Conclusions and Comment

In 2018, approximately one in four U.S. high school students and one in 14 middle school students reported current use of any tobacco product. Among both high school and middle school students, current use of e-cigarettes increased considerably between 2017 and 2018, reaching epidemic proportions, according to the U.S. Surgeon General (4); approximately 1.5 million more youths currently used e-cigarettes in 2018 (3.6 million) compared with 2017 (2.1 million) (5). However, no significant change in current use of combustible tobacco products, such as cigarettes and cigars, was observed in recent years (5) or during 2017–2018. This indicates that e-cigarettes were the driver of the observed increase in any tobacco product use. The recent changes in patterns of use of e-cigarettes and other tobacco products during 2017–2018 erased the decline in any tobacco product use that occurred in previous years (5).

E-cigarettes have been the most commonly used tobacco product among U.S. youths since 2014 (5). Before 2018, the prevalence of e-cigarette use by U.S. high school students had peaked in 2015 before declining by 29% during 2015–2016 (from 16% to 11.3%) (6); this decline was the first ever recorded for e-cigarette use among youths in the NYTS since monitoring began, and it was subsequently sustained during 2016–2017 (5). However, current e-cigarette use increased by 77.8% among high school students and 48.5% among middle school students during 2017–2018, erasing the progress in reducing e-cigarette use, as well as any tobacco product use, that had occurred in prior years (7).

This recent increase in e-cigarette use among youths is consistent with observed increases in sales of the e-cigarette JUUL (8), a USB-shaped e-cigarette device with a high nicotine content that can be used discreetly and is available in flavors that can appeal to youths. A single prefilled liquid nicotine JUUL pod contains as much nicotine as a pack of cigarettes (9). Media reports and a survey indicate that JUUL devices are being used among youths in schools, including inside bathrooms and classrooms.*** JUUL entered the U.S. market in 2015 and subsequently became a commonly used tobacco product among U.S. youths (10). Sales of JUUL increased by approximately 600% during 2016–2017 (8) and increased even further through 2018 (10). By December 2017, JUUL held the largest market share of any e-cigarette (8). Thus, given that NYTS is fielded annually in the spring, the 2018 data are the first to reflect the impact of rising sales of JUUL and other USB-shaped devices on e-cigarette and overall tobacco product use among U.S. youths.

Any form of tobacco product use among youths, irrespective of frequency, is unsafe (1–4). During 2017–2018, frequent e-cigarette use increased significantly by 38.5% among high school student users. Thus, in addition to more youths using e-cigarettes overall, current e-cigarette users also are using them more frequently.

Furthermore, among current tobacco product users, approximately 40% of high school students and one third of middle school students reported currently using more than one tobacco product; the prevalence of using two or more tobacco products increased significantly by 22.8% among high school students during 2017–2018. E-cigarettes were the most commonly reported product used in combination with other products among both middle and high school students in 2018. Most e-cigarettes contain nicotine (11), which is highly addictive and can harm the developing adolescent brain (3). Among youths, symptoms of nicotine dependence are increased in multiple tobacco product users than in single product users (12). In addition, some evidence suggests that e-cigarette use increases the risk for ever using cigarettes among youths, and that e-cigarette use might increase the frequency and intensity of subsequent cigarette smoking (13).

Differences in individual tobacco product use were also observed across population groups. In 2018, e-cigarettes were the most commonly used product among all racial/ethnic groups except black high school students, among whom cigars were the most commonly reported product. Targeted advertising of cigars in locations with a greater proportion of black residents, a relatively lower price, and the availability of cigars for purchase as a single unit might contribute to higher cigar smoking among blacks (14).

The findings in this report are subject to at least three limitations. First, changes in the wording and placement of survey questions for certain tobacco products during 2011–2018 might limit comparability of estimates between years. Second, data were self-reported and might be subject to recall and response bias. Finally, findings might not be generalizable to all youths, including those who are home-schooled, have dropped out of school, or are enrolled in alternative schools. However, in 2016, nearly 97% of students aged 10–17 years were enrolled in school.†††

Several factors continue to promote and influence tobacco product use among youths, including exposure to tobacco product advertising and imagery through various media, as well as the availability of flavored tobacco products (2,3,15,16). The sustained and comprehensive implementation of population-based strategies, in coordination with the regulation of tobacco products by the Food and Drug Administration (17), and continued research investments and cessation-related initiatives, including Smokefree Teen by the National Institutes of Health’s National Cancer Institute§§§ can reduce all forms of tobacco product use and initiation among U.S. youths (1–3). As a direct result of the considerable increase in e-cigarette use among youths during 2017–2018 (7), in November 2018, the Food and Drug Administration announced several proposed new steps to protect youths, including restricting sales of flavored e-cigarettes (other than tobacco, menthol, mint, or nonflavored) to physical locations with age restrictions or online with heightened age verification procedures, and plans to advance notices of proposed rulemaking that would ban menthol cigarettes and cigars and all other flavored cigars (18). Additional strategies to reduce tobacco product use among youths include increasing the price of tobacco products, implementing comprehensive smoke-free policies, implementing advertising and promotion restrictions and national antitobacco public education media campaigns, and implementing and enforcing policies that raise the minimum age of purchase for tobacco products to 21 years (1,3,19,20).