Last data update: May 20, 2024. (Total: 46824 publications since 2009)
Records 1-30 (of 32 Records) |
Query Trace: Cullen KA[original query] |
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Tobacco product use among U.S. Middle and high school students - National Youth Tobacco Survey, 2023
Birdsey J , Cornelius M , Jamal A , Park-Lee E , Cooper MR , Wang J , Sawdey MD , Cullen KA , Neff L . MMWR Morb Mortal Wkly Rep 2023 72 (44) 1173-1182 Tobacco product use during adolescence increases the risk for lifelong nicotine addiction and adverse health consequences. CDC and the Food and Drug Administration analyzed data from the 2023 National Youth Tobacco Survey to assess tobacco product use patterns among U.S. middle school (grades 6-8) and high school (grades 9-12) students. In 2023, 10.0% of middle and high school students (2.80 million) reported current (i.e., past 30-day) use of any tobacco product. Current use of any tobacco product by high school students declined by an estimated 540,000, from 2.51 million in 2022 to 1.97 million in 2023. From 2022 to 2023, current e-cigarette use among high school students declined from 14.1% to 10.0%. Among middle and high school students, e-cigarette products were the most used tobacco product in 2023 (7.7%; 2.13 million), followed by cigarettes (1.6%), cigars (1.6%), nicotine pouches (1.5%), smokeless tobacco (1.2%), other oral nicotine products (1.2%), hookahs (1.1%), heated tobacco products (1.0%), and pipe tobacco (0.5%). Among students who had ever used an e-cigarette, 46.7% reported current use. In 2023, among students reporting current e-cigarette use, 89.4% used flavored products and 25.2% used an e-cigarette daily; the most commonly reported brands were Elf Bar, Esco Bars, Vuse, JUUL, and Mr. Fog. Given the number of middle and high school students that use tobacco products, sustained efforts to prevent initiation of tobacco product use among young persons and strategies to help young tobacco users quit are critical to reducing U.S. youth tobacco product use. |
Nicotine pouch awareness and use among youth, National Youth Tobacco Survey, 2021
Kramer RD , Park-Lee E , Marynak KL , Jones JT , Sawdey MD , Cullen KA . Nicotine Tob Res 2023 25 (9) 1610-1613 INTRODUCTION: This manuscript examines prevalence of awareness and use of nicotine pouches among U.S. middle and high school students by sociodemographic characteristics and other tobacco product use and characterizes nicotine pouch and other tobacco product use behaviors among current nicotine pouch users. AIMS AND METHODS: Data are from the 2021 National Tobacco Youth Survey, a cross-sectional, school-based survey of middle and high school students (N = 20 413; overall response rate: 44.6%), which included questions on nicotine pouches in 2021 for the first time. Prevalence estimates, 95% confidence intervals, and estimated population counts were assessed for nicotine pouch awareness, ever use, and current (past 30 days) use, and for use behaviors related to nicotine pouches (frequency of use, flavor(s) used) and other tobacco products (ever, current, frequency of use) among current nicotine pouch users. RESULTS: Over one-third of students (35.5%) had ever heard of nicotine pouches. An estimated 1.9% (490 000) reported ever using them, while 0.8% (200 000) reported current use. Among current nicotine pouch users, 61.6% reported flavored nicotine pouch use, 64.2% reported current e-cigarette use, and 52.6% used multiple (≥2) tobacco products. Current use of nicotine pouches was common among current smokeless tobacco users (41.3%). CONCLUSIONS: Overall, in 2021, while relatively few students had ever tried nicotine pouches or currently used them, more than one-third had heard of them. Current nicotine pouch users tended to use other tobacco products, particularly e-cigarettes and smokeless tobacco. Given previous rapid increases in youth uptake of e-cigarettes, it is important to continue monitoring nicotine pouch use among young people. IMPLICATIONS: This study's findings provide an important baseline for future monitoring of nicotine pouch awareness and use among middle and high school students. Emerging tobacco products, particularly those that are flavored, widely available, discreet, and inexpensive have the potential to attract youth. Given the potential of these products to appeal to young people, ongoing monitoring of nicotine pouch use behaviors is important to inform public health and regulatory efforts. |
Impact of survey setting on current tobacco product use: National Youth Tobacco Survey, 2021
Park-Lee E , Gentzke AS , Ren C , Cooper M , Sawdey MD , Hu SS , Cullen KA . J Adolesc Health 2022 72 (3) 365-374 PURPOSE: To examine whether survey setting was associated with youth reporting of current (past 30-day) use of any tobacco product, e-cigarettes, cigarettes, and cigars. METHODS: Data from the 2021 National Youth Tobacco Survey (NYTS) were used to estimate the prevalence of current use of any tobacco product, e-cigarettes, cigarettes, and cigars by survey setting, sociodemographic characteristics, peer tobacco use, and other tobacco product use. Multivariable regression was used to test the impact of survey setting on current tobacco use. Tobacco access sources among current users were compared by survey setting. RESULTS: Among students who participated in the 2021 NYTS, 50.8% reported taking the survey on school campus and 49.2% at home/other place. The prevalence of current use of any tobacco product, e-cigarettes, cigarettes, and cigars was higher among students completing the survey on school campus than at home/other place. After adjusting for covariates, this association persisted only for current use of any tobacco product (adjusted odds ratio = 1.57; 95% confidence interval, 1.28-1.91) and e-cigarettes (adjusted odds ratio = 1.43; 95% confidence interval, 1.20-1.71). Current users reported similar sources of access to tobacco products, regardless of survey setting. DISCUSSION: The likelihood of youth reporting current use of any tobacco product and e-cigarettes differed by survey setting. Such differences could be due to lack of privacy at home, peer influence in school settings, and other unmeasured characteristics. Methodological changes were made due to COVID-19; caution is warranted in comparing results from the 2021 NYTS with those of previous or future NYTS conducted primarily on school campus. |
Tobacco product use among middle and high school students - United States, 2022
Park-Lee E , Ren C , Cooper M , Cornelius M , Jamal A , Cullen KA . MMWR Morb Mortal Wkly Rep 2022 71 (45) 1429-1435 Tobacco use* is the leading cause of preventable disease, disability, and death among adults in the United States (1). Youth use of tobacco products in any form is unsafe, and nearly all tobacco use begins during youth and young adulthood (2). The Food and Drug Administration (FDA) and CDC analyzed data from the 2022 National Youth Tobacco Survey (NYTS) to estimate current (past 30-day) use of eight tobacco products among U.S. middle (grades 6-8) and high school (grades 9-12) students. In 2022, approximately 11.3% of all students (representing 3.08 million persons) reported currently using any tobacco product, including 16.5% of high school and 4.5% of middle school students (2.51 million and 530,000 persons, respectively). Electronic cigarettes (e-cigarettes) were the most commonly used tobacco product among high school (14.1%; 2.14 million) and middle school (3.3%; 380,000) students. Approximately 3.7% of all students (representing 1 million persons) reported currently smoking any combustible tobacco product. Current use of any tobacco product was higher among certain population groups, including 13.5% of non-Hispanic American Indian or Alaska Native (AI/AN)(†) students; 16.0% of students identifying as lesbian, gay, or bisexual (LGB); 16.6% of students identifying as transgender; 18.3% of students reporting severe psychological distress; 12.5% of students with low family affluence; and 27.2% of students with low academic achievement. Implementation of comprehensive evidence-based tobacco control strategies, combined with FDA regulation, is important for preventing and reducing youth tobacco product use (1,2). |
Notes from the field: E-cigarette use among middle and high school students - United States, 2022
Cooper M , Park-Lee E , Ren C , Cornelius M , Jamal A , Cullen KA . MMWR Morb Mortal Wkly Rep 2022 71 (40) 1283-1285 Since 2014, e-cigarettes have been the most commonly used tobacco product among U.S. middle and high school students (1). Most e-cigarettes contain nicotine, which is highly addictive, can harm the developing adolescent brain, and can increase risk for future addiction to other drugs (2). Among middle and high school current e-cigarette users (i.e., use on ≥1 day during the past 30 days), use of disposable e-cigarette devices* increased significantly between 2019 and 2020 (3) and was the most commonly used device type reported in 2021 (4). In 2020 and 2021, approximately eight in 10 middle and high school students who used e-cigarettes reported using flavored e-cigarettes (4,5). CDC and the Food and Drug Administration (FDA) analyzed nationally representative data from the 2022 National Youth Tobacco Survey (NYTS), a school-based, cross-sectional, self-administered survey conducted during January 18–May 31, 2022,† using a web-based survey instrument and administered to U.S. middle school (grades 6–8) and high school (grades 9–12) students.§ Participating students could complete the survey whether they were physically in school or at home engaging in remote learning; 99.3% of students reported completing the survey in school. Current e-cigarette use was assessed overall and by frequency of use, device type, flavors, and brands used (any brand used and usual brand used).¶ Weighted prevalence estimates and population totals were calculated.** The NYTS study protocol was reviewed and approved by CDC’s institutional review board.†† |
Tobacco product use and associated factors among middle and high school students - national youth tobacco survey, United States, 2021
Gentzke AS , Wang TW , Cornelius M , Park-Lee E , Ren C , Sawdey MD , Cullen KA , Loretan C , Jamal A , Homa DM . MMWR Surveill Summ 2022 71 (5) 1-29 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. |
Notes from the field: E-cigarette use among middle and high school students - National Youth Tobacco Survey, United States, 2021
Park-Lee E , Ren C , Sawdey MD , Gentzke AS , Cornelius M , Jamal A , Cullen KA . MMWR Morb Mortal Wkly Rep 2021 70 (39) 1387-1389 Since 2014, e-cigarettes have been the most commonly used tobacco product among U.S. youths (1). In 2020, an estimated 3.6 million (13.1%) U.S. middle and high school students reported using e-cigarettes within the past 30 days (current use); more than 80% of current users reported flavored e-cigarette use (2). Whereas the most commonly used device type in 2019 and 2020 was a prefilled pod or cartridge, disposable e-cigarette use increased significantly during this time among youths who currently used e-cigarettes in middle school (from 3.0% to 15.2%) and high school (from 2.4% to 26.5%) (3). CDC and the Food and Drug Administration (FDA) analyzed nationally representative data from the 2021 National Youth Tobacco Survey (NYTS), a school-based, cross-sectional, self-administered survey of U.S. middle school (grades 6–8) and high school (grades 9–12) students conducted during January 18–May 21, 2021 (20,413 students from 279 schools; overall response rate = 44.6%). Because of the ongoing COVID-19 pandemic, data were collected online to allow participation of eligible students in remote learning settings. Current e-cigarette use was assessed overall, by frequency of use, device type, flavors, and usual brand. Weighted prevalence estimates and population totals were calculated. This study was reviewed and approved by the CDC IRB © 2021. MMWR Recommendations and Reports. All rights reserved. |
Characteristics of e-Cigarette Use Behaviors Among US Youth, 2020
Wang TW , Gentzke AS , Neff LJ , Glidden EV , Jamal A , Park-Lee E , Ren C , Cullen KA , King BA , Hacker KA . JAMA Netw Open 2021 4 (6) e2111336 IMPORTANCE: Comprehensive surveillance of e-cigarette use behaviors among youth is important for informing strategies to address this public health epidemic. OBJECTIVE: To characterize e-cigarette use behaviors among US youth in 2020. DESIGN, SETTING, AND PARTICIPANTS: The 2020 National Youth Tobacco Survey, a nationally representative, cross-sectional, school-based survey of middle school (grades 6-8) and high school (grades 9-12) students, was conducted from January 16, 2020, to March 16, 2020. A total of 14 531 students from 180 schools participated in the 2020 survey, yielding a corresponding student-level participation rate of 87.4% and school-level participation rate of 49.9%. The overall response rate, a product of the school-level and student-level participation rates, was 43.6%. EXPOSURES: Current (past 30-day) e-cigarette use. MAIN OUTCOMES AND MEASURES: Self-reported current e-cigarette use behaviors (frequency of use, usual e-cigarette brand, and access source) by school level and flavored e-cigarette use and flavor types among current e-cigarette users by school level and device type. Prevalence estimates were weighted to account for the complex survey design. RESULTS: Overall, 14 531 students completed the survey, including 7330 female students and 7133 male students with self-reported grade level and sex. In 2020, 19.6% (95% CI, 17.2%-22.2%) of high school students and 4.7% (95% CI, 3.6%-6.0%) of middle school students reported current e-cigarette use. Among them, 38.9% (95% CI, 35.2%-42.6%) of high school users and 20.0% (95% CI, 16.0%-24.8%) of middle school users reported e-cigarette use on 20 to 30 days within the past 30 days. Among current users, JUUL was the most commonly reported usual brand (high school: 25.4%; 95% CI, 18.8%-33.4%; middle school: 35.1%; 95% CI, 27.9%-43.1%). Among current users, the most common source of obtaining e-cigarettes was from a friend (high school: 57.1%; 95% CI, 52.6%-61.4%; middle school: 58.9%; 95% CI, 51.4%-66.1%). Among current users, 84.7% (95% CI, 82.2%-86.9%) of high school students and 73.9% (95% CI, 66.9%-79.8%) of middle school students reported flavored e-cigarette use. Fruit-flavored e-cigarettes were the most commonly reported flavor among current exclusive e-cigarette users of prefilled pods or cartridges (67.3%; 95% CI, 60.9%-73.0%), disposable e-cigarettes (85.8%; 95% CI, 79.8%-90.3%), and tank-based devices (82.7%; 95% CI, 68.9%-91.1%), followed by mint-flavored e-cigarettes. CONCLUSIONS AND RELEVANCE: These results suggest that although current e-cigarette use decreased during 2019 to 2020, overall prevalence, frequent use, and flavored e-cigarette use remained high. Continued actions are warranted to prevent and reduce e-cigarette use among US youth. |
State-Specific Prevalence of Tobacco Product Use Among US Women, Tobacco Use Supplement to the Current Population Survey, 2018-2019
Wang TW , Walton K , Reyes-Guzman C , Cullen KA , Jamal A . Prev Chronic Dis 2021 18 E36 In this study, we assessed tobacco product use among US women aged 18 years or older using data from the 2018-2019 Tobacco Use Supplement to the Current Population Survey. State-specific current use of any tobacco product (cigarettes, e-cigarettes, cigars, regular pipes, water pipes or hookah, and smokeless tobacco) ranged from 6.6% (California) to 23.1% (West Virginia); current use of 2 or more tobacco products ranged from 0.6% (New York) to 3.0% (Oklahoma). Current tobacco product use among US women differed significantly by age, education, race/ethnicity, household income, marital status, disability status, and US region. Comprehensive tobacco control strategies, including targeted interventions, can reduce tobacco use among all women. |
Disposable E-Cigarette Use among U.S. Youth - An Emerging Public Health Challenge
Wang TW , Gentzke AS , Neff LJ , Glidden EV , Jamal A , King BA , Hacker KA , Park-Lee E , Ren C , Cullen KA . N Engl J Med 2021 384 (16) 1573-1576 Previous increases in the use of electronic cigarettes (e-cigarettes) by youth were driven by multiple factors, including advertising, the use of appealing flavors, and the introduction of new devices with prefilled pods or cartridges and high nicotine levels, such as Juul.1 According to data from the National Youth Tobacco Survey (NYTS), 19.6% of high school students (3.02 million) and 4.7% of middle school students (550,000) reported current (within the preceding 30 days) e-cigarette use in 2020 — 1.8 million fewer than in 2019.2 However, e-cigarette use among youth remains prominent and the landscape of devices is evolving, both of which pose a public health challenge. We assessed the changes in device type–specific e-cigarette use during 2019 and 2020. |
Tobacco product use among middle and high school students - United States, 2020
Gentzke AS , Wang TW , Jamal A , Park-Lee E , Ren C , Cullen KA , Neff L . MMWR Morb Mortal Wkly Rep 2020 69 (50) 1881-1888 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 (1,2). CDC and the Food and Drug Administration (FDA) analyzed data from the 2019 and 2020 National Youth Tobacco Surveys (NYTS) to determine changes in the current (past 30-day) use of seven tobacco products among U.S. middle (grades 6-8) and high (grades 9-12) school students. In 2020, current use of any tobacco product was reported by 16.2% (4.47 million) of all students, including 23.6% (3.65 million) of high school and 6.7% (800,000) of middle school students. Electronic cigarettes (e-cigarettes) were the most commonly used tobacco product among high school (19.6%; 3.02 million) and middle school (4.7%; 550,000) students. From 2019 to 2020, decreases in current use of any tobacco product, any combustible tobacco product, multiple tobacco products, e-cigarettes, cigars, and smokeless tobacco occurred among high school and middle school students; these declines resulted in an estimated 1.73 million fewer current youth tobacco product users in 2020 than in 2019 (6.20 million) (3). From 2019 to 2020, no significant change occurred in the use of cigarettes, hookahs, pipe tobacco, or heated tobacco products. The comprehensive and sustained implementation of evidence-based tobacco control strategies at the national, state, and local levels, combined with tobacco product regulation by FDA, is warranted to help sustain this progress and to prevent and reduce all forms of tobacco product use among U.S. youths (1,2). |
E-cigarette use among middle and high school students - United States, 2020
Wang TW , Neff LJ , Park-Lee E , Ren C , Cullen KA , King BA . MMWR Morb Mortal Wkly Rep 2020 69 (37) 1310-1312 The use of any tobacco product by youths is unsafe, including electronic cigarettes (e-cigarettes) (1). Most e-cigarettes contain nicotine, which is highly addictive, can harm the developing adolescent brain, and can increase risk for future addiction to other drugs (1). E-cigarette use has increased considerably among U.S. youths since 2011 (1,2). Multiple factors have contributed to this increase, including youth-appealing flavors and product innovations (1-3). Amid the widespread use of e-cigarettes and popularity of certain products among youths, on February 6, 2020, the Food and Drug Administration (FDA) implemented a policy prioritizing enforcement against the manufacture, distribution, and sale of certain unauthorized flavored prefilled pod or cartridge-based e-cigarettes (excluding tobacco or menthol). |
Trends and associations of menthol cigarette smoking among US middle and high school students - National Youth Tobacco Survey, 2011-2018
Sawdey MD , Chang JT , Cullen KA , Rass O , Jackson KJ , Ali FRM , Odani S , Courtney-Long EA , Armour BS , Ambrose BK , Agaku IT . Nicotine Tob Res 2020 22 (10) 1726-1735 INTRODUCTION: Youth cigarette smoking decreased significantly over the last two decades in the United States. This study provides estimates and trends from 2011 to 2018 and factors associated with youth menthol and non-menthol smoking from 2016 to 2018. METHODS: Using data from the 2011-2018 National Youth Tobacco Surveys, past 30-day (current) menthol and non-menthol cigarette smoking were estimated for all youth (prevalence) and youth smokers (proportions). Trends were examined using Joinpoint regression, calculating the annual percent change (APC). Multivariate logistic regression analyses identified factors associated with menthol smoking. RESULTS: From 2011 to 2018, menthol cigarette smoking among current youth cigarette smokers significantly decreased from 57.3% to 45.7% (APC: -3.0%), while non-menthol (38.2% to 47.3% [APC: 2.9%]) and unknown menthol status (not sure\missing) (4.5% to 7.0% [APC: 7.1%]) significantly increased. Menthol cigarette smoking among high school, male, female, and non-Hispanic white current cigarette smokers decreased, but remained unchanged among middle school, non-Hispanic black, and Hispanic smokers. Significantly higher proportions of menthol cigarette smokers smoked on >/=20 days, >/=2 cigarettes per day, and >/=100 cigarettes in their lifetime compared to non-menthol smokers. Among current cigarette smokers, non-Hispanic blacks, Hispanics, flavored non-cigarette tobacco users, frequent smokers (>/=20 days), those smoking 2-5 cigarettes per day, and those living with someone who uses tobacco had higher odds of menthol cigarette smoking. CONCLUSIONS: In 2018, nearly half of current youth cigarette smokers smoked menthol cigarettes. While menthol cigarette smoking declined from 2011 to 2018 among all youth and among youth smokers, there was no change in menthol cigarette smoking among non-Hispanic black, Hispanic, and middle school cigarette smokers. IMPLICATIONS: This study finds that overall cigarette and menthol cigarette smoking declined in youth from 2011 to 2018. However, menthol cigarette smoking among non-Hispanic black, Hispanic, and middle school youth cigarette smokers did not change. Information from this study can help inform efforts to reduce menthol cigarette smoking among US youth, particularly racial/ethnic minority populations. |
Tobacco product use and associated factors among middle and high school students - United States, 2019
Wang TW , Gentzke AS , Creamer MR , Cullen KA , Holder-Hayes E , Sawdey MD , Anic GM , Portnoy DB , Hu S , Homa DM , Jamal A , Neff LJ . MMWR Surveill Summ 2019 68 (12) 1-22 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. |
Tobacco product use and cessation indicators among adults - United States, 2018
Creamer MR , Wang TW , Babb S , Cullen KA , Day H , Willis G , Jamal A , Neff L . MMWR Morb Mortal Wkly Rep 2019 68 (45) 1013-1019 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). |
E-cigarette use among youth in the United States, 2019
Cullen KA , Gentzke AS , Sawdey MD , Chang JT , Anic GM , Wang TW , Creamer MR , Jamal A , Ambrose BK , King BA . JAMA 2019 322 (21) 2095-2103 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. |
Flavored tobacco product use among middle and high school students - United States, 2014-2018
Cullen KA , Liu ST , Bernat JK , Slavit WI , Tynan MA , King BA , Neff LJ . MMWR Morb Mortal Wkly Rep 2019 68 (39) 839-844 The 2009 Family Smoking Prevention and Tobacco Control Act prohibits the inclusion of characterizing flavors (e.g., candy or fruit) other than tobacco and menthol in cigarettes; however, characterizing flavors are not currently prohibited in other tobacco products at the federal level.* Flavored tobacco products can appeal to youths and young adults and influence initiation and establishment of tobacco-use patterns (1). The Food and Drug Administration (FDA) and CDC analyzed data from the 2014-2018 National Youth Tobacco Surveys (NYTS) to determine prevalence of current (past 30-day) use of flavored tobacco products, including electronic cigarettes (e-cigarettes), hookah tobacco, cigars, pipe tobacco, smokeless tobacco, bidis, and menthol cigarettes among U.S. middle school (grades 6-8) and high school (grades 9-12) students. In 2018, an estimated 3.15 million (64.1%) youth tobacco product users currently used one or more flavored tobacco products, compared with 3.26 million (70.0%) in 2014. Despite this overall decrease in use of flavored tobacco products, current use of flavored e-cigarettes increased among high school students during 2014-2018; among middle school students, current use of flavored e-cigarettes increased during 2015-2018, following a decrease during 2014-2015. During 2014-2018, current use of flavored hookah tobacco decreased among middle and high school students; current use of flavored smokeless tobacco, cigars, pipe tobacco, and menthol cigarettes decreased among high school students. Full implementation of comprehensive tobacco prevention and control strategies, coupled with regulation of tobacco products by FDA, can help prevent and reduce use of tobacco products, including flavored tobacco products, among U.S. youths (2,3). |
Vital Signs: Tobacco product use among middle and high school students - United States, 2011-2018
Gentzke AS , Creamer M , Cullen KA , Ambrose BK , Willis G , Jamal A , King BA . MMWR Morb Mortal Wkly Rep 2019 68 (6) 157-164 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. |
Notes from the field: Use of electronic cigarettes and any tobacco product among middle and high school students - United States, 2011-2018
Cullen KA , Ambrose BK , Gentzke AS , Apelberg BJ , Jamal A , King BA . MMWR Morb Mortal Wkly Rep 2018 67 (45) 1276-1277 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). |
Tobacco product use among adults - United States, 2017
Wang TW , Asman K , Gentzke AS , Cullen KA , Holder-Hayes E , Reyes-Guzman C , Jamal A , Neff L , King BA . MMWR Morb Mortal Wkly Rep 2018 67 (44) 1225-1232 Cigarette smoking harms nearly every organ of the body and causes adverse health consequences, including heart disease, stroke, and multiple types of cancer (1). Although cigarette smoking among U.S. adults has declined considerably, tobacco products have evolved in recent years to include various combustible, noncombustible, and electronic products (1,2). 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 Institutes of Health's National Cancer Institute analyzed data from the 2017 National Health Interview Survey (NHIS). In 2017, an estimated 47.4 million U.S. adults (19.3%) currently used any tobacco product, including cigarettes (14.0%; 34.3 million); cigars, cigarillos, or filtered little cigars (3.8%; 9.3 million); electronic cigarettes (e-cigarettes) (2.8%; 6.9 million); smokeless tobacco (2.1%; 5.1 million); and pipes, water pipes, or hookahs (1.0%; 2.6 million). Among current tobacco product users, 86.7% (41.1 million) smoked combustible tobacco products, and 19.0% (9.0 million) used >/=2 tobacco products. By univariate analyses, the prevalence of current use of any tobacco product was higher among males than among females; adults aged <65 years than among those aged >/=65 years; non-Hispanic American Indian/Alaska Natives, whites, blacks, or multiracial adults than among Hispanics or non-Hispanic Asians; adults who lived in the South or Midwest than among those in the West or Northeast; adults who had a general educational development certificate (GED) than among those with other levels of education; adults who earned an annual household income of <$35,000 than among those with those with higher income; lesbian, gay, or bisexual adults than among heterosexual/straight adults; and adults who were divorced/separated/widowed or single/never married/not living with a partner than among those who were married/living with a partner. Prevalence was also higher among those who were uninsured, insured by Medicaid, or had some other public insurance than among those with private insurance or Medicare only; those who had a disability/limitation than among those who did not; and those who had serious psychological distress than among those who did not. Full implementation of evidence-based tobacco control interventions that address the diversity of tobacco products used by U.S. adults, in coordination with regulation of tobacco product manufacturing, marketing, and sales, can reduce tobacco-related disease and death in the United States (1-3). |
Tobacco product use among middle and high school students - United States, 2011-2017
Wang TW , Gentzke A , Sharapova S , Cullen KA , Ambrose BK , Jamal A . MMWR Morb Mortal Wkly Rep 2018 67 (22) 629-633 Tobacco use is the leading cause of preventable disease and death in the United States, and nearly all tobacco use begins during youth and young adulthood (1,2). CDC and the Food and Drug Administration (FDA) analyzed data from the 2011-2017 National Youth Tobacco Surveys (NYTS)* to determine patterns of current (past 30-day) use of seven tobacco product types among U.S. middle school (grades 6-8) and high school (grades 9-12) students and estimate use nationwide. Among high school students, current use of any tobacco product decreased from 24.2% (estimated 3.69 million users) in 2011 to 19.6% (2.95 million) in 2017. Among middle school students, current use of any tobacco product decreased from 7.5% (0.87 million) in 2011 to 5.6% (0.67 million) in 2017. In 2017, electronic cigarettes (e-cigarettes) were the most commonly used tobacco product among high (11.7%; 1.73 million) and middle (3.3%; 0.39 million) school students. During 2016-2017, decreases in current use of hookah and pipe tobacco occurred among high school students, while decreases in current use of any tobacco product, e-cigarettes, and hookah occurred among middle school students. Current use of any combustible tobacco product, >/=2 tobacco products, cigarettes, cigars, smokeless tobacco, and bidis did not change among middle or high school students during 2016-2017. Comprehensive and sustained strategies can help prevent and reduce the use of all forms of tobacco products among U.S. youths (1,2). |
Tobacco use among middle and high school students - United States, 2011-2016
Jamal A , Gentzke A , Hu SS , Cullen KA , Apelberg BJ , Homa DM , King BA . MMWR Morb Mortal Wkly Rep 2017 66 (23) 597-603 Tobacco use is the leading cause of preventable disease and death in the United States; nearly all tobacco use begins during youth and young adulthood (1,2). Among youths, use of tobacco products in any form is unsafe (1,3). CDC and the Food and Drug Administration (FDA) analyzed data from the 2011-2016 National Youth Tobacco Surveys (NYTS) to determine recent patterns of current (past 30-day) use of seven tobacco product types among U.S. middle (grades 6-8) and high (grades 9-12) school students. In 2016, 20.2% of surveyed high school students and 7.2% of middle school students reported current tobacco product use. In 2016, among current tobacco product users, 47.2% of high school students and 42.4% of middle school students used ≥2 tobacco products, and electronic cigarettes (e-cigarettes) were the most commonly used tobacco product among high (11.3%) and middle (4.3%) school students. Current use of any tobacco product did not change significantly during 2011-2016 among high or middle school students, although combustible tobacco product use declined. However, during 2015-2016, among high school students, decreases were observed in current use of any tobacco product, any combustible product, ≥2 tobacco products, e-cigarettes, and hookahs. Among middle school students, current use of e-cigarettes decreased. Comprehensive and sustained strategies can help prevent and reduce the use of all forms of tobacco products among U.S. youths (1-3). |
Severe morbidity and mortality risk from malaria in the United States, 1985-2011
Hwang J , Cullen KA , Kachur SP , Arguin PM , Baird JK . Open Forum Infect Dis 2014 1 (1) ofu034 BACKGROUND: Recent reports of Plasmodium vivax associated with severe syndromes and mortality from malaria endemic areas questions the "benign" course of non-falciparum malarias. METHODS: We retrospectively analyzed data from patients reported to the US Centers for Disease Control and Prevention with a diagnosis of malaria parasite single-species infection between 1985 and 2011. Patients classified as having severe illness were further classified according to outcome (survival versus death) and clinical syndrome. RESULTS: Among all cases, .9% of Plasmodium falciparum cases resulted in death and 9.3% were classified as severe, whereas .09% of P. vivax cases resulted in death and 1.3% were classified as severe. The odds ratios for severe illness among 15 272 diagnoses of P. falciparum relative to patients diagnosed with P. vivax (n = 12 152), Plasmodium malariae (n = 1254), or Plasmodium ovale (n = 903) was 7.5, 5.7, and 5.0, respectively (P < .0001 for all); in contrast, the corresponding odds ratios for death among those severely ill was 1.6, 1.1, and .8 (P > .1 for all), respectively. Compared with P. vivax (n = 163), the odds of P. falciparum cases classified as severely ill (n = 1416) were 1.9 (P = .0006), .5 (P = .001), and 1.3 times (P = .1) as likely to present as cerebral, acute respiratory distress, and renal syndromes, respectively. CONCLUSIONS: Although less common, patients presenting with non-falciparum even in the United States can develop severe illness, and severe illness in patients having malaria of any species threatens life. |
Malaria surveillance - United States, 2013
Cullen KA , Mace KE , Arguin PM . MMWR Surveill Summ 2016 65 (2) 1-22 PROBLEM/CONDITION: Malaria in humans is caused by intraerythrocytic protozoa of the genus Plasmodium. These parasites are transmitted by the bite of an infective female Anopheles mosquito. The majority of malaria infections in the United States occur among persons who have traveled to regions with ongoing malaria transmission. However, malaria is also occasionally acquired by persons who have not traveled out of the country through exposure to infected blood products, congenital transmission, laboratory exposure, or local mosquitoborne transmission. Malaria surveillance in the United States is conducted to identify episodes of local transmission and to guide prevention recommendations for travelers. PERIOD COVERED: This report summarizes cases in persons with onset of illness in 2013 and summarizes trends during previous years. DESCRIPTION OF SYSTEM: Malaria cases diagnosed by blood film, polymerase chain reaction, or rapid diagnostic tests are mandated to be reported to local and state health departments by health care providers or laboratory staff. Case investigations are conducted by local and state health departments, and reports are transmitted to CDC through the National Malaria Surveillance System, National Notifiable Diseases Surveillance System, or direct CDC consultations. CDC conducted antimalarial drug resistance marker testing on blood samples submitted to CDC by health care providers or local/state health departments. Data from these reporting systems serve as the basis for this report. RESULTS: CDC received 1,727 reported cases of malaria, including two congenital cases, with an onset of symptoms in 2013 among persons in the United States. The total number of cases represents a 2% increase from the 1,687 cases reported for 2012. Plasmodium falciparum, P. vivax, P. malariae, and P. ovale were identified in 61%, 14%, 3%, and 4% of cases, respectively. Forty (2%) patients were infected by two species. The infecting species was unreported or undetermined in 17% of cases. Polymerase chain reaction testing determined or corrected the species for 85 of the 137 (62%) samples evaluated for drug resistance marker testing. Of the 904 patients who reported purpose of travel, 635 (70%) were visiting friends or relatives (VFR). Among the 961 cases in U.S. civilians for whom information on chemoprophylaxis use and travel region was known, 42 (4%) patients reported that they had initiated and adhered to a chemoprophylaxis drug regimen recommended by CDC for the regions to which they had traveled. Thirty-six cases were reported in pregnant women, none of whom had adhered to chemoprophylaxis. Among all reported cases, approximately 270 (16%) were classified as severe illnesses in 2013. Of these, 10 persons with malaria died in 2013, the highest number since 2001. In 2013, a total of 137 blood samples submitted to CDC were tested for molecular markers associated with antimalarial drug resistance. Of the 100 P. falciparum-positive samples, 95 were tested for pyrimethamine resistance: 88 (93%) had genetic polymorphisms associated with pyrimethamine drug resistance, 74 (76%) with sulfadoxine resistance, 53 (53%) with chloroquine resistance, one (1%) with atovaquone resistance, none with mefloquine drug resistance, and none with artemisinin resistance. INTERPRETATION: The overall trend of malaria cases has been increasing since 1973; the number of cases reported in 2013 is the third highest annual total since then. Despite progress in reducing the global burden of malaria, the disease remains endemic in many regions, and the use of appropriate prevention measures by travelers is still inadequate. PUBLIC HEALTH ACTIONS: Completion of data elements on the malaria case report form increased slightly in 2013 compared with 2012, but still remains unacceptably low. This incomplete reporting compromises efforts to examine trends in malaria cases and prevent infections. VFRs continue to be a difficult population to reach with effective malaria prevention strategies. Evidence-based prevention strategies that effectively target VFRs need to be developed and implemented to have a substantial impact on the numbers of imported malaria cases in the United States. Fewer patients reported taking chemoprophylaxis in 2013 (32%) compared with 2012 (34%), and adherence was poor among those who did take chemoprophylaxis. Proper use of malaria chemoprophylaxis will prevent the majority of malaria illness and reduce the risk for severe disease (http://www.cdc.gov/malaria/travelers/drugs.html). Malaria infections can be fatal if not diagnosed and treated promptly with antimalarial medications appropriate for the patient's age and medical history, the likely country of malaria acquisition, and previous use of antimalarial chemoprophylaxis. Recent molecular laboratory advances have enabled CDC to identify and conduct molecular surveillance of antimalarial drug resistance markers (http://www.cdc.gov/malaria/features/ars.html). These advances will allow CDC to track, guide treatment, and manage drug resistance in malaria parasites both domestically and globally. For this to be successful, specimens should be submitted for all cases diagnosed in the United States. Clinicians should consult the CDC Guidelines for Treatment of Malaria and contact the CDC's Malaria Hotline for case management advice, when needed. Malaria treatment recommendations can be obtained online (http://www.cdc.gov/malaria/diagnosis_treatment) or by calling the Malaria Hotline (770-488-7788 or toll-free at 855-856-4713). |
Case 28-2015: a man with febrile symptoms after traveling from Liberia
Tan KR , Cullen KA , Arguin PM . N Engl J Med 2016 374 (3) 293-4; discussion 294 In the Case Record discussed by Biddinger et al. (Sept. 10 issue),1 the authors describe the care of a febrile traveler who was returning from an area in which malaria is highly endemic and who was considered to be in the “low (but not zero) risk category” for Ebola virus disease (EVD).2 Modifications made to safely assess the patient for EVD are reported, including the use of only a rapid diagnostic test to diagnose malaria. The Centers for Disease Control and Prevention (CDC) recommends immediate microscopy of thin and thick blood smears for the diagnosis of malaria, which can be safely performed by observing precautions against the transmission of EVD.3 Diagnosis by means of microscopy allows for the identification of species and the quantification of parasitemia, both of which are needed to determine the most appropriate treatment. Microscopy must always be performed after a rapid diagnostic test in order to confirm the result and obtain this additional information.4 The patient discussed could have had undiagnosed hyperparasitemia, which requires parenteral therapy. In addition, without identifying the species by means of microscopy or polymerasechain-reaction assay, the authors may have missed a mixed infection, which could have been treated with primaquine, thereby preventing a 6-week relapse. Correct determination of the initial infecting species is preferred over the reliance on knowledge of the geographic distribution of species that cause relapsing malaria and the use of empirical therapy with primaquine. |
Inadequate diagnosis and treatment of malaria among travelers returning from Africa during the Ebola epidemic - United States, 2014-2015
Tan KR , Cullen KA , Koumans EH , Arguin PM . MMWR Morb Mortal Wkly Rep 2016 65 (2) 27-9 Among 1,683 persons in the United States who developed malaria following international travel during 2012, more than half acquired disease in one of 16 countries* in West Africa (1). Since March 2014, West Africa has experienced the world's largest epidemic of Ebola virus disease (Ebola), primarily affecting Guinea, Sierra Leone, and Liberia; in 2014, approximately 20,000 Ebola cases were reported (2). Both Ebola and malaria are often characterized by fever and malaise and can be clinically indistinguishable, especially early in the course of disease. Immediate laboratory testing is critical for diagnosis of both Ebola and malaria, so that appropriate lifesaving treatment can be initiated. CDC recommends prompt malaria testing of patients with fever and history of travel to an area that is endemic for malaria, using blood smear microscopy, with results available within a few hours (3). Empiric treatment of malaria is not recommended by CDC (4). Reverse transcription-polymerase chain reaction (RT-PCR) testing is recommended to diagnose Ebola (5). During the Ebola outbreak in West Africa, CDC received reports of delayed laboratory testing for malaria in travelers returning to the United States because of infection control concerns related to Ebola (6). CDC reviewed documented calls to its malaria consultation service and selected three patient cases to present as examples of deficiencies in the evaluation and treatment of malaria among travelers returning from Africa during the Ebola epidemic. |
Factors associated with provider reporting of child and adolescent vaccination history to immunization information systems: results from the National Immunization Survey, 2006-2012
Cardemil CV , Cullen KA , Harris L , Greby SM , Santibanez TA . J Public Health Manag Pract 2015 22 (3) 245-54 CONTEXT: Use of Immunization information systems (IISs) by providers can improve vaccination rates by identifying missed opportunities. However, provider reporting of children's vaccination histories to IISs remains suboptimal. OBJECTIVE: To assess factors associated with provider reporting to an IIS. DESIGN: Analysis of 2006-2012 National Immunization Survey (NIS) and NIS-Teen data. NIS and NIS-Teen are ongoing random-digit-dial telephone surveys of households with children and adolescents, respectively, followed by a mail survey to providers to obtain the patient's vaccination history. SETTING AND PARTICIPANTS: A total of 115 285 children aged 19 to 35 months and 83 612 adolescents aged 13 to 17 years and their immunization providers in the United States. MAIN OUTCOME MEASURES: The percentage of children and adolescents with 1 or more providers reporting to or obtaining vaccination information from their local IISs. Multivariable logistic regression was used to examine patient and provider factors associated with provider reporting to IISs and adjusted prevalence of children and adolescents with 1 or more providers reporting to IISs. RESULTS: In 2012, 79.4% of children and 77.4% of adolescents had 1 or more providers report any of their vaccination data to an IIS, and 41.9% of children and 51.5% of adolescents had providers who obtained any of their vaccination histories from an IIS. During 2006-2012, children and adolescents were more likely to have any of their vaccination data reported to an IIS if they received care from all public versus all private providers (children: 84.4% vs 69.6%, P < .0001; adolescents: 84.6% vs 66.4%, P < .0001), had 1 or more providers who ordered vaccines from a state or local health department (children: 76.7% vs 59.5%, P < .0001; adolescents: 77.0% vs 55.6%, P < .0001), or had 1 or more providers obtain vaccination information from the IIS (children: 86.1% vs 71.2%, P < .0001; adolescents: 83.7% vs 64.6%, P < .0001). CONCLUSIONS: Health department staff should target providers less likely to use IIS services, including private providers, and providers not ordering vaccines from health departments to ensure they use IIS services. |
Malaria surveillance - United States, 2012
Cullen KA , Arguin PM . MMWR Surveill Summ 2014 63 Suppl 12 (12) 1-22 PROBLEM/CONDITION: Malaria in humans is caused by intraerythrocytic protozoa of the genus Plasmodium. These parasites are transmitted by the bite of an infective female Anopheles mosquito. The majority of malaria infections in the United States occur among persons who have traveled to regions with ongoing malaria transmission. However, malaria is also occasionally acquired by persons who have not traveled out of the country, through exposure to infected blood products, congenital transmission, laboratory exposure, or local mosquitoborne transmission. Malaria surveillance in the United States is conducted to identify episodes of local transmission and to guide prevention recommendations for travelers. PERIOD COVERED: This report summarizes cases in persons with onset of symptoms in 2012 and summarizes trends during previous years. DESCRIPTION OF SYSTEM: Malaria cases diagnosed by blood film, polymerase chain reaction, or rapid diagnostic tests are mandated to be reported to local and state health departments by health-care providers or laboratory staff. Case investigations are conducted by local and state health departments, and reports are transmitted to CDC through the National Malaria Surveillance System (NMSS), National Notifiable Diseases Surveillance System (NNDSS), or direct CDC consults. For the first time, CDC conducted antimalarial drug resistance testing on blood samples submitted to CDC by health-care providers or local/state health departments. Data from these reporting systems serve as the basis for this report. RESULTS: CDC received 1,687 reported cases of malaria with an onset of symptoms in 2012 among persons in the United States, including 1,683 cases classified as imported, one laboratory-acquired case, one nosocomial case, and two cryptic cases. The total number of cases represents a 12% decrease from the 1,925 cases reported for 2011. Plasmodium falciparum, P. vivax, P. malariae, and P. ovale were identified in 58%, 17%, 3%, and 3% of cases, respectively. Twenty (1%) patients were infected by two species. The infecting species was unreported or undetermined in 17% of cases, a decrease of 6 percentage points from 2011. Polymerase chain reaction testing determined or corrected the species for 45 (43%) of the 104 samples submitted for drug resistance testing. Of the 909 patients who reported purpose of travel, 604 (66%) were visiting friends or relatives (VFR). Among the 983 cases in U.S. civilians for whom information on chemoprophylaxis use and travel region was known, 63 (6%) patients reported that they had followed and adhered to a chemoprophylaxis drug regimen recommended by CDC for the regions to which they had traveled. Thirty-two cases were reported in pregnant women, among whom only one adhered to chemoprophylaxis. Among all reported cases, 231 (14%) were classified as severe infections in 2012. Of these, six persons with malaria died in 2012. Beginning in 2012, there were 104 blood samples submitted to CDC that were tested for molecular markers associated with antimalarial drug resistance. Of the 65 P. falciparum-positive samples, 53 (82%) had genetic polymorphisms associated with pyrimethamine drug resistance, 61 (94%) with sulfadoxine resistance, 29 (45%) with chloroquine resistance, 1 (2%) with mefloquine drug resistance, 2 (3%) with atovaquone resistance, and none with artemisinin resistance. INTERPRETATION: Despite the 12% decline in the number of cases reported in 2012 compared with 2011, the overall trend in malaria cases has been increasing since 1973. Although progress has been made in reducing the global burden of malaria, the disease remains endemic in many regions, and the use of appropriate prevention measures by travelers is still inadequate. PUBLIC HEALTH ACTIONS: Completion of data elements on the malaria case report form increased slightly in 2012 compared with 2011, but still remains unacceptably low. This incomplete reporting compromises efforts to examine trends in malaria cases and prevent infections. VFRs continue to be a difficult population to reach with effective malaria prevention strategies. Evidence-based prevention strategies that effectively target VFRs need to be developed and implemented to have a substantial impact on the numbers of imported malaria cases in the United States. Although more patients reported taking chemoprophylaxis to prevent malaria, the majority reported not taking it, and adherence was poor among those who did take chemoprophylaxis. Proper use of malaria chemoprophylaxis will prevent the majority of malaria illness and reduce the risk for severe disease (http://www.cdc.gov/malaria/travelers/drugs.html). Malaria infections can be fatal if not diagnosed and treated promptly with antimalarial medications appropriate for the patient's age and medical history, the likely country of malaria acquisition, and previous use of antimalarial chemoprophylaxis. Recent molecular laboratory advances have enabled CDC to identify and conduct molecular surveillance of antimalarial drug resistance (http://www.cdc.gov/malaria/features/ars.html). These advances will allow CDC to track, guide treatment, and manage drug resistant malaria parasites both domestically and globally. For this to be successful, specimens should be submitted for cases diagnosed in the United States and for ongoing specimen collection and testing globally. Clinicians should consult the CDC Guidelines for Treatment of Malaria and contact the CDC's Malaria Hotline for case management advice when needed. Malaria treatment recommendations can be obtained online (http://www.cdc.gov/malaria/diagnosis_treatment) or by calling the Malaria Hotline (770-488-7788 or toll-free at 855-856-4713). |
Uptake of human papillomavirus vaccine among adolescent males and females: Immunization Information System sentinel sites, 2009-2012
Cullen KA , Stokley S , Markowitz LE . Acad Pediatr 2014 14 (5) 497-504 OBJECTIVE: The Advisory Committee on Immunization Practices (ACIP) has recommended routine human papillomavirus (HPV) vaccination at age 11 or 12 years for girls since 2006 and for boys since 2011. We sought to describe adolescent HPV vaccination coverage, doses administered from 2009 to 2012, and age at first vaccination by sex. METHODS: Aggregate data were analyzed from 8 Immunization Information System sentinel sites on HPV vaccinations in children and adolescents aged 11 to 12 years, 13 to 15 years, and 16 to 18 years. Vaccination coverage by age group was reported for 2009 to 2012, and weekly doses administered were determined. Age at first HPV vaccination was calculated for girls in 2007 and 2011 and for boys in 2011. RESULTS: This analysis included data on 2.9 million adolescents aged 11 to 18 years. There were small increases in coverage for girls, with receipt of ≥1 dose of HPV vaccine reaching 27.1% of ages 11 to 12, 47.9% of ages 13 to 15, and 57.1% of ages 16 to 18 by December 31, 2012. Uptake of ≥1 dose in boys reached approximately 18% for all age groups. Doses administered showed seasonal variation, with highest uptake before back to school among girls and steady increases in boys after the 2009 ACIP recommendation for permissive use. Doses administered to boys surpassed those administered to girls by September 2012. Among vaccinated girls, more received vaccine at the recommended age of 11 to 12 years in 2011 (74.2%) compared to 2007 (9.9%). In 2011, 27.3% of vaccinated boys received their first dose at age 11 to 12 years. CONCLUSIONS: HPV vaccination coverage increased among adolescents between 2009 and 2012. However, increases among girls were small, and coverage for boys and girls remained below target levels. |
Two-dose varicella vaccination coverage among children aged 7 years - six sentinel sites, United States, 2006-2012
Lopez AS , Cardemil C , Pabst LJ , Cullen KA , Leung J , Bialek SR . MMWR Morb Mortal Wkly Rep 2014 63 (8) 174-7 In 2007, the Advisory Committee on Immunization Practices (ACIP) recommended a routine second dose of varicella vaccine for children at age 4-6 years, in addition to the first dose given at age 12-15 months. One strategy recommended for increasing varicella vaccination coverage is a school entry requirement of proof of varicella immunity. To determine the extent of implementation of the routine 2-dose varicella vaccination program, the number of states with a 2-dose varicella vaccination elementary school entry requirement in 2012 was compared with the number in 2007, and 2-dose varicella vaccination coverage during 2006 was compared with coverage in 2012 among children aged 7 years, using data from six Immunization Information System (IIS) sentinel sites. The number of states (including the District of Columbia) with a 2-dose varicella vaccination elementary school entry requirement increased from four in 2007 to 36 in 2012. Two-dose varicella vaccination coverage levels among children aged 7 years in the six IIS sentinel sites increased from a range of 3.6%-8.9% in 2006 to a range of 79.9%-92.0% in 2012 and were approaching the levels of 2-dose measles, mumps, and rubella (MMR) coverage, which had a range of 81.9%-94.0% in 2012. These increases suggest substantial progress in implementing the routine 2-dose varicella vaccination program in the first 6 years since its recommendation by ACIP. Wider adoption of 2-dose varicella vaccination school entry requirements might help progress toward the Healthy People 2020 target of 95% of kindergarten students having received 2 doses of varicella vaccine. |
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