips from Former Smokers 21.7 (20.0–23.5) 20.2 (18.3–22.2) 23.2 (21.5–25.0) 21.6 (18.1–25.5) 17.5 (15.7–19.4) 14.3 (10.2–19.7) 21.0 (19.6–22.5) 3,020,000
Fresh Empire 10.1 (7.0–14.3) 7.5 (6.2–8.9) 6.7 (4.9–9.2) 22.8 (17.3–29.4) 7.1 (5.7–8.8) 6.2 (3.9–9.6) 8.8 (6.9–11.2) 1,270,000
This Free Life 5.2 (4.4–6.0) 4.7 (3.9–5.7) 4.6 (3.8–5.6) 5.0 (3.8–6.6) 5.4 (4.4–6.6) 6.1 (4.1–9.0) 4.9 (4.4–5.6) 710,000
Some other advertisement 10.7 (9.6–12.0) 8.6 (7.6–9.8) 9.0 (7.9–10.3) 12.3 (9.9–15.2) 10.0 (8.7–11.6) 10.1 (6.9–14.5) 9.7 (8.9–10.6) 1,400,000
Middle school (grades 6–8)
One or more 72.9 (70.6–75.0) 66.8 (64.7–68.8) 72.4 (70.1–74.6) 73.1 (69.2–76.7) 68.0 (65.1–70.6) 62.2 (55.8–68.2) 69.8 (68.0–71.6) 7,940,000
The Real Cost 59.5 (56.5–62.4) 50.1 (47.4–52.8) 59.0 (56.5–61.5) 52.8 (46.4–59.1) 51.8 (47.7–55.8) 49.4 (43.5–55.3) 54.8 (52.4–57.3) 6,250,000
Truth 32.9 (30.9–34.9) 29.6 (27.8–31.5) 33.0 (30.8–35.2) 34.6 (30.5–38.8) 30.8 (28.3–33.3) 23.8 (20.2–27.8) 31.2 (29.7–32.8) 3,490,000
Tips, Tips from Former Smokers 17.5 (16.0–19.1) 19.2 (17.9–20.6) 19.7 (18.0–21.5) 19.8 (16.8–23.1) 16.3 (14.6–18.0) 18.5 (14.7–23.0) 18.3 (17.1–19.5) 2,040,000
Fresh Empire 4.1 (3.4–5.0) 5.0 (4.0–6.1) 3.4 (2.6–4.6) 10.5 (7.8–14.1) 4.6 (3.4–6.0) 4.5 (3.8–5.3) 500,000
This Free Life 4.7 (3.8–5.8) 4.4 (3.4–5.5) 4.7 (3.5–6.3) 6.8 (4.9–9.5) 3.9 (3.0–4.9) 4.5 (3.8–5.4) 500,000
Some other advertisement 13.6 (12.1–15.1) 14.6 (13.4–16.0) 13.7 (12.3–15.2) 15.6 (13.4–18.1) 14.6 (13.0–16.4) 11.0 (9.1–13.3) 14.1 (13.2–15.0) 1,580,000

Table 8. Recognition of public education campaign advertisements against tobacco product use in the past 12 months* among middle and high school students, overall and by school level — National Youth Tobacco Survey, United States, 2021

Abbreviation: e-cigarettes = electronic cigarettes.
*All respondents were asked, "In the past 12 months, have you seen or heard "The Real Cost," on television, the internet, social media, or radio as part of ads about tobacco?" Response options included "yes," "no," and "not sure." Those who selected "yes" were considered to have recognized the advertisement. Additionally, all respondents were asked, "In the past 12 months, have you seen or heard any other ads against tobacco with the following names or slogans on television, the internet, social media, or on the radio? (Select one or more)." Response options included : "Truth," "Tips or Tips from Former Smokers," "Fresh Empire," "This Free Life," "some other ad"; or exclusively select "I haven't seen or heard any of these ads." A composite of having recognized at least one ad was also assessed. Those who indicated "some other ad" could specify with a write-in response; analysis of these write-in responses (n = 892) was not included in this report.
Hispanic persons could be of any race.
§Estimated weighted total number of flavored tobacco product users was rounded down to the nearest 10,000 persons. Overall estimates might not directly total to sums of corresponding subgroup estimates because of rounding or inclusion of students who did not self-report grade level.
Data were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%.

 

Characteristic Retail stores % (95% CI) Internet§ % (95% CI) Television, streaming services, or movies % (95% CI) Newspapers or magazines** % (95% CI) Any source†† % (95% CI)
Prevalence of exposure to any tobacco product marketing (e-cigarettes, cigarettes, and other tobacco products)
Overall 65.4 (63.6–67.1) 43.9 (42.3–45.4) 30.3 (28.9–31.8) 34.0 (32.6–35.4) 75.7 (74.3–77.0)
Estimated no.§§ 16,240,000 11,050,000 7,460,000 4,830,000 19,210,000
Sex
Male 64.2 (62.3–66.1) 40.9 (39.2–42.6) 27.4 (25.9–29.0) 33.4 (31.5–35.3) 73.2 (71.7–74.8)
Female 66.6 (64.6–68.6) 46.9 (45.3–48.6) 33.3 (31.6–34.9) 34.6 (32.8–36.4) 78.3 (76.8–79.8)
Race and ethnicity
White, non-Hispanic 69.9 (67.7–71.9) 42.8 (40.6–45.0) 27.8 (26.0–29.8) 33.1 (31.1–35.0) 78.1 (76.5–79.6)
Black, non-Hispanic 61.7 (59.2–64.1) 49.2 (47.0–51.3) 39.7 (36.5–43.1) 36.2 (33.4–39.2) 76.0 (73.7–78.3)
Hispanic¶¶ 61.3 (59.6–63.0) 45.0 (42.9–47.0) 31.9 (30.0–33.8) 35.0 (32.7–37.3) 73.9 (72.3–75.3)
Other, non-Hispanic 53.9 (50.4–57.5) 40.6 (36.0–45.3) 27.7 (24.5–31.1) 34.1 (28.9–39.7) 66.0 (62.3–69.5)
School level
High school (grades 9–12) 69.7 (67.4–71.9) 45.8 (43.8–47.8) 32.6 (30.4–34.9) 35.6 (33.7–37.5) 79.6 (78.0–81.1)
Middle school (grades 6–8) 59.8 (57.7–61.9) 41.2 (39.3–43.2) 27.3 (25.5–29.2) 31.6 (29.5–33.8) 70.7 (69.1–72.3)
Exposure to e-cigarette marketing***
Overall 58.7 (56.9–60.5) 36.0 (34.8–37.2) 21.7 (20.5–23.0) 28.7 (27.2–30.1) 70.3 (68.8–71.7)
Estimated no. 14,370,000 8,970,000 5,240,000 3,500,000 17,770,000
Sex
Male 57.5 (55.6–59.4) 33.7 (32.3–35.1) 19.8 (18.5–21.2) 28.3 (26.3–30.4) 67.7 (66.1–69.3)
Female 60.0 (57.9–62.0) 38.4 (37.0–39.8) 23.6 (22.2–25.0) 29.1 (27.2–31.0) 73.0 (71.3–74.6)
Race and ethnicity
White, non-Hispanic 63.6 (61.5–65.7) 35.9 (34.2–37.6) 19.3 (17.7–21.1) 27.7 (25.8–29.7) 73.1 (71.4–74.7)
Black, non-Hispanic 52.4 (49.8–55.0) 38.6 (36.7–40.5) 30.4 (27.7–33.2) 30.6 (27.2–34.3) 70.4 (68.0–72.7)
Hispanic 54.7 (52.9–56.6) 36.2 (34.7–37.8) 23.1 (21.6–24.7) 30.4 (28.0–32.9) 67.7 (65.8–69.4)
Other, non-Hispanic 47.3 (43.5–51.1) 33.1 (29.0–37.5) 20.2 (17.2–23.5) 26.6 (21.4–32.5) 60.0 (56.1–63.8)
School level
High school (grades 9–12) 63.2 (60.8–65.6) 38.1 (36.4–39.8) 23.3 (21.5–25.3) 29.4 (27.4–31.6) 74.3 (72.6–75.9)
Middle school (grades 6–8) 52.8 (50.9–54.8) 33.2 (31.6–34.8) 19.5 (18.1–21.0) 27.4 (25.4–29.6) 65.1 (63.4–66.7)
Exposure to cigarette and other tobacco product marketing†††
Overall 50.9 (49.1–52.7) 27.0 (25.5–28.5) 21.4 (20.1–22.7) 25.5 (24.3–26.8) 59.1 (57.2–60.9)
Estimated no. 12,100,000 6,500,000 5,040,000 2,920,000 14,550,000
Sex
Male 49.6 (47.8–51.4) 25.1 (23.4–26.8) 19.4 (18.0–20.8) 24.7 (23.2–26.1) 56.8 (54.9–58.7)
Female 52.4 (50.2–54.6) 28.9 (27.0–30.8) 23.4 (21.9–25.0) 26.3 (24.6–28.2) 61.5 (59.1–63.9)
Race and ethnicity
White, non-Hispanic 54.9 (52.5–57.2) 25.6 (23.6–27.6) 19.3 (17.8–20.9) 25.2 (23.5–26.9) 61.8 (59.3–64.2)
Black, non-Hispanic 47.4 (44.6–50.1) 32.5 (30.3–34.7) 28.0 (25.4–30.8) 28.4 (26.1–30.9) 58.9 (56.3–61.4)
Hispanic 48.0 (46.2–49.8) 28.0 (26.1–29.9) 23.3 (21.6–25.0) 24.9 (22.7–27.4) 56.9 (55.1–58.7)
Other, non-Hispanic 40.2 (36.7–43.7) 25.4 (21.5–29.7) 18.8 (15.7–22.4) 24.9 (20.8–29.5) 49.3 (44.9–53.6)
School level
High school (grades 9–12) 53.9 (51.6–56.2) 27.3 (25.3–29.3) 23.3 (21.4–25.2) 27.0 (25.3–28.9) 61.7 (59.4–63.9)
Middle school (grades 6–8) 47.1 (44.8–49.4) 26.4 (24.7–28.2) 19.0 (17.5–20.5) 23.2 (21.1–25.4) 55.7 (53.4–57.9)

Table 9. Exposure* to sources of tobacco product marketing (advertisements or promotions) among middle and high school students who reported contact with each source, overall and by school level, sex, and race and ethnicity — National Youth Tobacco Survey, United States, 2021

Abbreviations: e-cigarettes = electronic cigarettes; TV = television.
*Exposure to tobacco product marketing was assessed for each of four marketing sources (retail stores; Internet; television, streaming sources, or movies; and newspapers or magazines) and any source combined. For each source, exposure was assessed separately for 1) e-cigarettes and 2) cigarettes or other tobacco products. A composite measure of exposure to any tobacco product marketing was also assessed. Prevalence of exposure to tobacco product marketing was restricted to students who reported using each source.
Assessed by the questions, "When you go to a convenience store, supermarket, or gas station, how often do you see ads or promotions for (e-cigarettes; cigarettes or other tobacco products)?" Response options for both questions included, "I never go to a convenience store, supermarket, or gas station," "never," "rarely," "sometimes," "most of the time," and "always." Respondents were categorized as exposed if they reported "sometimes," "most of the time," or "always"; respondents were categorized as unexposed if they reported "never" or "rarely." Persons who reported "I never go to a convenience store, supermarket, or gas station" were set to missing and excluded from product-specific analyses. Total unweighted denominators included n = 18,065 (e-cigarettes) and n = 17,571 (cigarettes or other tobacco products). A composite measure of exposure to any tobacco product marketing when going to retail stores (e-cigarettes and cigarettes or other tobacco products) was assessed among respondents who had visited a retail outlet and had nonmissing data for at least one measure (n = 18,361).
§Assessed by the questions, "When you are using the Internet, how often do you see ads or promotions for (e-cigarettes; cigarettes or other tobacco products)?" Response options for both questions included, "I do not use the Internet," "never," "rarely," "sometimes," "most of the time," and "always." Respondents were categorized as exposed if they reported "sometimes," "most of the time," or "always"; respondents were categorized as unexposed if they reported "never" or "rarely." Persons who reported "I do not use the Internet" were set to missing and excluded from product-specific analyses. Total unweighted denominators included n = 18,408 (e-cigarettes) and n = 17,858 (cigarettes or other tobacco products). A composite measure of exposure to any tobacco product marketing when using the Internet (e-cigarettes and cigarettes or other tobacco products) was assessed among respondents who had used the Internet and had nonmissing data for at least one measure (n = 18,627).
Assessed by the questions, "When you watch TV or streaming services (such as Netflix, Hulu, or Amazon Prime), or go to the movies, how often do you see ads or promotions for (e-cigarettes; cigarettes or other tobacco products)?" Response options for both questions included, "I do not watch TV or streaming services, or go to the movies," "never," "rarely," "sometimes," "most of the time," and "always." Respondents were categorized as exposed if they reported "sometimes," "most of the time," or "always"; respondents were categorized as unexposed if they reported "never" or "rarely." Persons who reported "I do not watch TV or streaming services or go to the movies" were set to missing and excluded from product-specific analyses. Total unweighted denominators for exposure to tobacco product marketing included n = 17,883 (e-cigarettes) and n = 17,428 (cigarettes or other tobacco products). A composite measure of exposure to any tobacco product marketing when watching television or streaming services or going to the movies (e-cigarettes and cigarettes or other tobacco products) was assessed among respondents who had watched TV or streaming services or who went to the movies and had nonmissing data for at least one measure (n = 18,215).
**Assessed by the questions, "When you read newspapers or magazines, how often do you see ads or promotions for (e-cigarettes; cigarettes or other tobacco products)?" Response options for both questions included, "I do not read newspapers or magazines," "never," "rarely," "sometimes," "most of the time," and "always." Respondents were categorized as exposed if they reported "sometimes," "most of the time," or "always"; respondents were categorized as unexposed if they reported "never" or "rarely." Persons who reported "I do not read newspapers or magazines" were set to missing and excluded from the analyses. Total unweighted denominators for exposure to tobacco product marketing included n = 9,082 (e-cigarettes) and n = 8,583 (cigarettes or other tobacco products). A composite measure of exposure to any tobacco product marketing when reading newspapers or magazines (e-cigarettes and cigarettes or other tobacco products) was assessed among respondents who had read newspapers or magazines and had nonmissing data for at least one measure (n = 10,627).
††A composite measure of any advertising or promotion exposure (any source) was assessed based on exposure to retail stores; the Internet, television, streaming services, movies; and newspapers or magazines. Total unweighted denominators included n = 18,696 (e-cigarettes), n = 18,220 (cigarettes or other tobacco products), and n = 18,763 (e-cigarettes and cigarettes or other tobacco products). For each category (e-cigarettes, cigarettes or other tobacco products, and overall), persons with missing data across each potential source or those who reported "I never go to a convenience stores, supermarket, or gas station," "I do not use the Internet," "I do not watch TV or streaming services or go to the movies," and "I do not read newspapers or magazines" were excluded from the analysis.
§§Estimated weighted total number of students was rounded down to the nearest 10,000 persons.
¶¶Hispanic persons could be of any race.
***Respondents were instructed as follows: "The next five questions ask about issues related to e-cigarette advertisement. Do not think about cigarettes or other tobacco products when answering these questions."
†††Respondents were instructed as follows: "The next five questions ask about issues related to advertisements for tobacco products such as cigarettes, cigars, smokeless tobacco, hookahs, roll-your-own cigarettes, pipe tobacco, snus, dissolvable tobacco products, bidis, heated tobacco products, and nicotine pouches. Do not think of e-cigarettes when answering these questions."

 

Characteristic Sex Race and ethnicity Total
Female % (95% CI) Male % (95% CI) White, non-Hispanic % (95% CI) Black, non-Hispanic % (95% CI) Hispanic % (95% CI) Other, non-Hispanic % (95% CI)
% (95% CI) Estimated no.§
Overall
Seeing e-cigarette–related post or content
Never 23.9 (22.2–25.8) 29.1 (27.5–30.7) 23.3 (21.8–24.8) 32.3 (30.0–34.6) 28.3 (26.4–30.2) 31.1 (25.9–36.7) 26.5 (25.2–27.9) 6,060,000
Less than monthly 25.6 (24.3–26.8) 27.2 (25.7–28.7) 26.6 (25.2–28.0) 24.7 (22.6–26.8) 25.6 (24.0–27.3) 31.8 (29.0–34.6) 26.4 (25.3–27.5) 6,030,000
Monthly 14.1 (13.1–15.3) 13.2 (12.3–14.1) 14.7 (13.7–15.7) 10.5 (9.1–12.0) 13.7 (12.8–14.7) 12.1 (9.6–15.1) 13.7 (13.0–14.3) 3,120,000
Weekly 20.4 (18.8–22.2) 19.1 (17.7–20.5) 21.8 (20.1–23.5) 17.4 (15.5–19.4) 17.8 (16.2–19.5) 16.3 (13.5–19.7) 19.7 (18.5–21.0) 4,510,000
Daily 15.9 (14.5–17.4) 11.5 (10.7–12.5) 13.6 (12.3–15.1) 15.2 (13.4–17.2) 14.6 (13.4–15.9) 8.8 (6.7–11.4) 13.7 (12.8–14.7) 3,130,000
Posting pictures or videos of e-cigarette use (by self or others)**
Never 85.8 (84.5–87.0) 85.5 (84.2–86.8) 87.4 (86.0–88.6) 80.0 (77.1–82.5) 84.0 (82.6–85.3) 87.4 (84.3–89.9) 85.6 (84.6–86.6) 19,490,000
Less than monthly 6.8 (6.0–7.6) 6.3 (5.6–7.1) 6.1 (5.4–6.8) 8.0 (6.7–9.5) 7.4 (6.3–8.7) 5.8 (3.9–8.8) 6.6 (6.1–7.1) 1,490,000
Monthly 2.4 (1.9–3.0) 3.3 (2.8–3.9) 2.5 (2.1–3.0) 4.0 (3.3–5.0) 3.1 (2.6–3.7) 3.0 (2.1–4.2) 2.9 (2.5–3.2) 640,000
Weekly 3.3 (2.8–3.9) 2.6 (2.2–3.2) 2.7 (2.1–3.4) 3.6 (2.8–4.7) 3.1 (2.6–3.7) 2.7 (1.6–4.6) 2.9 (2.6–3.3) 670,000
Daily 1.8 (1.5–2.1) 2.2 (1.8–2.8) 1.3 (1.0–1.7) 4.4 (3.3–5.9) 2.4 (2.0–3.0) †† 2.0 (1.7–2.3) 450,000
Liking, commenting, sharing e-cigarette–related posts or content§§
Never 70.4 (69.0–71.8) 77.5 (76.2–78.7) 73.6 (72.2–74.9) 72.1 (69.8–74.3) 73.6 (72.1–75.0) 79.9 (76.1–83.3) 73.9 (72.9–74.9) 16,750,000
Less than monthly 16.9 (15.8–18.1) 13.0 (11.8–14.3) 15.8 (14.8–17.0) 15.2 (13.2–17.4) 14.1 (12.7–15.6) 12.6 (10.2–15.6) 15.0 (14.2–15.8) 3,390,000
Monthly 5.2 (4.6–5.8) 4.0 (3.4–4.6) 4.7 (4.1–5.3) 3.8 (2.9–4.9) 5.2 (4.4–6.1) 3.2 (2.1–4.8) 4.6 (4.1–5.0) 1,030,000
Weekly 5.0 (4.4–5.8) 3.5 (3.1–4.0) 4.1 (3.7–4.6) 4.6 (3.9–5.6) 4.6 (4.1–5.2) 2.9 (1.9–4.3) 4.3 (4.0–4.6) 960,000
Daily 2.5 (2.0–3.1) 2.0 (1.6–2.4) 1.7 (1.4–2.2) 4.3 (3.3–5.5) 2.6 (1.9–3.4) 1.3 (0.8–2.1) 2.3 (1.9–2.7) 510,000
High school (grades 9–12)
Seeing e-cigarette–related post or content
Never 17.7 (15.8–19.7) 22.3 (20.8–23.9) 17.2 (15.7–18.8) 29.1 (26.1–32.3) 21.5 (19.9–23.1) 23.0 (15.8–32.1) 20.0 (18.7–21.4) 2,650,000
Less than monthly 24.3 (22.8–25.8) 27.7 (25.8–29.7) 25.9 (24.1–27.7) 22.6 (20.2–25.2) 26.9 (24.9–29.0) 32.2 (28.4–36.3) 26.1 (24.7–27.5) 3,450,000
Monthly 15.3 (13.7–17.0) 15.0 (13.6–16.5) 16.2 (14.8–17.7) 12.3 (10.4–14.6) 14.3 (12.8–15.9) 14.5 (10.7–19.4) 15.1 (14.2–16.2) 2,000,000
Weekly 23.6 (21.6–25.7) 21.3 (19.6–23.1) 24.6 (22.5–26.8) 18.3 (15.6–21.3) 19.8 (17.4–22.3) 20.7 (15.9–26.5) 22.4 (20.9–24.0) 2,970,000
Daily 19.1 (17.2–21.3) 13.7 (12.4–15.1) 16.1 (14.2–18.3) 17.7 (15.4–20.2) 17.6 (15.6–19.8) 9.5 (6.7–13.4) 16.3 (15.0–17.7) 2,160,000
Posting pictures or videos of e-cigarette use (by self or others)
Never 83.9 (82.6–85.2) 84.2 (82.4–85.8) 85.9 (84.0–87.6) 79.3 (76.5–81.8) 82.0 (80.2–83.6) 85.1 (80.9–88.5) 84.0 (82.8–85.2) 11,080,000
Less than monthly 7.1 (6.2–8.1) 6.8 (5.9–7.8) 6.6 (5.6–7.7) 7.4 (5.9–9.3) 7.8 (5.7–10.6) 6.6 (4.3–10.0) 6.9 (6.3–7.7) 910,000
Monthly 2.9 (2.3–3.6) 3.8 (3.0–4.8) 2.9 (2.4–3.7) 4.5 (3.4–5.9) 3.8 (2.9–4.8) 3.3 (1.9–5.7) 3.4 (2.9–4.0) 440,000
Weekly 3.9 (3.3–4.7) 3.0 (2.5–3.6) 3.1 (2.5–3.7) 4.1 (3.0–5.5) 3.8 (3.1–4.6) 3.4 (3.0–3.9) 450,000
Daily 2.1 (1.7–2.7) 2.3 (1.7–3.1) 1.5 (1.1–2.1) 4.7 (3.2–6.7) 2.7 (2.1–3.5) 2.2 (1.8–2.6) 290,000
Liking, commenting, sharing e-cigarette–related posts or content
Never 66.7 (65.0–68.4) 73.7 (72.0–75.3) 69.9 (68.0–71.8) 70.9 (67.8–73.9) 69.8 (68.0–71.4) 74.6 (68.8–79.8) 70.3 (69.1–71.4) 9,230,000
Less than monthly 19.6 (18.0–21.3) 15.6 (14.1–17.3) 18.2 (16.7–19.8) 16.7 (13.9–19.8) 17.2 (15.3–19.3) 16.3 (12.7–20.6) 17.6 (16.5–18.7) 2,310,000
Monthly 5.7 (5.0–6.6) 4.9 (4.0–5.9) 5.6 (4.9–6.6) 3.5 (2.3–5.2) 5.7 (4.9–6.7) 4.0 (2.2–7.1) 5.3 (4.7–5.9) 690,000
Weekly 5.7 (4.8–6.7) 3.9 (3.3–4.6) 4.7 (4.0–5.5) 5.3 (4.2–6.7) 4.9 (4.0–6.0) 3.7 (2.4–5.7) 4.8 (4.2–5.4) 620,000
Daily 2.2 (1.7–2.9) 1.9 (1.4–2.6) 1.6 (1.2–2.0) 3.6 (2.6–5.0) 2.4 (1.7–3.5) 2.1 (1.7–2.5) 270,000
Middle school (grades 6–8)
Seeing e-cigarette–related post or content
Never 32.2 (30.2–34.3) 39.1 (36.5–41.7) 32.8 (30.6–35.2) 37.1 (33.7–40.7) 36.9 (33.9–39.9) 38.8 (33.4–44.5) 35.5 (33.7–37.3) 3,390,000
Less than monthly 27.2 (25.4–29.0) 26.3 (24.1–28.5) 27.7 (25.7–29.8) 27.4 (24.2–30.9) 24.0 (21.6–26.5) 31.3 (27.3–35.7) 26.7 (25.3–28.2) 2,550,000
Monthly 12.6 (11.1–14.3) 10.5 (9.3–11.8) 12.3 (10.8–13.9) 7.8 (5.9–10.3) 13.0 (10.9–15.5) 9.7 (7.2–12.9) 11.6 (10.6–12.7) 1,100,000
Weekly 16.4 (14.8–18.1) 15.8 (14.0–17.7) 17.5 (15.7–19.4) 16.1 (13.9–18.6) 15.2 (13.1–17.7) 12.1 (9.5–15.2) 16.1 (14.8–17.5) 1,530,000
Daily 11.6 (10.1–13.3) 8.4 (7.1–9.8) 9.7 (8.2–11.5) 11.6 (9.2–14.4) 10.9 (9.3–12.8) 8.1 (5.5–11.8) 10.1 (9.0–11.3) 960,000
Posting pictures or videos of e-cigarette use (by self or others)
Never 88.4 (86.3–90.3) 87.6 (85.8–89.2) 89.7 (88.0–91.2) 81.3 (75.8–85.7) 86.7 (84.3–88.8) 89.6 (86.2–92.2) 88.0 (86.3–89.4) 8,370,000
Less than monthly 6.2 (5.1–7.6) 5.6 (4.8–6.6) 5.3 (4.3–6.5) 8.4 (6.5–10.8) 6.9 (5.5–8.5) 6.0 (5.2–6.9) 570,000
Monthly 1.7 (1.2–2.4) 2.6 (2.1–3.2) 1.8 (1.4–2.4) 3.4 (2.2–5.2) 2.2 (1.5–3.3) 2.7 (1.9–3.8) 2.1 (1.8–2.6) 200,000
Weekly 2.4 (1.6–3.4) 2.1 (1.5–3.1) 2.1 (1.3–3.4) 2.9 (1.8–4.7) 2.2 (1.4–3.7) 2.2 (1.6–3.0) 210,000
Daily 1.3 (0.9–1.9) 2.0 (1.4–2.9) 1.0 (0.6–1.7) 4.0 (2.3–6.9) 1.9 (1.3–2.9) 1.7 (1.2–2.2) 150,000
Liking, commenting, sharing e-cigarette–related posts or content
Never 75.2 (72.9–77.4) 83.0 (81.1–84.7) 79.3 (77.4–81.1) 73.7 (70.1–77.0) 78.4 (75.6–80.9) 85.0 (81.0–88.2) 79.0 (77.3–80.5) 7,480,000
Less than monthly 13.3 (11.9–15.0) 9.3 (8.0–10.7) 12.2 (11.0–13.6) 13.0 (11.2–15.0) 10.1 (8.3–12.4) 9.2 (6.8–12.4) 11.4 (10.4–12.4) 1,070,000
Monthly 4.4 (3.6–5.3) 2.7 (2.2–3.4) 3.2 (2.6–3.9) 4.3 (3.2–5.7) 4.5 (3.4–6.0) 2.5 (1.5–4.1) 3.6 (3.0–4.2) 330,000
Weekly 4.2 (3.4–5.1) 3.0 (2.3–3.8) 3.3 (2.7–4.1) 3.7 (2.6–5.2) 4.2 (3.4–5.3) 3.6 (3.1–4.1) 330,000
Daily 2.9 (2.1–3.8) 2.0 (1.4–2.9) 2.0 (1.4–2.8) 5.3 (3.3–8.5) 2.7 (1.9–4.0) 2.5 (2.0–3.2) 230,000

Table 10. Observance of, and engagement with, e-cigarette content on social media among middle and high school students who reported using social media,* overall and by school level, sex, and race and ethnicity — National Youth Tobacco Survey, United States, 2021

Abbreviation: e-cigarettes = electronic cigarettes.
*All respondents were asked, "How often do you use social media?" Response options included "never/I don't use social media"; "less than one time per week"; "about one time per week"; "a few times per week"; "less than 1 hour, daily"; "about 1–2 hours, daily"; "about 3–4 hours, daily"; "4 hours or more, daily." Subsequent questions on observance and engagement with e-cigarette content were assessed among those with nonmissing data who reported a response other than "never/I don't use social media" (n = 16,960).
Hispanic persons could be of any race.
§Estimated weighted total number of students was rounded down to the nearest 10,000 persons. Overall estimates might not directly total to sums of corresponding subgroup estimates because of rounding or inclusion of students who did not self-report grade level.
Assessed by the question, "When you use social media, how often do you see posts or content (pictures, videos, or text) related to e-cigarettes?"
**Assessed by the question, "When you use social media, how often do you post pictures or videos of yourself or someone else using e-cigarettes?"
††Data were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%.
§§Assessed by the question, "When you use social media, how often have you liked, comments, or shared posts or content (pictures, videos, or text) related to e-cigarettes?"

 

Characteristic Past–30-day craving Within 30 minutes of waking§ Thinking about quitting Past-year quit attempt**
% (95% CI) Estimated no. of users†† % (95% CI) Estimated no. of users % (95% CI) Estimated no. of users % (95% CI) Estimated no. of users
Overall 27.2 (24.1–30.5) 620,000 19.5 (16.9–22.4) 440,000 65.3 (61.7–68.9) 1,320,000 60.2 (57.0–63.3) 1,200,000
Sex
Male 22.1 (18.3–26.5) 240,000 19.8 (16.2–24.0) 220,000 61.8 (56.5–66.8) 630,000 57.6 (53.4–61.7) 590,000
Female 32.1 (27.6–37.0) 370,000 19.4 (15.6–23.8) 220,000 69.4 (64.8–73.6) 680,000 63.0 (58.7–67.1) 600,000
Race and ethnicity
White, non-Hispanic 30.7 (26.7–34.9) 440,000 21.5 (18.6–24.7) 310,000 66.6 (62.0–70.9) 870,000 59.8 (55.9–63.5) 770,000
Black, non-Hispanic 19.4 (13.5–27.1) 40,000 11.3 (6.4–19.2) 20,000 62.0 (52.3–70.8) 130,000 63.0 (53.4–71.6) 140,000
Hispanic§§ 22.0 (17.1–27.9) 90,000 17.1 (11.7–24.4) 70,000 65.6 (58.1–72.4) 240,000 61.3 (52.0–69.8) 210,000
Other, non-Hispanic 21.1 (13.0–32.3) 10,000 ¶¶ 54.8 (34.4–73.8) 40,000 56.7 (35.9–75.4) 40,000
High school (Grades 9–12) 27.1 (23.5–31.0) 500,000 21.8 (18.8–25.1) 400,000 64.9 (60.3–69.1) 1,070,000 58.2 (54.5–61.8) 950,000
Sex
Male 23.1 (18.6–28.2) 210,000 21.7 (17.7–26.4) 200,000 61.8 (55.2–68.0) 530,000 55.9 (51.4–60.3) 480,000
Female 31.4 (26.4–36.9) 280,000 22.1 (17.6–27.3) 200,000 68.7 (63.7–73.3) 540,000 60.7 (55.4–65.7) 460,000
Race and ethnicity
White, non-Hispanic 30.6 (26.2–35.5) 380,000 22.9 (19.7–26.3) 280,000 66.0 (60.8–70.8) 750,000 59.2 (55.0–63.2) 670,000
Black, non-Hispanic 20.0 (13.0–29.5) 30,000 14.1 (8.0–23.6) 20,000 59.6 (48.5–69.8) 100,000 57.4 (46.4–67.8) 90,000
Hispanic 17.7 (11.8–25.7) 50,000 20.4 (12.9–30.7) 50,000 65.4 (55.0–74.5) 160,000 57.6 (45.1–69.1) 130,000
Other, non-Hispanic
Middle school (grades 6–8) 28.1 (22.6–34.3) 120,000 9.4 (6.5–13.4) 30,000 67.6 (60.2–74.3) 240,000 68.4 (63.1–73.2) 240,000
Sex
Male 17.7 (12.2–25.0) 30,000 10.3 (6.2–16.7) 10,000 62.5 (52.6–71.4) 100,000 65.8 (57.3–73.4) 100,000
Female 35.6 (26.9–45.3) 80,000 8.8 (5.1–14.5) 20,000 71.6 (61.7–79.8) 130,000 71.6 (63.5–78.5) 130,000
Race and ethnicity
White, non-Hispanic 31.4 (23.2–40.9) 50,000 12.9 (8.3–19.7) 20,000 70.2 (62.2–77.1) 110,000 63.3 (55.3–70.6) 100,000
Black, non-Hispanic 71.1 (50.4–85.6) 30,000 81.9 (69.8–89.8) 40,000
Hispanic 32.1 (22.7–43.3) 40,000 67.1 (52.6–78.9) 70,000 67.7 (53.5–79.3) 70,000
Other, non-Hispanic

Table 11. Urges to use tobacco products and quitting behaviors among middle and high school students who reported current (past 30-day) tobacco product use,* overall and by school level, sex, and race and ethnicity — National Youth Tobacco Survey, United States, 2021

Abbreviation: e-cigarettes = electronic cigarettes.
*Any current tobacco product use was defined as use of any tobacco product (e-cigarettes, cigarettes, cigars [cigars, cigarillos, or little cigars], smokeless tobacco [chewing tobacco, snuff or dip; snus; or dissolvable tobacco products], hookahs, pipe tobacco, heated tobacco products, nicotine pouches, or bidis [small brown cigarettes wrapped in a leaf]) on ≥1 day during the past 30 days.
Assessed by the question, "During the past 30 days, have you had a strong craving or felt like you really needed to use a tobacco product of any kind?" The response options were "yes" or "no."
§Assessed by the question, "How soon after you wake up do you want to use a tobacco product?" Response options were dichotomized as within 30 minutes ("within 5 minutes" or "from 6 to 30 minutes") or not within 30 minutes ("from more than 30 minutes to 1 hour"; "after >1 hour but <24 hours"; "I rarely want to use tobacco products"; or "I do not want to use tobacco products").
Assessed by the question, "Are you seriously thinking about quitting the use of all tobacco products?" Response options were dichotomized as yes ("yes, during the next 30 days"; "yes, during the next 6 months"; "yes, during the next 12 months"; or "yes, but not during the next 12 months") or no ("no, I am not thinking about quitting the use of all tobacco products").
**Assessed by the question, "During the past 12 months, how many times have you stopped using all tobacco products for one day or longer because you were trying to quit all tobacco products for good?" Response options were dichotomized as yes ("1 time," "2 times," "3 to 5 times, "6 to 9 times," or "10 or more times") or no ("no, I did not try to quit all tobacco products during the past 12 months").
††Estimated weighted total numbers of users were rounded down to the nearest 10,000 persons. Overall estimates might not directly total to sums of corresponding subgroup estimates because of rounding or inclusion of students who did not self-report sex, race and ethnicity, or grade level.
§§Hispanic persons could be of any race.
¶¶Data were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%.

CME / ABIM MOC / CE

Tobacco Product Use and Associated Factors Among Middle and High School Students — National Youth Tobacco Survey, United States, 2021

  • Authors: Andrea S. Gentzke, PhD; Teresa W. Wang, PhD; Monica Cornelius, PhD; Eunice Park-Lee, PhD; Chunfeng Ren, PhD; Michael D. Sawdey, PhD; Karen A. Cullen, PhD; Caitlin Loretan, MPH; Ahmed Jamal, MBBS; David M. Homa, PhD
  • CME / ABIM MOC / CE Released: 7/12/2022
  • Valid for credit through: 7/12/2023
Start Activity

  • Credits Available

    Physicians - maximum of 1.50 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 1.50 ABIM MOC points

    Nurses - 1.50 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 1.50 Knowledge-based ACPE (0.150 CEUs)

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for public health officials, pediatricians, family practice clinicians, and other clinicians caring for youths currently using tobacco or at risk for tobacco use.

The goal of this activity is to describe US prevalence of youth tobacco product use and associated factors, including flavored tobacco product use, reasons for use, access to tobacco products, exposure to pro-tobacco and antitobacco product marketing, harm perceptions, tobacco cravings, and quitting behaviors, according to findings of the 2021 National Youth Tobacco Survey (NYTS), the only nationally representative survey of US middle (grades 6-8) and high school (grades 9-12) students focusing exclusively on tobacco product use.

Upon completion of this activity, participants will:

  • Describe U.S. prevalence, demographics, and patterns of youth tobacco product use, including electronic cigarettes (e-cigarettes), cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco, heated tobacco products, nicotine pouches, and bidis (small brown cigarettes wrapped in a leaf), according to findings of the 2021 National Youth Tobacco Survey (NYTS)
  • Determine reasons for e-cigarette use, access to tobacco products, exposure to protobacco and antitobacco product marketing, harm perceptions, tobacco cravings, and quitting behaviors among U.S. youths, according to findings of the 2021 NYTS
  • Identify public health implications of tobacco product use among U.S. youths, according to findings of the 2021 NYTS


Disclosures

Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated according to Medscape policies. Others involved in the planning of this activity have no relevant financial relationships.


Faculty

  • Andrea S. Gentzke, PhD

    Office on Smoking and Health
    National Center for Chronic Disease Prevention and Health Promotion
    Centers for Disease Control and Prevention (CDC)
    Atlanta, Georgia

    Disclosures

    Disclosure: Andrea S. Gentzke, PhD, has disclosed no relevant financial relationships.

  • Teresa W. Wang, PhD

    Office on Smoking and Health
    National Center for Chronic Disease Prevention and Health Promotion
    Centers for Disease Control and Prevention (CDC)
    Atlanta, Georgia

    Disclosures

    Disclosure: Teresa W. Wang, PhD, has disclosed no relevant financial relationships.

  • Monica Cornelius, PhD

    Office on Smoking and Health
    National Center for Chronic Disease Prevention and Health Promotion
    Centers for Disease Control and Prevention (CDC)
    Atlanta, Georgia

    Disclosures

    Disclosure: Monica Cornelius, PhD, has disclosed no relevant financial relationships.

  • Eunice Park-Lee, PhD

    Center for Tobacco Products
    Food and Drug Administration (FDA)
    Rockville, Maryland

    Disclosures

    Disclosure: Eunice Park-Lee, PhD, has disclosed no relevant financial relationships.

  • Chunfeng Ren, PhD

    Center for Tobacco Products
    Food and Drug Administration (FDA)
    Rockville, Maryland

    Disclosures

    Disclosure: Chunfeng Ren, PhD, has disclosed no relevant financial relationships.

  • Michael D. Sawdey, PhD

    Center for Tobacco Products
    Food and Drug Administration (FDA)
    Rockville, Maryland

    Disclosures

    Disclosure: Michael D. Sawdey, PhD, has disclosed no relevant financial relationships.

  • Karen A. Cullen, PhD

    Center for Tobacco Products
    Food and Drug Administration (FDA)
    Rockville, Maryland

    Disclosures

    Disclosure: Karen A. Cullen, PhD, has disclosed no relevant financial relationships.

  • Caitlin Loretan, MPH

    Office on Smoking and Health
    National Center for Chronic Disease Prevention and Health Promotion
    Centers for Disease Control and Prevention (CDC)
    Atlanta, Georgia

    Disclosures

    Disclosure: Caitlin Loretan, MPH, has disclosed no relevant financial relationships.

  • Ahmed Jamal, MBBS

    Office on Smoking and Health
    National Center for Chronic Disease Prevention and Health Promotion
    Centers for Disease Control and Prevention (CDC)
    Atlanta, Georgia

    Disclosures

    Disclosure: Ahmed Jamal, MBBS, has disclosed no relevant financial relationships.

  • David M. Homa, PhD

    Office on Smoking and Health
    National Center for Chronic Disease Prevention and Health Promotion
    Centers for Disease Control and Prevention (CDC)
    Atlanta, Georgia

    Disclosures

    Disclosure: David M. Homa, PhD, has disclosed no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed the following relevant financial relationships:
    Stock, stock options, or bonds: AbbVie Inc. (former)

Editor/Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Amanda Jett, PharmD, BCACP, has disclosed no relevant financial relationships.

Peer Reviewer

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CME / ABIM MOC / CE

Tobacco Product Use and Associated Factors Among Middle and High School Students — National Youth Tobacco Survey, United States, 2021

Authors: Andrea S. Gentzke, PhD; Teresa W. Wang, PhD; Monica Cornelius, PhD; Eunice Park-Lee, PhD; Chunfeng Ren, PhD; Michael D. Sawdey, PhD; Karen A. Cullen, PhD; Caitlin Loretan, MPH; Ahmed Jamal, MBBS; David M. Homa, PhDFaculty and Disclosures

CME / ABIM MOC / CE Released: 7/12/2022

Valid for credit through: 7/12/2023

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Abstract and Introduction

Abstract

Problem/Condition: Commercial tobacco use is the leading cause of preventable disease, disability, and death in the United States. Most tobacco product use begins during adolescence. In recent years, tobacco products have evolved to include various combusted, smokeless, and electronic products.

Period Covered: 2021.

Description of System: The National Youth Tobacco Survey (NYTS) is an annual, cross-sectional, school-based, self-administered survey of U.S. middle school (grades 6–8) and high school (grades 9–12) students. A three-stage cluster sampling procedure is used to generate a nationally representative sample of U.S. students attending public and private schools. NYTS is the only nationally representative survey of U.S. middle and high school students that focuses exclusively on tobacco use patterns and associated factors. NYTS provides data to support the design, implementation, and evaluation of comprehensive youth tobacco use prevention and control programs and to guide tobacco regulatory activities. Since 2019, NYTS has been administered electronically via tablet computers. Because of emergency COVID-19 protocols that were in place across the United States during the 2021 NYTS fielding window (January 18–May 21, 2021), the 2021 survey was administered using a web URL to allow participation by eligible students learning under varying instructional models (in-person, distance/virtual, and hybrid). In total, 50.8% of student respondents reported completing the survey in a school building or classroom and 49.2% at home or some other place. CDC and the Food and Drug Administration (FDA) analyzed data from the 2021 NYTS to assess tobacco product use patterns and associated factors among U.S. middle and high school students. Overall, 20,413 students (out of 25,149 sampled students; student response rate: 81.2%) completed the questionnaire from 279 schools (out of 508 sampled schools; school response rate: 54.9%). The overall response rate, defined as the product of the student and school response rates, was 44.6%. The sample was weighted to represent approximately 11.97 million middle school students and 15.44 million high school students. Students with missing information about grade level were excluded from the school-level analyses (n = 135).

Results: In 2021, an estimated 34.0% of high school students (5.22 million) and 11.3% of middle school students (1.34 million) reported ever using a tobacco product (i.e., electronic cigarettes [e-cigarettes], cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco, heated tobacco products, nicotine pouches, and bidis [small brown cigarettes wrapped in a leaf]). Current (past 30-day) use of a tobacco product was 13.4% for high school students (2.06 million) and 4.0% for middle school students (470,000). E-cigarettes were the most commonly currently used tobacco product, cited by 11.3% of high school students (1.72 million) and 2.8% of middle school students (320,000), followed by cigarettes, cigars, smokeless tobacco, hookahs, nicotine pouches, heated tobacco products, and pipe tobacco. Current use of any tobacco product was reported by 14.2% of students identifying as lesbian, gay, or bisexual (LGB) (versus 7.9% of heterosexual); 18.9% of students identifying as transgender (versus 8.2% of not transgender); and 14.2% of students reporting severe psychological distress (versus 5.5% with no distress). Among students who currently used each respective tobacco product, frequent use (on ≥20 days of the past 30 days) ranged from 17.2% for nicotine pouches to 39.4% for e-cigarettes. Among current users of any tobacco product, 79.1% reported using a flavored tobacco product; by product, e-cigarettes were the most commonly used flavored tobacco product. Among current users of any tobacco product, the most commonly reported source of access was from a friend (32.8%). Among students who currently used e-cigarettes, 53.7% used a disposable device, 28.7% used a prefilled/refillable pod or cartridge device, 9.0% used a tank or mod system (a system that can be customized by the user), and 8.6% did not know the device type. Among students who had ever used e-cigarettes, the most common reason for first trying them was "a friend used them" (57.8%); among current e-cigarette users, the most commonly cited reason for current use was "I am feeling anxious, stressed, or depressed" (43.4%). Among all middle and high school students, 75.2% reported past-year recognition of any antitobacco public education campaign ads. Exposure to marketing or advertising for any tobacco product was reported by 75.7% of students who had contact with an assessed potential source of tobacco product advertisements or promotions (going to a convenience store, supermarket, or gas station; using the Internet; watching television or streaming services or going to the movies; or reading newspapers or magazines). Among students who reported using social media, 73.5% had ever seen e-cigarette–related content. Among all students, perceiving "no" or "little" harm from intermittent tobacco product use was highest for e-cigarettes (16.6%) and lowest for cigarettes (9.6%). Among students who currently used any tobacco product, 27.2% had experienced cravings during the past 30 days; 19.5% reported wanting to use a tobacco product within 30 minutes of waking. Moreover, 65.3% of students who currently used tobacco products were seriously thinking about quitting the use of all products, and 60.2% had stopped using all products for ≥1 day because they were trying to quit during the past 12 months.

Interpretation: In 2021, approximately one in 10 U.S. middle and high school students (9.3%) had used a tobacco product during the preceding 30 days. By school level, this represented more than one in eight high school students (13.4%) and approximately one in 25 middle school students (4.0%). E-cigarettes were the most commonly used tobacco product in 2021. Tobacco product use was higher among certain subpopulations, such as those identifying as LGB or transgender, or those reporting psychological distress. Importantly, approximately two thirds of students who currently used tobacco products were seriously thinking about quitting. However, factors that might continue to promote tobacco product use among U.S. youths, such as the availability of flavors, access to tobacco products, exposure to tobacco product marketing, and misperceptions about harm from tobacco product use, remained prevalent in 2021.

Public Health Action: The continued monitoring of all forms of youth tobacco product use and associated factors through surveillance efforts including NYTS is important to the development of public health policy and action at national, state, and local levels. The 2021 NYTS was successfully administered during the COVID-19 pandemic using a web URL to allow participation by eligible students learning under varying instructional models. As a result of these modifications to the fielding procedures, any comparison of results between 2021 NYTS findings with previous years, including the direct attribution of any potential changes in tobacco product use, is not possible. Parents, educators, youth advocates, and health care providers can help protect youths from the harms of tobacco products, including e-cigarettes. In addition, the comprehensive and sustained implementation of evidence-based tobacco control strategies, combined with FDA's regulation of tobacco products, is important for reducing all forms of tobacco product use among U.S. youths.

Introduction

Tobacco* product use is the leading cause of preventable disease, disability, and death in the United States.[1] Preventing tobacco product use among youths is critical to decreasing morbidity and mortality because almost all tobacco product use begins during adolescence or young adulthood; approximately nine in 10 adults who smoke cigarettes started before age 18 years.[1–3] In recent years, tobacco products have evolved to include various combusted, smokeless, and electronic products.

The National Youth Tobacco Survey (NYTS), conducted periodically during 1999–2009 and annually since 2011, provides national data on estimates of tobacco product use to support the design, implementation, and evaluation of comprehensive youth tobacco prevention and control programs and to inform tobacco regulatory activities in the United States.[4] NYTS is the only nationally representative survey of U.S. middle (grades 6–8) and high school (grades 9–12) students that focuses exclusively on tobacco product use.

This report presents findings from the 2021 NYTS and describes the prevalence of youth tobacco product use and associated factors, including flavored tobacco product use, reasons for use, access to tobacco products, exposure to pro-tobacco and antitobacco product marketing, harm perceptions, urges to use tobacco products, and quitting behaviors. These findings can be used by public health professionals, health care providers, policymakers, parents, and other youth advocates to prevent and reduce tobacco product use among U.S. youths.

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*The term “tobacco” as used in this report refers to commercial tobacco products and not to sacred and traditional use of tobacco by some American Indian communities.