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Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students — United States, 2011–2018

Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students — United States, 2011–2018

Authors:  Karen A. Cullen, PhD1; Bridget K. Ambrose, PhD1; Andrea S. Gentzke, PhD2; Benjamin J. Apelberg, PhD1; Ahmed Jamal, MBBS2; Brian A. King, PhD2 (View author affiliations)

Electronic cigarettes (e-cigarettes) are battery-powered devices that provide nicotine and other additives to the user in the form of an aerosol (1). E-cigarettes entered the U.S. marketplace in 2007 (1), and by 2014, e-cigarettes were the most commonly used tobacco product among U.S. youths (2). Data from the 2011–2018 National Youth Tobacco Survey (NYTS), a cross-sectional, voluntary, school-based, self-administered, pencil-and-paper survey of U.S. middle and high school students, were analyzed to determine the prevalence of current use (≥1 day in past 30 days) of e-cigarettes,* current use of any tobacco product, frequency of (number of days during the preceding 30 days) e-cigarette use, and current use (any time during preceding 30 days) of any flavored e-cigarettes among U.S. middle school (grades 6–8) and high school (grades 9–12) students. Logistic regression (2011–2018) and t-tests (2017–2018) were performed to determine statistically significant differences (p<0.05).

Among high school students, current e-cigarette use increased from 1.5% (220,000 students) in 2011 to 20.8% (3.05 million students) in 2018 (p<0.001) (Figure). During 2017–2018, current e-cigarette use increased by 78% (from 11.7% to 20.8%, p<0.001). The proportion of current e-cigarette users who reported use on ≥20 of the past 30 days increased from 20.0% in 2017 to 27.7% in 2018 (p = 0.008). Among high school students, during 2017–2018, current use of any flavored e-cigarettes increased among current e-cigarette users (from 60.9% to 67.8%, p = 0.02); current use of menthol- or mint-flavored e-cigarettes increased among all current e-cigarette users (from 42.3% to 51.2%, p = 0.04) and current exclusive e-cigarette users (from 21.4% to 38.1%, p = 0.002).

Among middle school students, current e-cigarette use increased from 0.6% in 2011 (60,000 students) to 4.9% (570,000 students) in 2018 (p<0.001) (Figure). During 2017–2018, current e-cigarette use increased by 48% (from 3.3% to 4.9%, p = 0.001); the proportion of current e-cigarette users who reported use on ≥20 days of the past 30 days did not significantly change (from 12.9% to 16.2%, p = 0.26).

Current use of any tobacco product among high school students was 24.2% (3.69 million students) in 2011 and 27.1% (4.04 million students) in 2018 (p>0.05) (Figure). Current use of any tobacco product among middle school students was 7.5% (870,000 students) in 2011 and 7.2% (840,000 students) in 2018 (p>0.05). During 2017–2018, overall tobacco product use increased by 38% among high school students (from 19.6% to 27.1%, p<0.001) and by 29% among middle school students (from 5.6% to 7.2%, p = 0.008).

Current e-cigarette use increased considerably among U.S. middle and high school students during 2017–2018, reversing a decline observed in recent years and increasing overall tobacco product use (3). Moreover, during 2017–2018, frequent e-cigarette use increased among high school students. Although e-cigarettes have the potential to benefit adult smokers if used as a complete substitute for combustible tobacco smoking, the use of any form of tobacco product among youths, including e-cigarettes, is unsafe (1). The Surgeon General has concluded that e-cigarette use among youths and young adults is of public health concern; exposure to nicotine during adolescence can cause addiction and can harm the developing adolescent brain (1).

The rise in e-cigarette use during 2017–2018 is likely because of the recent popularity of e-cigarettes shaped like a USB flash drive, such as JUUL; these products can be used discreetly, have a high nicotine content, and come in flavors that appeal to youths (4). In September 2018, the Food and Drug Administration (FDA) issued more than 1,300 warning letters and civil money penalty fines to retailers who illegally sold e-cigarette products to minors, the majority of which were blu, JUUL, Logic, MarkTen XL, and Vuse; this was the largest coordinated enforcement effort in FDA’s history (5). Sustained implementation of proven population-based strategies, in coordination with the regulation of tobacco products by FDA, is key to reducing all forms of tobacco product use and initiation, including e-cigarettes, among U.S. youths (1).

8 in 10 Support raising the minimum age to purchase tobacco products, e-cigarettes, and vaping devices to 21

Last week, Texas Medical Center, in Houston released a nationwide survey that found:

-82 percent of Americans support preventing the sale of all tobacco products to people under the age of 21;
-80 percent of Americans support preventing the sale of e-cigarettes and other vaping devices to anyone under age 21;
-79 percent of Americans support limiting the amount of nicotine in tobacco products;
-65 percent of Americans support banning the use of candy and fruit flavorings in e-cigarettes and other vaping products;
-60 percent of Americans support banning the use of candy and fruit flavorings in cigars and cigarillos;
-60 percent of Americans support banning the use of menthol, a minty flavoring, in cigarettes; and
-52 percent of Americans support banning the sale of all tobacco products.

The relevant findings were based on a nationwide survey of more than 4,000 people.
See graphic of these statistics here:

smoking_data

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

The CDC long recognized racial/ethnic disparities in tobacco product use among the largest racial/ethnic groups in the US. But, they wanted to know more about tobacco use among youths. Pooled data from the 2014 – 2017 National Youth Tobacco Surveys were used to assess use of cigarettes, cigars, smokeless tobacco, e-cigarettes, hookahs, pipes, and bidis among US middle and high school students from white, black, Hispanic, Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and multiracial students.

Among highlights are highest current tobacco use is among Native Hawaiians / Other Pacific Islanders and lowest tobacco use is among Asians. E-cigarettes are the most commonly-used tobacco products overall. The paper noted observed disparities in tobacco product use might be attributable to racial/ethnic variations in targeted tobacco industry advertising, marketing, and promotional activities.

The paper noted evidence-based strategies proven to reduce youth tobacco use include tobacco product price increases, clean indoor air policies, advertising and promotion restrictions, national public education
campaigns, bans on flavored tobacco products, and raising the minimum legal sales age of tobacco products to 21 years.

More U.S. stores likely sell cigarettes to minors than reported

Researchers determined that more than half of retail stores may be inadvertently, and illegally, selling cigarettes to underage buyers, according to the results published in JAMA Pediatrics.

Federal estimates are based on single visits to stores, the researchers note. The new study was based on six visits per store by teens too young to purchase cigarettes. Sometimes the teenage buyers were turned away, but sometimes a clerk at a store that refused one teen would allow another to purchase cigarettes.

“Policy makers need to understand that the way they are monitoring illegal sales from retail stores is pretty seriously flawed,” said the study’s lead author, Arnold Levinson, an associate professor of community and behavioral health at the Colorado School of Public Health in Aurora.

With the government underestimating illegal sales, it’s unlikely there will be stricter enforcement, Levinson added.

For the new study, Levinson and his colleagues rounded up 17 clean-cut teens between the ages of 15 and 16. The teens were sent into 201 convenience stores, liquor stores, groceries, gas stations and other tobacco retailers in Colorado’s Jefferson County to try to purchase cigarettes. The teens were told it was up to them whether to present an ID if asked for one. Most did. But in many cases the clerks gave the ID only a cursory glance and then handed over the cigarettes.

The researchers determined that 55 percent of retailers sold cigarettes during at least one of the six visits by the underage study volunteers. And 53 out of the 201 stores, or just over 24 percent, sold to the minor volunteers at least twice, while 24 out of 201, or about 12 percent sold to the volunteers three or more times.

Levinson points out that there is a move to raise the age at which tobacco can be purchased nationwide to 21. “That would make a huge difference,” he said. “But it would require consistent firm enforcement, which brings us back to this article. Which shows we’re not doing very well. So if we increase the age we’ve got to increase the monitoring and enforcement.”

Local doctor tests Tobacco 21 enforcement; says 9 stores sold to underage teen

FRANKLIN COUNTY, Ohio
A local doctor took research into his own hands when asking the Franklin County Board of Health to enforce city ordinance Tobacco 21.

“I don’t like surprising people like this, but I had to get their attention,” said Dr. Rob Crane, a family medicine physician for Ohio State. “I came to the same board meeting and made a presentation, down on one knee begging for their help and they ignored me.”

Tobacco 21 makes the legal age to purchase tobacco products 21 years of age in Bexley, Upper Arlington, New Albany, Grandview and Dublin.

Crane says he’s spent the last 16 months asking the Department to run youth-based stings as a way to see if retailers are following the law.

“They don’t want to be involved in stings. I’ve told them, this is not James Bond,” he said.
So, Crane worked with Christal Welch, a 19-year-old college student to see how many stores would sell to her.

Of the 18 stores they went to in the central Ohio area, nine sold to her overlooking her age or not checking ID.

“I was shocked,” Welch said. “Half the time they would ask ‘are you old enough?’, and I would say yes, but they didn’t ask for my ID. Other times, they would look at my ID that says I’ll be 21 in 2019, and they still sold it to me.”

Tuesday, Welch and Dr. Crane presented their findings to the Franklin County Board of Health.