Identifying trends in smoking behaviors among youth cigarette smokers could inform youth policy and interventions.
Using 2011–2018 National Youth Tobacco Survey data, logistic/linear regressions were used to analyze trends in smoking frequency, intensity, age of first cigarette use, and electronic cigarette (e-cigarette) use frequency among current smokers. Stratified analyses were conducted among male, female, middle school, and high school students and race and ethnicity subgroups separately.
From 2011 to 2018, there was a decrease in smoking ≥10 days (50.0% to 38.3%), ≥20 days (37.2% to 26.3%), and 30 days (26.6% to 18.2%) among current smokers. Smoking prevalence decreased among male, female, high school, non-Hispanic white, and non-Hispanic other students. Overall, light smoking (≤5 cigarettes per day [CPDs]) increased (76.6% to 82.7%), and moderate smoking (6–10 CPDs) decreased (10.7% to 8.3%). Trends in light, moderate, and heavy smoking varied by demographic groups. Age at first cigarette use increased among female (12.28 to 13.29), high school (12.91 to 13.18), and non-Hispanic other students (11.64 to 12.83) and decreased among male students (12.90 to 12.57). From 2014 to 2018, there was an increase in e-cigarette use frequency for ≥10 days (20.8% to 40.9%), ≥20 days (13.5% to 31.7%), and all 30 days (9.3% to 22%).
From 2011 to 2018, current youth cigarette smokers smoked fewer days and fewer CPDs, and age of first cigarette use increased. However, over time, male youth smoked more heavily and started smoking earlier. E-cigarette use increased from 2014 to 2018. Differences by demographic characteristics can inform future research and interventions.
Cigarette use has declined among youth, but it is unclear whether smoking behaviors such as smoking frequency, smoking intensity, and age of first use have changed among continuing smokers.
Between 2011 and 2018, current cigarette-smoking youth smoked fewer days per month and fewer cigarettes per day, and the age of first cigarette use increased. However, over time, male youth smoked more heavily and started smoking earlier.
Despite years of progress, tobacco use is still the leading cause of preventable death in the United States.1 Since the first Surgeon General Report in 1964, which concluded cigarette smoking substantially contributes to morbidity and mortality, the prevalence of adult cigarette smokers has declined from 42% to 14% in 2017.1,2 However, 34.3 million adults still smoke, and >480 000 Americans die each year because of smoking-related disease.1,2 Smoking is responsible for >87% of lung cancer deaths, 61% of all pulmonary disease deaths, and 32% of all deaths from coronary heart disease.2 It has also been linked to health conditions in all major organs, including stroke, diabetes, tuberculosis, cancers, and many other chronic diseases.2 In 2018, 1.18 million high school students and 200 000 middle school students reported smoking cigarettes in the past 30 days.3 Consequently, 5.6 million US youth are projected to die prematurely from smoking-related causes.2
Reducing smoking among youth was one of the goals of the 2009 Family Smoking Prevention and Tobacco Control Act (FSPTCA).4 The act granted the US Food and Drug Administration (FDA) the authority to regulate the content, marketing, and sale of tobacco products.4 The use of this authority was specifically focused on restricting tobacco marketing and sales to youth.4 From 2011 to 2018, the prevalence of cigarette smoking among all US middle school and high school students declined significantly from 15.8% to 8.1%. However, little is known about the trend of smoking behaviors among US youth cigarette smokers during that time.
Many studies on youth smoking have examined smoking prevalence, comparing results between smokers and nonsmokers.3,5–7 However, few studies have analyzed behaviors, such as frequency and intensity, specifically among youth cigarette smokers.8–12 These studies tend to include users and nonusers and focus on multiple products, which may mask important findings among cigarette smokers. Despite increases in other product use, such as electronic cigarettes (e-cigarettes), cigarettes remain the most harmful tobacco product, and efforts should be made to continue targeting youth who smoke cigarettes. However, e-cigarettes are also of major concern because they are now the most commonly used tobacco product among US youth. In 2018, 21% of youth reported past 30-day e-cigarette use compared with 8.1% of youth who reported cigarette use.13
Vapor products are not without risk and have been linked to >2000 cases of lung injury (e-cigarette or vaping product use–associated lung injury), including 47 deaths.14 In addition, most youth e-cigarette users report polytobacco use.15–17 Those who use combustible cigarettes and e-cigarettes concurrently could be at risk for increased substance abuse and other risky behavior.11,18–20
Analyzing youth smoking behavior over time provides additional insights to inform policy and prevention efforts. Jones et al10 found that smoking intensity decreased among current cigarette-smoking youth, with heavy smokers decreasing from 18.0% to 7.8% and light smokers increasing from 67.2% in 1991 to 79.4% in 2009. If youth are transitioning from heavy to light smoking, efforts might be focused on educating youth that light smoking remains harmful. In addition, there is further understanding to be gained from examining trends in youth smoking by demographic characteristics given the disparities in smoking among subpopulations.7,21 Identifying differences in smoking behaviors between demographic groups (eg, male or female sex) could help target populations who are at greatest risk. However, to our knowledge, no studies have examined national trends in youth smoking behaviors since the implementation of the FSPTCA in 2009. The current study used the National Youth Tobacco Survey (NYTS) to examine the trends of smoking behaviors among middle and high school students in the United States from 2011 to 2018.
Methods
Data
The NYTS was designed to provide comprehensive national data on tobacco-related indicators for middle school (grades 6–8) and high school (grades 9–12) students to support the design, implementation, and evaluation of comprehensive tobacco prevention and control programs.22 The NYTS uses a stratified 3-stage cluster sample design and a weighting factor for each student, which results in nationally representative data for public, Catholic, and other private school students enrolled in grades 6 through 12 in the United States. For each year, students in randomly selected US states and the District of Columbia were invited to participate; participation was confidential, voluntary, and approved by parents. During a regular class period, participants completed self-administered, paper-and-pencil, scannable questionnaires that included questions regarding tobacco-related beliefs, attitudes, behaviors, and exposure to pro- and antitobacco influences. For each year, the overall response rates ranged from 63% to 89%, and the number of participants ranged from 17 711 to 24 658. In our study, we restricted our analysis to students who were current smokers and were not missing grade information. Current smokers were defined as students who smoked cigarettes at least once in the 30 days before the survey on the basis of the response to the survey question, “During the past 30 days, on how many days did you smoke cigarettes?” On the basis of the study criteria, 11 123 middle and high school students were included in the analyses.
Measures
The main outcome variables of interest were 3 smoking behaviors: smoking frequency (in days), cigarettes smoked per day, and the age of first cigarette use. Smoking frequency items were derived from the question, “During the past 30 days, on how many days did you smoke cigarettes?” Possible answers included “0 days,” “1 or 2 days,” “3 to 5 days,” “6 to 9 days,” “10 to 19 days,” “20 to 29 days,” and “all 30 days.” Consistent with a study conducted by Jones et al,10 3 dichotomous variables were created to measure trends for smoking frequency: smoked cigarettes ≥10 days, smoked cigarettes ≥20 days, and smoked cigarettes every day (all 30 days).
Cigarettes smoked per day (smoking intensity) was derived from the question “During the past 30 days, on the days you smoked, about how many cigarettes did you smoke per day?” We categorized current smokers by cigarettes smoked per day into 3 categories: light smokers (≤1–5 cigarettes per day [CPDs]), moderate smokers (6–10 CPDs), and heavy smokers (≥11 CPDs).
Age at first cigarette use was measured by using the survey question, “How old were you when you first tried cigarette smoking, even 1 or 2 puffs?” and was analyzed as a continuous variable.
E-cigarette use frequency was derived from the question “During the past 30 days, on how many days did you use e-cigarettes?” for all available years (2014–2018). Three dichotomous variables that were similar to measures of smoking frequency were created to measure trends for e-cigarette frequency: use e-cigarettes ≥10 days, use e-cigarettes ≥20 days, and use e-cigarettes every day (all 30 days). Demographic variables included in the analyses were sex (male or female), race and ethnicity (non-Hispanic white, non-Hispanic African American, Hispanic, or non-Hispanic others), and grade (6th–12th grade). Because of small sample sizes, non-Hispanic Asian American, non-Hispanic American Indian or Alaskan native, non-Hispanic Native Hawaiian or Pacific Islander, and multiple races were recoded into the “non-Hispanic others” group.
Statistical Analyses
We generated national estimates of smoking behaviors (smoking frequency, smoking intensity, age of first cigarette use, and e-cigarette use frequency) among current smokers in middle school and high school students for each year of data independently. Additionally, estimates were calculated for the full sample and in male, female, middle school, and high school subgroups separately. Logistic regression models were used to test the statistical significance of the linear trend for measurements of smoking frequency, smoking intensity, and e-cigarette use frequency. Linear regression models were used to test the statistical significance of the linear trend of the mean age of first cigarette use. The age variable was treated as a continuous variable. Sex, race and ethnicity, and grade were included as covariates. Subgroup trend analyses were conducted among male, female, middle school, and high school students and race and ethnicity separately by using the same covariates except for the stratified criteria. Sampling weights and survey stratum were included in all analyses to account for the complex survey design. All tests were 2 sided and used a 5% significance level. All of the statistical analyses were performed by using SAS 9.4 (SAS Institute, Inc, Cary, NC).
Results
Of the 11 123 students included in our study, 8966 (83.4%) were high school students, and 51.3% were male. More than half of participating students were non-Hispanic white (59.8%), followed by Hispanic (22.8%), non-Hispanic others (9.1%), and non-Hispanic African American (8.3%). Among the included current smokers, 35.2% smoked 1 to 2 days during the 30 days before the survey, 23.5% smoked 3 to 9 days, 11.8% smoked 10 to 19 days, 8.8% smoked 20 to 29 days, and 20.8% smoked all 30 days. In terms of smoking intensity, 80.7% were light smokers (≤5 CPDs), 9.3% were moderate smokers (6–10), and 9.9% were heavy smokers (≥11 CPDs). For e-cigarette use among current smokers, 40.3% did not use e-cigarettes during the past 30 days before the survey, 15.7% used 1 to 2 days, 16.9% used 3 to 9 days, 7.4% used 10 to 19 days, 5.2% used 20 to 29 days, and 12.5% used all 30 days (Supplemental Table 2).
Trends in Smoking Frequency and Smoking Intensity
The trends in smoking frequency and smoking intensity for current cigarette users from 2011 to 2018 are presented in Fig 1. A significant decrease was found in all 3 measures of smoking frequency. The percentage of current smokers smoking ≥10 days, ≥20 days, and all 30 days decreased 11.7 percentage points (from 50.0% to 38.3%), 10.9 percentage points (from 37.2% to 26.3%), and 8.4 percentage points (from 26.6% to 18.2%), respectively, over the 8-year period. Light smoking among current cigarette users increased significantly from 76.6% in 2011 to 82.7% in 2018. Moderate smoking decreased significantly from 10.7% in 2011 to 8.3% in 2018. Heavy smoking decreased from 9.7% in 2011 to 9.0% in 2018, although the trend was not statistically significant for heavy smoking.
Smoking frequency and smoking intensity among current cigarette smokers from 2011 to 2018. A, Smoking frequency. B, Smoking intensity. Smoking frequency was measured by the number of days smoked in the past 30 days: smoked cigarettes ≥10 days, smoked cigarettes ≥20 days, and smoked cigarettes every day (all 30 days). Smoking intensity was measured by the number of cigarettes smoked per day: light smokers (≤1–5 CPDs), moderate smokers (6–10 CPDs), and heavy smokers (≥11 CPDs).
Smoking frequency and smoking intensity among current cigarette smokers from 2011 to 2018. A, Smoking frequency. B, Smoking intensity. Smoking frequency was measured by the number of days smoked in the past 30 days: smoked cigarettes ≥10 days, smoked cigarettes ≥20 days, and smoked cigarettes every day (all 30 days). Smoking intensity was measured by the number of cigarettes smoked per day: light smokers (≤1–5 CPDs), moderate smokers (6–10 CPDs), and heavy smokers (≥11 CPDs).
The trends in smoking frequency and smoking intensity for current cigarette users and by demographic characteristics from 2011 to 2018 are presented in Figs 2 and 3 and Supplemental Fig 6. The percentage of current smokers smoking ≥10 days, ≥20 days, and all 30 days decreased among male, female (Fig 2), high school (Fig 3), non-Hispanic white, and non-Hispanic other students. Similar to all current cigarette users, light smoking increased significantly among female (from 75.9% to 88.4%; Fig 2), high school (from 78.1% to 82.1%; Fig 3), non-Hispanic white (from 78.9% to 84.1%; Supplemental Fig 6), and non-Hispanic other students (from 77.9% to 88.4%; Supplemental Fig 6), whereas moderate smoking decreased significantly among female (from 11.0% to 7.4%; Fig 2), high school (from 12.0% to 9.2%; Fig 3), and non-Hispanic white students (from 12.5% to 9.4%; Supplemental Fig 6). In addition, heavy smoking decreased significantly among female students (from 13.1% to 4.2%) but increased significantly among male students (from 5.5% to 12.8%) from 2011 to 2018 (Fig 2). No other significant trends were observed for smoking frequency or smoking intensity.
Smoking frequency and smoking intensity among current cigarette smokers from 2011 to 2018, stratified by sex. A, Smoking intensity. B, Smoking frequency. Current cigarette smokers were defined as students who smoked cigarettes on ≥1 of the 30 days before the survey. Smoking frequency was measured by the number of days smoked in the past 30 days: smoked cigarettes ≥10 days, smoked cigarettes ≥20 days, and smoked cigarettes every day (all 30 days). Smoking intensity was measured by the number of cigarettes smoked per day: light smokers (≤1–5 CPDs), moderate smokers (6–10 CPDs), and heavy smokers (≥11 CPDs). Prevalence and the 95% confidence interval (error bar) were presented for each year.
Smoking frequency and smoking intensity among current cigarette smokers from 2011 to 2018, stratified by sex. A, Smoking intensity. B, Smoking frequency. Current cigarette smokers were defined as students who smoked cigarettes on ≥1 of the 30 days before the survey. Smoking frequency was measured by the number of days smoked in the past 30 days: smoked cigarettes ≥10 days, smoked cigarettes ≥20 days, and smoked cigarettes every day (all 30 days). Smoking intensity was measured by the number of cigarettes smoked per day: light smokers (≤1–5 CPDs), moderate smokers (6–10 CPDs), and heavy smokers (≥11 CPDs). Prevalence and the 95% confidence interval (error bar) were presented for each year.
Smoking frequency and smoking intensity among current cigarette smokers from 2011 to 2018, stratified by age (middle school or high school). A, Smoking frequency. B, Smoking intensity. Current cigarette smokers were defined as students who smoked cigarettes on ≥1 of the 30 days before the survey. Smoking frequency was measured by the number of days smoked in the past 30 days: smoked cigarettes ≥10 days, smoked cigarettes ≥20 days, and smoked cigarettes every day (all 30 days). Smoking intensity was measured by the number of cigarettes smoked per day: light smokers (≤1–5 CPDs), moderate smokers (6–10 CPDs), and heavy smokers (≥11 CPDs). Prevalence and the 95% confidence interval (error bar) were presented for each year.
Smoking frequency and smoking intensity among current cigarette smokers from 2011 to 2018, stratified by age (middle school or high school). A, Smoking frequency. B, Smoking intensity. Current cigarette smokers were defined as students who smoked cigarettes on ≥1 of the 30 days before the survey. Smoking frequency was measured by the number of days smoked in the past 30 days: smoked cigarettes ≥10 days, smoked cigarettes ≥20 days, and smoked cigarettes every day (all 30 days). Smoking intensity was measured by the number of cigarettes smoked per day: light smokers (≤1–5 CPDs), moderate smokers (6–10 CPDs), and heavy smokers (≥11 CPDs). Prevalence and the 95% confidence interval (error bar) were presented for each year.
E-cigarette use frequency among current cigarette smokers from 2014 to 2018, stratified by demographic characteristics. Current cigarette smokers were defined as students who smoked cigarettes on ≥1 of the 30 days before the survey. E-cigarette use frequency was measured by the number of days e-cigarette was used in the past 30 days: used e-cigarettes ≥10 days, used e-cigarettes ≥20 days, and used e-cigarettes every day (all 30 days). The smoking frequency was measured by the number of days smoked in the past 30 days: smoked cigarettes ≥10 days, smoked cigarettes ≥20 days, and smoked cigarettes everyday (all 30 days). Prevalence and the 95% confidence interval (error bar) were presented for each year.
E-cigarette use frequency among current cigarette smokers from 2014 to 2018, stratified by demographic characteristics. Current cigarette smokers were defined as students who smoked cigarettes on ≥1 of the 30 days before the survey. E-cigarette use frequency was measured by the number of days e-cigarette was used in the past 30 days: used e-cigarettes ≥10 days, used e-cigarettes ≥20 days, and used e-cigarettes every day (all 30 days). The smoking frequency was measured by the number of days smoked in the past 30 days: smoked cigarettes ≥10 days, smoked cigarettes ≥20 days, and smoked cigarettes everyday (all 30 days). Prevalence and the 95% confidence interval (error bar) were presented for each year.
Trends in Age of First Cigarette Use
The trends in the age of first cigarette use overall and by demographic characteristics from 2011 to 2018 are presented in Table 1 and Supplemental Table 3. Over the 8 years, the mean age of first use of cigarettes increased significantly from 12.56 years in 2011 to 12.86 years in 2018. Similarly, in the demographic subgroups, we found a significant increasing trend among female students from 12.28 to 13.29 years and among high school students from 12.91 to 13.18 years during 2011–2018; however, the mean age of first use decreased significantly among male students during the same period from 12.90 to 12.57 years. In addition, the mean age of first use increased significantly from 11.64 to 12.83 years among non-Hispanic other students (Supplemental Table 3). No significant trend in the mean age of first use was found among other demographic subgroups.
Age of First Cigarette Use Among Current Cigarette Smokers From 2011 to 2018, Overall and by Subgroups
| Year | All Studentsa | Maleb | Femalea | Middle School | High Schoola |
|---|---|---|---|---|---|
| 2011 | 12.56 (12.40–12.71) | 12.90 (12.69–13.11) | 12.28 (12.07–12.49) | 10.83 (10.63–11.04) | 12.91 (12.74–13.09) |
| 2012 | 12.75 (12.57–12.93) | 12.92 (12.63–13.21) | 12.62 (12.45––12.80) | 10.82 (10.55–11.10) | 13.12 (12.94–13.29) |
| 2013 | 12.70 (12.49–12.90) | 12.50 (12.23–12.76) | 12.94 (12.68–13.19) | 10.75 (10.33–11.17) | 13.04 (12.83–13.24) |
| 2014 | 12.64 (12.42–12.86) | 12.45 (12.15–12.76) | 12.92 (12.66–13.19) | 10.85 (10.49–11.21) | 13.01 (12.80–13.21) |
| 2015 | 12.85 (12.60–13.11) | 12.58 (12.25–12.91) | 13.22 (12.93–13.51) | 11.24 (10.91–11.56) | 13.17 (12.88–13.45) |
| 2016 | 12.66 (12.42–12.90) | 12.55 (12.23–12.88) | 12.83 (12.50–13.16) | 10.73 (10.44–11.03) | 13.05 (12.80–13.30) |
| 2017 | 13.00 (12.74–13.27) | 12.88 (12.49–13.28) | 13.20 (12.90––13.51) | 11.18 (10.67–11.68) | 13.40 (13.10–13.69) |
| 2018 | 12.86 (12.63––13.10) | 12.57 (12.24–12.89) | 13.29 (13.01–13.57) | 10.96 (10.60–11.31) | 13.18 (12.94–13.43) |
| Year | All Studentsa | Maleb | Femalea | Middle School | High Schoola |
|---|---|---|---|---|---|
| 2011 | 12.56 (12.40–12.71) | 12.90 (12.69–13.11) | 12.28 (12.07–12.49) | 10.83 (10.63–11.04) | 12.91 (12.74–13.09) |
| 2012 | 12.75 (12.57–12.93) | 12.92 (12.63–13.21) | 12.62 (12.45––12.80) | 10.82 (10.55–11.10) | 13.12 (12.94–13.29) |
| 2013 | 12.70 (12.49–12.90) | 12.50 (12.23–12.76) | 12.94 (12.68–13.19) | 10.75 (10.33–11.17) | 13.04 (12.83–13.24) |
| 2014 | 12.64 (12.42–12.86) | 12.45 (12.15–12.76) | 12.92 (12.66–13.19) | 10.85 (10.49–11.21) | 13.01 (12.80–13.21) |
| 2015 | 12.85 (12.60–13.11) | 12.58 (12.25–12.91) | 13.22 (12.93–13.51) | 11.24 (10.91–11.56) | 13.17 (12.88–13.45) |
| 2016 | 12.66 (12.42–12.90) | 12.55 (12.23–12.88) | 12.83 (12.50–13.16) | 10.73 (10.44–11.03) | 13.05 (12.80–13.30) |
| 2017 | 13.00 (12.74–13.27) | 12.88 (12.49–13.28) | 13.20 (12.90––13.51) | 11.18 (10.67–11.68) | 13.40 (13.10–13.69) |
| 2018 | 12.86 (12.63––13.10) | 12.57 (12.24–12.89) | 13.29 (13.01–13.57) | 10.96 (10.60–11.31) | 13.18 (12.94–13.43) |
Data are presented as mean (95% confidence interval).
Significant increase in the mean age of first cigarette use was found from 2011 to 2018 (P < .05).
Significant decrease in the mean age of first cigarette use was found from 2011 to 2018 (P < .05).
Trends in E-cigarette Use Frequency
The trends in e-cigarette use frequency among current cigarette smokers from 2014 to 2018, stratified by demographic characteristics, are presented in Figs 4 and 5. The percentage of current smokers using e-cigarettes ≥10 days, ≥20 days, and all 30 days increased 20.1 percentage points (from 20.8% to 40.9%), 18.2 percentage points (from 13.5% to 31.7%), and 12.7 percentage points (from 9.3% to 22.0%), respectively, over the 4-year period (Fig 4). A similar increase was found among male, female, middle school, and high school students as well as race and ethnicity subgroups. However, the trends were not significant for the percentage of current female smokers using e-cigarettes ≥10 days (from 18.6% to 30.1%; Fig 4) and percentage of current Hispanic smokers using e-cigarettes ≥20 days (from 18.7% to 26.5%; Fig 5) or using e-cigarettes every day (from 15.1% to 20.1%; Fig 5).
E-cigarette use frequency among current cigarette smokers from 2014 to 2018, stratified by race and ethnicity. Current cigarette smokers were defined as students who smoked cigarettes on ≥1 of the 30 days before the survey. E-cigarette use frequency was measured by the number of days e-cigarette was used in the past 30 days: used e-cigarettes ≥10 days, used e-cigarettes ≥20 days, and used e-cigarettes every day (all 30 days). NH, non-Hispanic.
E-cigarette use frequency among current cigarette smokers from 2014 to 2018, stratified by race and ethnicity. Current cigarette smokers were defined as students who smoked cigarettes on ≥1 of the 30 days before the survey. E-cigarette use frequency was measured by the number of days e-cigarette was used in the past 30 days: used e-cigarettes ≥10 days, used e-cigarettes ≥20 days, and used e-cigarettes every day (all 30 days). NH, non-Hispanic.
Discussion
We examined 2011–2018 NYTS data to determine trends in smoking frequency, smoking intensity, and age of first cigarette use among current cigarette smokers. Over the period, current youth smokers smoked fewer days and fewer CPDs, and the age of first cigarette use increased. However, in subgroup analyses by grade and sex, we identified important differences.
The percentage of current smokers smoking ≥10 days, ≥20 days, and all 30 days decreased significantly over the 8 years. We found that the percentage of current smokers smoking at least 10, 20, and all 30 days decreased among male, female, high school, non-Hispanic white, and non-Hispanic other subgroups. These trends highlight decreasing cigarette use frequency among current cigarette smokers. In contrast, Bold et al23 found an increase in frequency of cigarette use from 2013 to 2015 among high school students. However, Bold et al’s23 study was among Connecticut students, which is not a nationally representative sample, and their analyses did not appear to control for age or grade.
We found that from 2011 to 2018, most youth smokers smoked less intensely. Notably, light smoking (≤5 CPDs) among current cigarette users increased significantly. Similarly, Jones et al10 found that light smokers increased from 67.2% in 1991 to 79.4% in 2009. We also found that light smoking increased significantly among female, high school, non-Hispanic white, and non-Hispanic other subgroups. In the current study, moderate smoking decreased significantly overall and among female and high school students. The number of previous comparable studies is limited, but authors of a national study of US adults found that from 2005 to 2014, the mean number of cigarettes smoked for adult daily smokers decreased from 16.7 to 13.8.21 Our results also indicate that heavy smoking decreased significantly among female students but increased significantly among male students from 2011 to 2018, thus highlighting the importance of stratifying by sex.
In the current study, the frequency of e-cigarette use among current smokers increased significantly over the period. This trend was also significant in almost every demographic subgroup. These results are in line with evidence that current youth e-cigarette use increased 78% from 2017 to 2018.24 This finding suggests that some youth might be reducing cigarette use in favor of e-cigarettes while still continuing to smoke. Although there is some evidence that e-cigarettes contain fewer toxicants than combustible cigarettes, they still contain nicotine, ultrafine particles, chemicals, organic compounds, and heavy metals that can lead to serious health consequences, such as e-cigarette or vaping product use–associated lung injury and cancer.14,25 Evidence also shows that dual use of cigarettes and e-cigarettes is positively associated with illicit substance use, alcohol use, truancy, and poor academic performance and is negatively related to quit intention.11,18–20 The increase we observed in e-cigarette use among cigarette smokers is concerning and warrants further investigation.
Over the 8 years analyzed, the mean age of first cigarette use increased significantly. In the demographic subgroup analyses, we found a significant increasing trend among female, high school, and non-Hispanic other students. However, the mean age of first use decreased significantly among male students during the same period. It appears male youth smokers are starting earlier and smoking more intensely.
The contrast found in trends among young men and women could stem from differences in social behavior and roles.26 Authors of 1 study of high school students concluded that the number of cigarettes smoked in a day is a good measure for current smoking among young women but not young men.26 In a 2006 study of high school students, smoking was positively associated with buzz, pleasure, taste and/or smell, and stimulation and was negatively associated with exercise and/or sport impairment among boys. Among girls, weight control was positively associated with smoking, whereas negative aesthetics, addiction, and negative mood were negatively associated with smoking.27 The differences in smoking behaviors by sex are notable because they could impact responses to tobacco control efforts targeted to youth.27
In our analyses of NYTS data post-FDA’s regulation of cigarettes, there were important improvements in youth cigarette-smoking frequency, intensity, and age of first use. As part of the FSPTCA, the FDA targets youth and young adults through educational campaigns such as The Real Cost. Some estimates suggest these efforts have reduced youth cigarette use,28 which is in line with our trend analyses. However, our subgroup analyses highlight that male youth smokers remain a priority population. Additionally, increases in light smoking and e-cigarette use may suggest youth are smoking less but not necessarily quitting. Thus, efforts to educate youth about the harms of any tobacco use might be warranted.
There are several limitations to this study. Because analyses relied on survey responses, the results may be subject to recall bias. In addition, the survey was administered in a school setting, which resulted in the exclusion of youth who are not enrolled or were not in attendance. Survey participation was also optional and required parent permission, which may have introduced nonresponse bias. Despite limitations, this study is unique in its analysis of US youth smoking trends, stratified by sex and age group.
Conclusions
In this study, we used the NYTS to examine the trends of smoking behaviors among middle and high school students in the United States from 2011 to 2018. The percentage of current smokers smoking at least 10, 20, and all 30 days decreased significantly overall and among male, female, and high school subgroups. Past-month e-cigarette use frequency rose significantly, surpassing cigarette use in 2018, highlighting the need for improved e-cigarette prevention and cessation strategies. Light smoking among current cigarette users increased significantly overall and among female and high school subgroups. Moderate smoking decreased significantly overall and among female and high school students. Heavy smoking decreased significantly among female students but increased significantly among male students. The mean age of first use of cigarettes increased significantly overall and among female and high school students but decreased significantly among male students. Differences in results between young men and women are of particular note and can help inform future research and interventions.
Dr Azagba conceptualized and designed the study and supervised all aspects of the study; Mr Shan conducted the data analysis; and all authors contributed to the drafting of the manuscript, critically reviewed the manuscript, and approved the final manuscript as submitted.
FUNDING: No external funding.
Comments
RE: Trends in Smoking Behaviors Among US Adolescent Cigarette Smokers: Letter to the Editor
Article
Trends in Smoking Behaviors Among US Adolescent Cigarette Smokers
Sunday Azagba, Lauren Manzione, Lingpeng Shan and Jessica King
Pediatrics March 2020, 145 (3) e20193047; DOI: https://doi.org/10.1542/peds.2019-3047
Trends in Smoking Behaviors Among US Adolescent Cigarette Smokers: Letter to the Editor
Tyler Blair, Student, Utica College
• Other Contributors:
• Mary Siniscarco, MS, OTR/L, Associate Professor of Health Studies
Dear Editor,
We read with great interest the article “Trends in smoking behaviors among US adolescent cigarette smokers” by Azagba et al.1 The authors reported a decline in smoking from 2011 to 2018 in frequency, amplitude, and initial exposure for most age ranges in the youth population (middle school to high school).1 Although most incidences of smoking have decreased, the prevalence of e-cigarettes continues to rise.1,2 “The percent of high school seniors who had used an e-cigarette in the past 30 days increased from 1.5 percent in 2010 to 26.7 percent in 2018.”2 One of the main health concerns related to vaping in youth populations is bronchiolitis obliterans, or, “popcorn lung.”3 Consequently, popcorn lung can cause major damage to the lungs, leading to hospitalizations and in extreme cases, death.3 In order to prevent potential long-term health effects of such prolific lung damage to developing children 4, an aggressive public health campaign regarding an e-cigarette vaping cessation program is indicated, immediately. As health care professionals, we need to begin such an initiative at an elementary school level while utilizing an interdisciplinary approach.
In particular, D.A.R.E. (Drug Abuse Resistance Education) has introduced education plans for middle and high school levels to address the present vaping crisis however, such has not been implemented at a national level for all elementary schools.5 An elementary “friendly” prevention approach needs to be instituted at a national level. At present, the state of Minnesota has already implemented a statewide initiative focused on the e-cig and vaping issue at hand with educational resources for students, teachers, parents, and administrators.6 Another disturbing research trend as mentioned by Azagba and colleagues is the fact that boys started smoking sooner and with an increased amplitude;1 such trends may be due to social behavior and roles. 1
Through “consultation and collaboration”7, with other health care workers, Occupational Therapists have a prominent role in health promotion and disease prevention.7 This can be applied to vaping abuse in the elementary school population. Although Occupational Therapists need to operate within their scope of practice, they can specifically offer the following therapeutic interventions to prevent e-cigarette and vaping use such as: “promoting healthy lifestyles; emphasizing occupation as an essential element of health promotion strategies; and providing interventions, not only with individuals but also with populations.”7 In addition to this, they can offer some level of education on the subject matter as a “primary prevention intervention.”7 In sum, as a society, we are in great need of therapeutic intervention with regards to providing e-cigarette vaping cessation educational programs starting at the elementary school level; Occupational Therapists can be part of the interdisciplinary solution.
1 Azagba S, Manzione L, Shan L, King J. Trends in Smoking Behaviors Among US Adolescent Cigarette Smokers. Pediatrics. 2020;145(3). doi:10.1542/peds.2019-3047
2 Office of Adolescent Health. Adolescents and Tobacco: Trends. HHS.gov. https://www.hhs.gov/ash/oah/adolescent-development/substance-use/drugs/t.... Published May 1, 2019. Accessed April 10, 2020.
3 Landman ST, Dhaliwal I, Mackenzie CA, Martinu T, Steele A, Bosma KJ. Life-threatening bronchiolitis related to electronic cigarette use in a Canadian youth. Canadian Medical Association Journal. 2019;191(48). doi:10.1503/cmaj.191402
4 Smoking as an occupation: Occupational therapists' perspectives. Forensicare. https://www.forensicare.vic.gov.au/researcheducation-2/research-projects.... Published February 20, 2017. Accessed April 10, 2020.
5 D.A.R.E. Responds to Vaping Crisis with New Enhancement Lesson. D.A.R.E. America. https://dare.org/d-a-r-e-responds-to-vaping-crisis-with-new-enhancement-.... Accessed April 10, 2020.
6 5 School E-cigarette Toolkit: Addressing Student Use of E-cigarettes and Vapes. Minnesota Department of Health. https://www.health.state.mn.us/communities/tobacco/ecigarettes/docs/scho.... Published October 7, 2019. Accessed April 10, 2020.
7 Occupational Therapy Services in the Promotion of Health and the Prevention of Disease and Disability. American Journal of Occupational Therapy. 2008;62(6):694-703. doi:10.5014/ajot.62.6.694