Tobacco Product Use Among Middle and High School Students - National Youth Tobacco Survey, United States, 2024.

Use of tobacco products in any form is unsafe, and nearly all tobacco product use begins during adolescence. CDC and the Food and Drug Administration (FDA) analyzed data from the 2024 National Youth Tobacco Survey to determine tobacco product use among U.S. middle school (grades 6-8) and high school (grades 9-12) students. In 2024, current (previous 30-day) use of any tobacco product was reported by 10.1% of high school students (representing 1.58 million students) and 5.4% of middle school students (representing 640,000 students). Among all students, e-cigarettes were the most commonly reported tobacco product currently used (5.9%), followed by nicotine pouches (1.8%), cigarettes (1.4%), cigars (1.2%), smokeless tobacco (1.2%), other oral nicotine products (1.2%), heated tobacco products (0.8%), hookahs (0.7%), and pipe tobacco (0.5%). During 2023-2024, among all students, the estimated number who reported current use of any tobacco product decreased from 2.80 to 2.25 million students; e-cigarette use decreased (from 2.13 to 1.63 million students); and hookah use decreased (from 290,000 to 190,000 students). Among high school students, current use of any tobacco product decreased from 12.6% to 10.1% of students, and e-cigarette use decreased from 10.0% to 7.8%. Among middle school students, no statistically significant changes occurred. Evidence-based strategies can help prevent initiation and promote cessation of tobacco product use among U.S. youths.

Characteristics Associated with Ice Flavor Use among Middle and High School Students Currently Using E-cigarettes: National Youth Tobacco Survey, 2023.

PURPOSE: To examine ice flavor use and its correlates among middle and high school students who currently (any past 30-day) used e-cigarettes. METHODS: The 2023 National Youth Tobacco Survey (NYTS) assessed for the first time the use of e-cigarette flavors that included the word "ice" or "iced" in the name. Using logistic regression, data from the 2023 NYTS were used to examine differences in sociodemographic characteristics and tobacco use behaviors by ice flavor use among students who currently used e-cigarettes (n=1,565). RESULTS: Among middle and high school students who currently used e-cigarettes, an estimated 1.1 million or 57.9% reported ice flavor use. Youth who currently used e-cigarettes were more likely to use ice flavors if they used e-cigarettes on ≥20 of the past 30 days compared to 1-5 days (adjusted Odds Ratio [aOR]=2.31, 95% CI: 1.36-3.94); used fruit (aOR=2.27, 95% CI: 1.36-3.80), candy (aOR=2.73, 95% CI:1.54-4.82), or mint flavors (aOR=3.63, 95% CI:1.98-6.65) compared to those who did not use the respective flavor type; reported any nicotine dependence compared to those who did not (aOR= 1.71, 95% CI:1.04-2.80); or had mild/moderate (aOR=1.97, 95% CI: 1.01-3.83) or severe psychological distress (aOR=2.41, 95% CI: 1.25-4.62) compared to those without psychological distress. CONCLUSIONS: The present study found that ice-flavored e-cigarette use among youth was associated with use of e-cigarettes on ≥20 days, use of fruit, candy, or mint flavors, any symptoms of nicotine dependence, and psychological distress (mild/moderate, severe). Emergence of novel flavor categories and features of e-cigarettes warrant continued surveillance to provide an understanding of associated use patterns, especially among youth. IMPLICATIONS: This study examined ice flavor use and its correlates among middle and high school students who currently used e-cigarettes. Ice-flavored e-cigarette use among youth was positively associated with frequent e-cigarettes use, use of fruit, candy, or mint flavors, and any symptoms of nicotine dependence. Additionally, the likelihood of ice-flavored e-cigarette use was associated with severity of psychological distress.

Notes from the Field: E-Cigarette and Nicotine Pouch Use Among Middle and High School Students - United States, 2024.

Current e-cigarette use among U.S. youth has declined considerably since 2019*; however, approximately 2.13 million youths used e-cigarettes in 2023 (1). As sales of nicotine pouches (small, dissolvable, flavored pouches containing nicotine derived from tobacco that users place in the mouth between the lip and gum)† have continued to rise nationally since 2016, their use among U.S. youths has become concerning (2,3). All pouches and most e-cigarettes contain nicotine,§ which is highly addictive and can harm the developing adolescent brain (4,5).

Trends in Smoking Before, During, and After Pregnancy in the United States from 2000 to 2020: Pregnancy Risk Assessment Monitoring System.

Objectives: This study used 2000-2020 Pregnancy Risk Assessment Monitoring System data to estimate trends in smoking before, during, and after pregnancy, as well as quitting smoking during pregnancy. Materials and Methods: Weighted prevalence and 95% confidence intervals (CIs) were calculated by year for each smoking-related measure. Annual percent change (APC) and average annual percent change (AAPC) in prevalence were estimated using Joinpoint regression to characterize trends over time. Results: Between 2000 and 2020, significant decreases in the prevalence of smoking before (23.0% to 14.0%; AAPC = -2.3% [95% CI = -2.9% to -1.7%]), during (13.2% to 6.5%; AAPC = -3.4% [95% CI = -4.0% to -2.7%]), and after pregnancy (18.9% to 8.8%; AAPC = -3.6% [95% CI = -4.3% to -2.9%]) were observed. For each measure, the fastest declines occurred largely throughout the 2010s (before: APC = -5.5% [2012-2020]; during: APC = -5.1% [2009-2020]; and after: APC = -6.4% [2012-2020]). The proportion of people who quit smoking during pregnancy significantly increased from 43.2% in 2000 to 53.7% in 2020 (AAPC = 1.0%; 95% CI = 0.2%-1.9%); however, Joinpoint regression detected relatively no change in quitting during pregnancy between 2010 and 2020 (APC = 0.0%; 95% CI = -0.4% to 0.5%). Conclusions: The prevalence of smoking before, during, and after pregnancy has reduced dramatically in the United States between 2000 and 2020, with the fastest declines occurring throughout the second decade of the twenty-first century. However, prevention and cessation efforts are still needed since approximately half of people who smoked before pregnancy continue to smoke during pregnancy.

Tobacco Product Use Among U.S. Middle and High School Students - National Youth Tobacco Survey, 2023.

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.

Smoking cessation prevalence by menthol cigarette use and select demographics among adults in the United States, TUS-CPS, 2003-2019.

People who smoke menthol cigarettes, particularly those who are non-Hispanic Black/African American, are less likely to achieve successful smoking cessation compared with people who smoke non-menthol cigarettes. This study examined the 2003-2019 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) harmonized data to estimate cross-sectional trends in cigarette smoking cessation among U.S. adults, stratified by menthol cigarette use, race/ethnicity, sex, and age. The analytic sample included respondents who smoked for ≥ 2 years (current users and former users who reported quitting during the past year). We tested cessation trends using orthogonal polynomial contrasts for overall, menthol, and non-menthol smoking cessation prevalence and stratified by race/ethnicity, sex, and age in logistic regression models. We also analyzed the 2018-2019 non-harmonized TUS-CPS data among recent quitters to examine differences in characteristics (e.g., demographic characteristics, smoking frequency, use of smoking cessation aids, switching to other tobacco products) by menthol cigarette use. We observed significant linear changes in prevalence trends for overall cigarette smoking cessation, menthol smoking cessation, and non-menthol smoking cessation (p < 0.0001 for all linear trends), and changes in menthol cessation among non-Hispanic White and non-Hispanic Other race/ethnicity categories during 2003-2019. In the 2018-2019 wave, we observed differences in menthol status for sex, race/ethnicity, age, and educational attainment. We did not observe differences for other characteristics. We observed changes in overall cigarette smoking cessation, menthol, and non-menthol smoking cessation prevalence during the study period; however, gains in cigarette smoking cessation were not experienced among non-Hispanic Black/African American adults who smoke.

Trends and Associations of Past-30-Day Cigar Smoking in the U.S. by Age, Race/Ethnicity, and Sex, NSDUH 2002-2020.

Cigar smoking remains a public health issue in the United States (U.S.), with a heterogeneous prevalence based on sociodemographic characteristics. Nationally representative data suggest changes in cigar smoking over time, with some evidence for sociodemographic differences. Using data from the 2002-2019 National Survey on Drug Use and Health (NSDUH), the prevalence of past-30-day cigar smoking was examined overall and stratified by sociodemographic characteristics; joinpoint regression examined the trends. Logistic regression analyses identified the correlates of cigar smoking using 2020 NSDUH data. From 2002 to 2004, the prevalence of cigar smoking remained stable (5.33-5.73%), but declined from 2004 to 2019 (5.73-4.29%). Cigar smoking declined in some periods between 2002-2019 among the non-Hispanic White, Hispanic, ages 12-17, ages 18-20, ages 21-25, age ≥ 35, and male subgroups, but remained unchanged among the non-Hispanic Other, ages 26-34, and female subgroups. Cigar smoking increased among non-Hispanic Black persons overall from 2002 to 2019 (6.67-8.02%). Past-30-day cigarette smoking and drug or alcohol use disorder was associated with an increased likelihood of cigar use, while female sex was associated with a decreased likelihood of cigar use, across all age groups. Though a decline in the prevalence of past-30-day cigar smoking is seen in the general population, the same is not evident among all sociodemographic subgroups. Our findings have the potential to inform tobacco cessation efforts within clinical practice, as well as regulatory efforts to reduce cigar use.

Nicotine Pouch Awareness and Use Among Youth, National Youth Tobacco Survey, 2021.

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.

Indicators of Tobacco Dependence Among Youth: Findings From Wave 1 (2013-2014) of the Population Assessment of Tobacco and Health Study.

BACKGROUND: Prior work established a measure of tobacco dependence (TD) among adults that can be used to compare TD across different tobacco products. We extend this approach to develop a common, cross-product metric for TD among youth. METHODS: One thousand one hundred and forty-eight youth aged 12-17 who used a tobacco product in the past 30 days were identified from 13 651 youth respondents in Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study. FINDINGS: Analyses confirmed a single primary latent construct underlying responses to TD indicators for all mutually exclusive tobacco product user groups. Differential Item Functioning analyses supported the use of 8 of 10 TD indicators for comparisons across groups. With TD levels anchored at 0.0 (standard deviation [SD] = 1.0) among cigarette only (n = 265) use group, mean TD scores were more than a full SD lower for e-cigarette only (n = 150) use group (mean = -1.09; SD = 0.64). Other single product use group (cigar, hookah, pipe, or smokeless; n = 262) on average had lower TD (mean = -0.60; SD = 0.84), and the group with the use of multiple tobacco products (n = 471) experienced similar levels of TD (mean = 0.14; SD = 0.78) as the cigarette only use group. Concurrent validity was established with product use frequency among all user groups. A subset of five TD items comprised a common metric permitting comparisons between youth and adults. CONCLUSION: The PATH Study Youth Wave 1 Interview provided psychometrically valid measures of TD that enable future regulatory investigations of TD across tobacco products and comparisons between youth and adult tobacco product use group. IMPLICATIONS: A measure of tobacco dependence (TD) has been established previously among adults to compare TD across tobacco products. This study established the validity of a similar, cross-product measure of TD among youth. Findings suggest a single latent TD construct underlying this measure, concurrent validity of the scale with product use frequency across different types of tobacco users, and a subset of common items that can be used to compare TD between youth and adults who use tobacco.

Impact of Survey Setting on Current Tobacco Product Use: National Youth Tobacco Survey, 2021.

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.

Symptoms of tobacco dependence among middle and high school tobacco users - Data from the 2019-2020 National Youth Tobacco Survey.

INTRODUCTION: Previous studies have indicated that youth who use tobacco products, including cigarettes, cigars, and smokeless tobacco, demonstrate dependence symptoms. However, the tobacco marketplace has expanded dramatically in recent years, and few studies have examined dependence symptoms among youth who use novel products. This study combined 2019-2020 National Youth Tobacco Survey data to report the prevalence and determinants of tobacco dependence symptoms among U.S. middle and high school current (past 30-day) tobacco users. METHODS: Prevalence estimates were calculated to examine dependence outcomes and other covariates by user groups (single product users and multiple product users). Multivariable logistic regression analyses were used to identify independent predictors of tobacco dependence among current users of cigarettes, cigars (regular cigars, cigarillos, and little cigars), e-cigarettes, heated tobacco products, hookah, pipe tobacco, bidis, and smokeless tobacco products (chew, snuff, dip, snus, and dissolvables). RESULTS: Among current tobacco users, 15.7 % (95 % CI: 14.2-17.3) reported wanting to use tobacco within 30 min of waking and 28.3 % (95 % CI: 26.3-30.5) reported strong cravings for tobacco in the past 30 days. Nearly-two-thirds of current users were single product users, of which 80.5 % reported using e-cigarettes. Reporting of dependence symptoms was generally associated with multiple product use, higher frequency of use, earlier initiation age, and use of flavored products. CONCLUSIONS: Among U.S. adolescents, a considerable amount of current tobacco product users, even infrequent users, reported symptoms of dependence. These findings highlight the continued importance of prevention strategies for youth tobacco experimentation and progression to regular use.

Tobacco Product Use and Associated Factors Among Middle and High School Students - National Youth Tobacco Survey, United States, 2021.

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.

Patterns and Trends in Use of Electronic Nicotine Delivery Systems Before and During Pregnancy: Pregnancy Risk Assessment Monitoring System, United States, 2016-2019.

INTRODUCTION: This study used 2016-2019 Pregnancy Risk Assessment Monitoring System data to estimate prevalence of electronic nicotine delivery system (ENDS) use around pregnancy, changes in ENDS use and cigarette smoking from before to during pregnancy, and trends in these behaviors over time. METHODS: ENDS and cigarette use during the 3 months before and the last three months of pregnancy were measured. Weighted prevalence estimates and 95% confidence intervals were estimated for outcomes overall and ENDS use by maternal characteristic for 2016-2019; logistic regression tested for differences in ENDS use by maternal characteristic and for linear trends in ENDS and cigarette use before and during pregnancy. Analyses were completed in 2021. RESULTS: In 2019, 4.3% (N = 98,050) of women used ENDS before and 1.3% (N = 28,811) used ENDS during pregnancy. Most exclusive ENDS users (82.2%) and exclusive cigarette smokers (55.0%) stopped use during pregnancy. Among dual users, 46.3% stopped use during pregnancy while 20.2% continued dual use and 24.9% smoked cigarettes exclusively. Few dual users (8.6%) and exclusive cigarette smokers (0.5%) reported using ENDS exclusively during pregnancy. From 2016-2019, exclusive ENDS use increased and exclusive cigarette smoking decreased both before and during pregnancy. CONCLUSIONS: ENDS use during pregnancy is low but increased since 2016. Less than one-half of dual ENDS and cigarettes users quit during pregnancy; few dual users or exclusive cigarette smokers switched to exclusive ENDS use during pregnancy. Continued surveillance of ENDS and other tobacco use during pregnancy is critical to inform public health activities that protect maternal and child health.

Characteristics of Past 30-Day Cigar Smoking, U.S. Adolescents, 2020.

INTRODUCTION: Data from the 2019 National Youth Tobacco Survey indicated that cigars were the most commonly used combustible tobacco product in the past 30 days among youth. This study uses 2020 National Youth Tobacco Survey data to report the prevalence estimates and characteristics of current cigar use, overall and by cigar type, among middle- and high-school students in the U.S. METHODS: Weighted prevalence estimates and 95% CIs were calculated in 2020 for overall cigar use and by cigar type. RESULTS: In 2020, current cigar smoking was reported by 3.5% of students (1.5% middle school and 5.0% high school). Cigarillos (44.1%) were the most reported cigar type smoked, followed by regular (33.1%) and little (22.6%) cigars; 21.8% did not know the cigar type. Most cigar smokers were in high school (81.2%) and were male (52.4%), and 42.3% were non-Hispanic White. More than half of cigar smokers reported smoking flavored cigars (58.3%), with fruit (61.5%), candy/desserts/other sweets (34.0%), and mint (30.4%) as the most frequently reported flavor categories. Approximately 1 in 5 current cigar smokers (18.4%) smoked on ≥20 days in the past 30 days, and 78.8% reported multiple tobacco product use. CONCLUSIONS: Cigar smoking was highest among non-Hispanic Black and Hispanic youth. More than half of youth cigar smokers reported using flavored cigars, and most were also currently using other tobacco products. Cigarillos were the most reported cigar type used by youth, followed by regular cigars. These findings highlight the continued importance of youth tobacco use reduction strategies and can inform policy development.

E-Cigarette Flavors and Frequency of E-Cigarette Use among Adult Dual Users Who Attempt to Quit Cigarette Smoking in the United States: Longitudinal Findings from the PATH Study 2015/16-2016/17.

Potential mechanisms by which e-cigarette use may relate to combustible cigarette smoking cessation are not well-understood. We used U.S. nationally representative data to prospectively evaluate the relationship between e-cigarette flavor use and frequency of e-cigarette use among adult cigarette/e-cigarette dual users who attempted to quit smoking cigarettes. Analyses used Population Assessment of Tobacco and Health (PATH) Study data from adult dual users (2015/16) who attempted to quit smoking between 2015/16 and 2016/17 (Wave 3-Wave 4, n = 685, including those who did/did not quit by 2016/17). E-cigarette flavor use (usual/last flavor, past 30-day flavor; assessed in 2015/16) was categorized into Only tobacco; Only menthol/mint; Only non-tobacco, non-menthol/mint; and Any combination of tobacco, menthol/mint, other flavor(s). The key outcome, evaluated at follow-up in 2016/17, was frequent e-cigarette use, which was defined as use on 20+ of past 30 days. Logistic regression was used to evaluate associations between e-cigarette flavor use in 2015/16 and frequent e-cigarette use at follow-up in 2016/17. Dual users who attempted to quit smoking had greater odds of frequent e-cigarette use at follow-up when they used only non-tobacco, non-menthol/mint flavor than when they used only tobacco flavor as their regular/last e-cigarette flavor (OR = 1.9, 95% CI: 1.1-3.4); findings were no longer significant when adjusted for factors including e-cigarette device type (AOR = 1.4, 95% CI: 0.7-2.8). Past 30-day e-cigarette flavor use results were generally similar, although frequent e-cigarette use at follow-up was highest among those who used any combination of tobacco, menthol/mint, or other flavors. Findings indicate that e-cigarette flavor use among dual users who attempt to quit smoking may be related to e-cigarette use frequency overall, which may indicate a mechanism underlying findings for e-cigarette use and smoking cessation. Further longitudinal research may help to disentangle how e-cigarette characteristics uniquely impact e-cigarette use frequency and smoking cessation/sustained use.

Menthol and Mint Cigarettes and Cigars: Initiation and Progression in Youth, Young Adults and Adults in Waves 1-4 of the PATH Study, 2013-2017.

INTRODUCTION: This study examined in youth (12-17 years), young adults (18-24 years), and adults (25+ years): (1) the prevalence of the first menthol cigarette and menthol/mint cigar use among new tobacco users; (2) association between the first menthol/mint use, subsequent tobacco use, and nicotine dependence ~1 year later compared with the first non-menthol/mint use. AIMS AND METHODS: Longitudinal analysis of data from Waves 1 to 4 of the Population Assessment of Tobacco and Health (PATH) Study (2013-2017; 10 086 youth and 21 281 adults). Main outcome measures were past 12-month and past 30-day cigarette and cigar use, and nicotine dependence. RESULTS: Youth and young adult new cigarette users are more likely to smoke a menthol cigarette or indicate that they do not know the flavor compared with adults aged 25+. A greater proportion of adults aged 25+ first used menthol/mint-flavored cigars (13.4%) compared with youth (8.5%) and young adults (7.4%). Among young adults, first use of a menthol cigarette is associated with past 12-month use of cigarettes at the subsequent wave and first use of any menthol/mint-flavored cigars is associated with past 30-day use of these products at the subsequent wave in both youth and young adults. In youth and adults, there were no significant relationships between first use of a menthol/mint cigarette or cigar and nicotine dependence scores at a subsequent wave in multivariable analyses. CONCLUSIONS: The first use of menthol/mint cigarettes and cigars is associated with subsequent cigarette and cigar use in young people aged 12-24. IMPLICATIONS: This study examined the relationship between initiation with menthol cigarettes and menthol/mint cigars, subsequent tobacco use, and nicotine dependence in US youth, young adults, and adults who participated in Waves 1-4 of the Population Assessment of Tobacco and Health study. New use of menthol cigarettes was associated with greater past 12-month cigarette use in young adults and new use of menthol/mint-flavored cigars was associated with greater past 30-day cigar use in youth and young adults compared with non-menthol use. Initiation with menthol/mint cigarette and cigar products may lead to subsequent use of those products.

Trends and Associations of Menthol Cigarette Smoking Among US Middle and High School Students-National Youth Tobacco Survey, 2011-2018.

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.

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.

e-Cigarette Use Among Youth in the United States, 2019.

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 19 018 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 10 097 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.