Tobacco product use is the leading cause of preventable disease, disability, and death in the United States. This report used data from the 2019 Youth Risk Behavior Survey to assess the following among U.S. high school students: ever use of cigarettes and electronic vapor products, current use (≥1 day during the 30 days before the survey) of tobacco products, frequent use (≥20 days during the 30 days before the survey) among current users of tobacco products, trends in use over time, and usual source of electronic vapor products among current electronic vapor product users. In 2019, a total of 50.1% of U.S. high school students had ever used electronic vapor products, and 24.1% had ever tried cigarette smoking. Current electronic vapor product use was 32.7%, current cigarette smoking was 6.0%, current cigar smoking was 5.7%, and current smokeless tobacco use was 3.8%. Approximately 36.5% of students were current users of any tobacco product, and 8.2% were current users of two or more tobacco products. Frequent use among users of individual products was 32.6% for electronic vapor products, 28.5% for smokeless tobacco, 22.2% for cigarettes, and 18.4% for cigars. Among current electronic vapor product users who were aged ≤17 years, the most commonly reported source was borrowing them from someone else (42.8%). Significant decreases occurred in current cigarette smoking (1991: 27.5%; 2019: 6.0%), cigar smoking (1997: 22.0%; 2019: 5.7%), and smokeless tobacco use (2017: 5.5%; 2019: 3.8%). However, significant increases occurred in current electronic vapor product use (2015: 24.1%; 2019: 32.7%) and any tobacco product use (2017: 19.5%; 2019: 36.5%). Although current cigarette smoking, cigar smoking, and smokeless tobacco use has decreased among high school students, the increased prevalence of electronic vapor product use among youths is concerning. Continued surveillance for all tobacco product use is warranted for guiding and evaluating public health policy at the local, state, tribal, and national levels.

OBJECTIVE: To determine if the declining trend in U.S. youth cigarette smoking changed after e-cigarettes were introduced, and if youth e-cigarette users would have been likely to smoke cigarettes based on psychosocial and demographic predictors of smoking. METHODS: An interrupted time series analysis was used for cross-sectional data from the 2004 to 2018 National Youth Tobacco Surveys (NYTS) to assess changes in cigarette and e-cigarette use over time. A multivariable logistic regression model used 2004-2009 NYTS data on psychosocial risk factors to predict individual-level cigarette smoking risk from 2011 to 2018. Model-predicted and actual cigarette smoking behavior were compared. RESULTS: The decline in current cigarette smoking slowed in 2014 (-0.75 [95% CI: -0.81, -0.68] to -0.26 [95% CI: -0.40, -0.12] percentage points per year). The decline in ever cigarette smoking accelerated after 2012 (-1.45 [95% CI: -1.59, -1.31] to -1.71 [95% CI: -1.75, -1.66]). Ever and current combined cigarette and/or e-cigarette use declined during 2011-2013 and increased during 2013-2014 with no significant change during 2014-2018 for either variable. The psychosocial model estimated that 69.0% of current cigarette smokers and 9.3% of current e-cigarette users (who did not smoke cigarettes) would smoke cigarettes in 2018. CONCLUSIONS: The introduction of e-cigarettes was followed by a slowing decline in current cigarette smoking, a stall in combined cigarette and e-cigarette use, and an accelerated decline in ever cigarette smoking. Traditional psychosocial risk factors for cigarette smoking suggest that e-cigarette users do not fit the traditional risk profile of cigarette smokers.

This study examined patterns of tobacco product use and its influence on nicotine dependence among U.S. youth. Combined data from the 2017-2018 National Youth Tobacco Surveys were analyzed for students that reported current (past-30-day) use of e-cigarettes, cigarettes, cigars, smokeless tobacco, or hookah (n = 6106). Analyses assessed multiple product use (≥2 tobacco products) overall and by sex, school level, race/ethnicity, current use, and frequent use (use of a product for ≥20 of the preceding 30 days). Multivariable logistic regression was used to identify correlates of nicotine dependence. During 2017-2018, 40.8% of tobacco product users reported use of multiple products. Multiple product use ranged from 47.0% among e-cigarette users to 80.7% among cigarette users. Among frequent users of each respective product, 80.0% of cigarette smokers, 74.9% of cigar smokers, 73.6% of smokeless tobacco users, 70.7% of hookah smokers, and 40.3% of e-cigarette users reported use of multiple products. Most youth who reported nicotine dependence (64.0%) were multiple product users. E-cigarettes were the most common single product used (36.3%) and the product most commonly used in combination with other products; ecigarettes plus cigarettes (6.7%) was the most common product combination. Combustible product use, smokeless tobacco use, multiple product use and frequent use were associated with greater odds of nicotine dependence. Nicotine dependence among youth is especially influenced by cigarette use, smokeless tobacco use, frequent use of any tobacco product, and multiple product use. Proven tobacco control interventions in coordination with regulatory efforts can reduce youth tobacco product use.

PROBLEM/CONDITION: 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 smoked, smokeless, and electronic products. PERIOD COVERED: 2019. 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 is designed to provide national data on tobacco product use and has been conducted periodically during 1999-2009 and annually since 2011. Data from NYTS are used to support the design, implementation, and evaluation of comprehensive tobacco use prevention and control programs and to inform tobacco regulatory activities. Since its inception in 1999 through 2018, NYTS had been conducted via paper and pencil questionnaires. In 2019, NYTS for the first time was administered in schools using electronic data collection methods. CDC's Office on Smoking and Health, in collaboration with the U.S. Food and Drug Administration's (FDA's) Center for Tobacco Products, analyzed data from the 2019 NYTS to assess tobacco product use patterns and associated factors among U.S. middle and high school students. Overall, 19,018 questionnaires were completed and weighted to represent approximately 27.0 million students. On the basis of self-reported grade level, this included 8,837 middle school questionnaires (11.9 million students) and 10,097 high school questionnaires (15.0 million students); 84 questionnaires with missing information on grade level were excluded from school-level analyses. RESULTS: In 2019, an estimated 53.3% of high school students (8.0 million) and 24.3% of middle school students (2.9 million) reported having ever tried a tobacco product. Current (past 30-day) use of a tobacco product (i.e., electronic cigarettes [e-cigarettes], cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco, and bidis [small brown cigarettes wrapped in a leaf]) was reported by 31.2% of high school students (4.7 million) and 12.5% of middle school students (1.5 million). E-cigarettes were the most commonly cited tobacco product currently used by 27.5% of high school students (4.1 million) and 10.5% of middle school students (1.2 million), followed in order by cigars, cigarettes, smokeless tobacco, hookahs, and pipe tobacco. Tobacco product use also varied by sex and race/ethnicity. Among current users of each tobacco product, the prevalence of frequent tobacco product use (on >/=20 days of the preceding 30 days) ranged from 16.8% of cigar smokers to 34.1% of smokeless tobacco product users. Among current users of each individual tobacco product, e-cigarettes were the most commonly used flavored tobacco product (68.8% of current e-cigarette users). Among students who reported ever having tried e-cigarettes, the three most commonly selected reasons for use were "I was curious about them" (55.3%), "friend or family member used them" (30.8%), and "they are available in flavors, such as mint, candy, fruit, or chocolate" (22.4%). Among never users of each individual tobacco product, curiosity and susceptibility (a construct that can help to identify future tobacco product experimentation or use) was highest for e-cigarettes (39.1% and 45.0%, respectively) and cigarettes (37.0% and 45.9%, respectively). Overall, 86.3% of students who reported 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) reported exposure to marketing for any tobacco product; 69.3% reported exposure to e-cigarette marketing and 81.7% reported exposure to marketing for cigarettes or other tobacco products. Among all students, perceiving no harm or little harm from intermittent tobacco product use (use on some days but not every day) was 28.2% for e-cigarettes, 16.4% for hookahs, 11.5% for smokeless tobacco products, and 9.5% for cigarettes. Among current users of any tobacco product, 24.7% reported experiencing cravings to use tobacco products during the past 30 days and 13.7% reported wanting to use a tobacco product within 30 minutes of waking. Moreover, 57.8% of current tobacco product users reported they were seriously thinking about quitting the use of all tobacco products and 57.5% reported they had stopped using all tobacco products for >/=1 day because they were trying to quit. INTERPRETATION: In 2019, approximately one in four youths (23.0%) had used a tobacco product during the past 30 days. By school level, this represented approximately three in 10 high school students (31.2%) and approximately one in eight middle school students (12.5%). Since 2014, e-cigarettes have been the most commonly used tobacco product among youths. Importantly, more than half of current youth tobacco product users reported seriously thinking about quitting all tobacco products in 2019. However, established factors of use and initiation, including the availability of flavors, exposure to tobacco product marketing, curiosity and susceptibility, and misperceptions about harm from tobacco product use, remained prevalent in 2019 and continue to promote tobacco product use among youths. 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 community levels. Everyone, including public health professionals, health care providers, policymakers, educators, parents, and others who influence youths, can help protect youths from the harms of all tobacco products. 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.

Cigarette smoking is the leading cause of preventable disease and death in the United States (1). The prevalence of adult cigarette smoking has declined in recent years to 14.0% in 2017 (2). However, an array of new tobacco products, including e-cigarettes, has entered the U.S. market (3). To assess recent national estimates of tobacco product use among U.S. adults aged >/=18 years, CDC, the Food and Drug Administration (FDA), and the National Cancer Institute analyzed data from the 2018 National Health Interview Survey (NHIS). In 2018, an estimated 49.1 million U.S. adults (19.7%) reported currently using any tobacco product, including cigarettes (13.7%), cigars (3.9%), e-cigarettes (3.2%), smokeless tobacco (2.4%), and pipes* (1.0%). Most tobacco product users (83.8%) reported using combustible products (cigarettes, cigars, or pipes), and 18.8% reported using two or more tobacco products. The prevalence of any current tobacco product use was higher in males; adults aged </=65 years; non-Hispanic American Indian/Alaska Natives; those with a General Educational Development certificate (GED); those with an annual household income <$35,000; lesbian, gay, or bisexual adults; uninsured adults; those with a disability or limitation; and those with serious psychological distress. The prevalence of e-cigarette and smokeless tobacco use increased during 2017-2018. During 2009-2018, there were significant increases in all three cigarette cessation indicators (quit attempts, recent cessation, and quit ratio). Implementing comprehensive population-based interventions in coordination with regulation of the manufacturing, marketing, and distribution of all tobacco products can reduce tobacco-related disease and death in the United States (1,4).

Importance: The prevalence of e-cigarette use among US youth increased from 2011 to 2018. Continued monitoring of the prevalence of e-cigarette and other tobacco product use among youth is important to inform public health policy, planning, and regulatory efforts. Objective: To estimate the prevalence of e-cigarette use among US high school and middle school students in 2019 including frequency of use, brands used, and use of flavored products. Design, Setting, and Participants: Cross-sectional analyses of a school-based nationally representative sample of 19018 US students in grades 6 to 12 participating in the 2019 National Youth Tobacco Survey. The survey was conducted from February 15, 2019, to May 24, 2019. Main Outcomes and Measures: Self-reported current (past 30-day) e-cigarette use estimates among high school and middle school students; frequent use (>/=20 days in the past 30 days) and usual e-cigarette brand among current e-cigarette users; and use of flavored e-cigarettes and flavor types among current exclusive e-cigarette users (no use of other tobacco products) by school level and usual brand. Prevalence estimates were weighted to account for the complex sampling design. Results: The survey included 10097 high school students (mean [SD] age, 16.1 [3.0] years; 47.5% female) and 8837 middle school students (mean [SD] age, 12.7 [2.8] years; 48.7% female). The response rate was 66.3%. An estimated 27.5% (95% CI, 25.3%-29.7%) of high school students and 10.5% (95% CI, 9.4%-11.8%) of middle school students reported current e-cigarette use. Among current e-cigarette users, an estimated 34.2% (95% CI, 31.2%-37.3%) of high school students and 18.0% (95% CI, 15.2%-21.2%) of middle school students reported frequent use, and an estimated 63.6% (95% CI, 59.3%-67.8%) of high school students and 65.4% (95% CI, 60.6%-69.9%) of middle school students reported exclusive use of e-cigarettes. Among current e-cigarette users, an estimated 59.1% (95% CI, 54.8%-63.2%) of high school students and 54.1% (95% CI, 49.1%-59.0%) of middle school students reported JUUL as their usual e-cigarette brand in the past 30 days; among current e-cigarette users, 13.8% (95% CI, 12.0%-15.9%) of high school students and 16.8% (95% CI, 13.6%-20.7%) of middle school students reported not having a usual e-cigarette brand. Among current exclusive e-cigarette users, an estimated 72.2% (95% CI, 69.1%-75.1%) of high school students and 59.2% (95% CI, 54.8%-63.4%) of middle school students used flavored e-cigarettes, with fruit, menthol or mint, and candy, desserts, or other sweets being the most commonly reported flavors. Conclusions and Relevance: In 2019, the prevalence of self-reported e-cigarette use was high among high school and middle school students, with many current e-cigarette users reporting frequent use and most of the exclusive e-cigarette users reporting use of flavored e-cigarettes.

INTRODUCTION: Tobacco use is the leading cause of preventable disease and death in the United States; nearly all tobacco product use begins during youth and young adulthood. METHODS: CDC, the Food and Drug Administration, and the National Cancer Institute analyzed data from the 2011-2018 National Youth Tobacco Surveys to estimate tobacco product use among U.S. middle and high school students. Prevalence estimates of current (past 30-day) use of seven tobacco products were assessed; differences over time were analyzed using multivariable regression (2011-2018) or t-test (2017-2018). RESULTS: In 2018, current use of any tobacco product was reported by 27.1% of high school students (4.04 million) and 7.2% of middle school students (840,000); electronic cigarettes (e-cigarettes) were the most commonly used product among high school (20.8%; 3.05 million) and middle school (4.9%; 570,000) students. Use of any tobacco product overall did not change significantly during 2011-2018 among either school level. During 2017-2018, current use of any tobacco product increased 38.3% (from 19.6% to 27.1%) among high school students and 28.6% (from 5.6% to 7.2%) among middle school students; e-cigarette use increased 77.8% (from 11.7% to 20.8%) among high school students and 48.5% (from 3.3% to 4.9%) among middle school students. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: A considerable increase in e-cigarette use among U.S. youths, coupled with no change in use of other tobacco products during 2017-2018, has erased recent progress in reducing overall tobacco product use among youths. The sustained implementation of comprehensive tobacco control strategies, in coordination with Food and Drug Administration regulation of tobacco products, can prevent and reduce the use of all forms of tobacco products among U.S. youths.

The author of a recent letter, who declared interests related to the tobacco and electronic cigarette industries, critiqued the objectivity and evidence related to the 2016 US Surgeon General’s Report, E-cigarette Use Among Youth and Young Adults.1 The 2016 report was compiled using a longstanding, peer-reviewed, and comprehensive process to safeguard the scientific rigor and practical relevance of US Surgeon General’s Reports on Tobacco. In this commentary, we describe that process in detail, including specific components that clarify and correct the assertions made in the aforementioned critique.

The 1994-1995 National Health Interview Survey on Disability (NHIS-D) has been one of the most unique and important data sources for studying disability, impairment, and health in the United States. In celebration of the NHIS-D's twenty-year anniversary, we created an extensive bibliography (n=212) of research that has used these data.