Sociodemographic and Temporal Differences in Menthol Cigarette Use Among US Adults Who Smoke, 1999-2018.

Introduction: Monitoring menthol cigarette use allows for identification of potential health disparities. We examined sociodemographic and temporal differences in menthol cigarette use among US adults who smoke. Methods: We analyzed data from the 1999-2018 National Health and Nutrition Examination Survey for adults aged 20 years or older who smoke (N = 11,431) using binary logistic regression. Results: Among US adults who smoke, 28.8% used menthol cigarettes. After adjusting for age, sex, race and ethnicity, education, income-to-poverty ratio, and health status, the prevalence of menthol use among adults who smoke increased on average by 3.8% (95% CI, 2.7%-4.9%) annually. Non-Hispanic Black adults had the highest average prevalence of menthol cigarette use, 73.0% (95% CI, 70.9%-75.2%), and Mexican American adults had higher average annual increase in menthol cigarette use, 7.1% (95% CI, 4.0%-10.3%). Adults with fair or poor health status had a 4.3% annual increase in menthol cigarette use (95% CI, 2.5%-6.1%). The adjusted prevalence ratios of menthol cigarette use were 1.61 (95% CI, 1.39-1.83) for adults aged 20-29 years compared with those aged 65 years or older, 1.41 (95% CI, 1.32-1.49) for female adults compared with male adults, and 1.17 (95% CI, 1.07-1.27) for high school graduates or higher compared with those with no high school diploma. Conclusion: Non-Hispanic Black adults who smoke had the highest prevalence of menthol cigarette use among all racial and ethnic groups; the prevalence of menthol cigarette use among adults who smoke increased especially among Mexican American adults, younger adults, and adults who reported fair to poor health status.

State-Specific Prevalence of Adult Tobacco Product Use and Cigarette Smoking Cessation Behaviors, United States, 2018-2019.

Introduction: Increasing quitting among people who smoke cigarettes is the quickest approach to reducing tobacco-related disease and death. Methods: We analyzed data from the 2018-2019 Tobacco Use Supplement to the Current Population Survey for 137,471 adult self-respondents from all 50 US states and the District of Columbia to estimate state-specific prevalence of current tobacco product use, interest in quitting smoking, past-year quit attempts, recent successful cessation (past-year quit lasting ≥6 months), receipt of advice to quit smoking from a medical doctor, and use of cessation medications and/or counseling to quit. Results: Prevalence of current any-tobacco use (use every day or some days) ranged from 10.2% in California to 29.0% in West Virginia. The percentage of adults who currently smoked cigarettes and were interested in quitting ranged from 68.2% in Alabama to 87.5% in Connecticut; made a past-year quit attempt ranged from 44.1% in Tennessee to 62.8% in Rhode Island; reported recent successful cessation ranged from 4.6% in West Virginia and Wisconsin to 10.8% in South Dakota; received advice to quit from a medical doctor ranged from 63.3% in Colorado to 86.9% in Rhode Island; and used medications and/or counseling to quit ranged from 25.5% in Nevada to 50.1% in Massachusetts. Several states with the highest cigarette smoking prevalence reported the lowest prevalence of interest in quitting, quit attempts, receipt of advice to quit, and use of counseling and/or medication, and the highest prevalence of e-cigarette, smokeless tobacco, and cigar use. Conclusion: Adults who smoke struggle with smoking cessation and could benefit from additional intervention.

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.

Tobacco Product Use Among Adults - United States, 2021.

Commercial cigarette smoking among U.S. adults has declined during the preceding 5 decades (1,2); however, tobacco product use remains the leading cause of preventable disease and death in the United States, and some populations continue to be disproportionately affected by tobacco use (1,2). To assess recent national estimates of commercial tobacco use among U.S. persons aged ≥18 years, CDC, the Food and Drug Administration (FDA), and the National Cancer Institute analyzed 2021 National Health Interview Survey (NHIS) data. In 2021, an estimated 46 million U.S. adults (18.7%) reported currently using any tobacco product, including cigarettes (11.5%), e-cigarettes (4.5%), cigars (3.5%), smokeless tobacco (2.1%), and pipes (including hookah)* (0.9%).† Among those who used tobacco products, 77.5% reported using combustible products (cigarettes, cigars, or pipes), and 18.1% reported using two or more tobacco products.§ The prevalence of current use of any tobacco product use was higher among the following groups: men; persons aged <65 years; persons of non-Hispanic other races; non-Hispanic White (White) persons¶; residents of rural (nonmetropolitan) areas; financially disadvantaged (income-to-poverty ratio = 0-1.99); lesbian, gay, or bisexual (LGB) persons; those uninsured or enrolled in Medicaid; adults whose highest level of education was a general educational development (GED) certificate; who had a disability; and who had serious psychological distress. Continued surveillance of tobacco product use, implementation of evidence-based tobacco control strategies (e.g., hard-hitting media campaigns, smoke-free policies, and tobacco price increases), conducting linguistically and culturally appropriate educational campaigns, and FDA regulation of tobacco products will aid in reducing tobacco-related disease, death, and disparities among U.S. adults (3,4).

Cigarettes, Smokeless Tobacco, and E-Cigarettes: State-Specific Use Patterns Among U.S. Adults, 2017-2018.

INTRODUCTION: State-level monitoring of changes in tobacco product use can inform tobacco control policy and practice. This study examines the state-specific prevalence of current cigarette smoking, smokeless tobacco use, and E-cigarette use and related cigarette quitting behaviors among E-cigarette users during 2017-2018. METHODS: Data from the 2017 and 2018 Behavioral Risk Factor Surveillance System were used to assess state-specific current use of cigarettes, smokeless tobacco, and E-cigarettes among adults aged ≥18 years. Analyzed in 2021, state-specific tobacco product estimates and relative percentage changes between 2017 and 2018 were computed for U.S. states and the District of Columbia. Chi-square tests captured subgroup differences, and logistic regression assessed changes over time. RESULTS: Prevalence of adult current cigarette smoking and smokeless tobacco use varied across states and remained relatively stable during 2017-2018, whereas the prevalence of adult E-cigarette use significantly increased during 2017-2018 among 19 of 36 states that collected Behavioral Risk Factor Surveillance System E-cigarette data in 2018. In all states and the District of Columbia during 2017-2018 combined, the percentage of current cigarette smoking among current E-cigarette users was higher than that of never cigarette smoking; the percentage of attempting to quit cigarette smoking in the past year among dual users of cigarettes and E-cigarettes was >50%. CONCLUSIONS: During 2017-2018, the prevalence of adult current cigarette smoking and smokeless tobacco use varied across states and remained relatively stable, whereas adult E-cigarette use prevalence significantly increased. Comprehensive state-based tobacco prevention and control efforts are warranted to reduce the morbidity and mortality attributed to the use of all tobacco products, including E-cigarettes, among U.S. adults.

Trends in Secondhand Smoke Exposure, 2011-2018: Impact and Implications of Expanding Serum Cotinine Range.

INTRODUCTION: The impact of defining secondhand smoke exposure among nonsmokers using an expanded serum cotinine range is currently unknown. METHODS: This study assessed the trends in secondhand smoke exposure prevalence among a nationally representative sample of 23,753 U.S. nonsmokers aged ≥3 years. Serum cotinine ranges of 0.05-10 ng/mL (established) and of 0.015-10 ng/mL (expanded) were analyzed in 2021 using data from the 2011-2018 National Health and Nutrition Examination Survey. RESULTS: During 2011-2018, the percentage of people with a serum cotinine range of 0.05-10 ng/mL remained stable (25.3% to 24.6%) across most sociodemographic subgroups but declined significantly among adult Mexican Americans aged ≥20 years (23.9% to 14.1%). However, the percentage of people with serum cotinine range of 0.015-10 ng/mL significantly declined (58.3% to 52.3%) among male individuals (60.9% to 55.0%), among female individuals (56.2% to 50.0%), among adults aged ≥20 years (55.8% to 49.2%), among Mexican Americans (60.9% to 41.2%), among people with a college degree or higher (44.4% to 36.0%), among those who rented their housing (71.7% to 62.5%), among people not living with someone who smoked inside the home (56.1% to 50.0%), and among Mexican Americans aged ≥20 years (60.9% to 39.1%) (all p<0.05 for linear trend test). CONCLUSIONS: Expanding the serum cotinine range to 0.015-10 ng/mL more than doubles the estimated proportion of U.S. nonsmokers exposed to secondhand smoke. In contrast to a serum cotinine range of 0.05-10 ng/mL, it suggests that progress has been made in reducing population-level secondhand smoke exposure during 2011-2018, especially among nonsmokers experiencing lower exposure levels.

Characteristics of e-Cigarette Use Behaviors Among US Youth, 2020.

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.

Tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, product use behaviors among adults after the onset of the 2019 outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI).

INTRODUCTION: During the E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) outbreak, patient data on tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, product (EVP) use was collected, but data on non-affected adult product use after the onset of the EVALI outbreak is limited. This study describes adult THC-EVP use after EVALI began. METHODS: THC-EVP use data came from an 18-state web-based panel survey of adult THC- and nicotine-containing EVP users conducted February 2020. Unweighted descriptive statistics were calculated; logistic regression assessed correlates of use. RESULTS: Among 3,980 THC-EVP users, 23.5% used THC-EVPs daily. Common brands of THC-EVPs used were Dank Vapes (47.7%) and Golden Gorilla (38.7%). Reported substances used included THC oils (69.6%), marijuana herb (63.6%) and THC concentrate (46.4%). Access sources included: recreational dispensaries (41.1%), friend/family member (38.6%) and illicit dealers (15.1%). Respondents aged 45-64 years had lower odds for daily use compared with those aged 25-34 years (aOR = 0.73; 95% CI = 0.60, 0.90). Compared with White respondents, Asian respondents had lower odds (aOR = 0.55; 95% CI = 0.36, 0.84) and Black respondents higher odds (aOR = 1.48; 95% CI = 1.17, 1.86) of daily use. Respondents odds of daily use and accessing THC-EVPs through commercial sources were higher among states with legalized nonmedical adult marijuana use compared to states without. CONCLUSIONS: Almost half of respondents reported daily or weekly THC-EVP use, and accessed products through both informal and formal sources, even after EVALI began. Given the potential for future EVALI-like conditions to occur, it is important to monitor the use of THC-EVPs and ensure effective education activities about associated risk.

U.S. healthcare spending attributable to cigarette smoking in 2014.

INTRODUCTION: Cigarette smoking continues to be the leading cause of preventable disease and death in the U.S. Smoking also carries an economic burden, including smoking-attributable healthcare spending. This study assessed smoking-attributable fractions in healthcare spending between 2010 and 2014, overall and by insurance type (Medicaid, Medicare, private, out-of-pocket, other federal, other) and by medical service (inpatient, non-inpatient, prescriptions). METHODS: Data were obtained from the 2010-2014 Medical Expenditure Panel Survey linked to the 2008-2013 National Health Interview Survey. The final sample (n = 49,540) was restricted to non-pregnant adults aged 18 years or older. Estimates from two-part models (multivariable logistic regression and generalized linear models) and data from 2014 national health expenditures were combined to estimate the share of and total (in 2014 dollars) annual healthcare spending attributable to cigarette smoking among U.S. adults. All models controlled for socio-demographic characteristics, health-related behaviors, and attitudes. RESULTS: During 2010-2014, an estimated 11.7% (95% CI = 11.6%, 11.8%) of U.S. annual healthcare spending could be attributed to adult cigarette smoking, translating to annual healthcare spending of more than $225 billion dollars based on total personal healthcare expenditures reported in 2014. More than 50% of this smoking-attributable spending was funded by Medicare or Medicaid. For Medicaid, the estimated healthcare spending attributable fraction increased more than 30% between 2010 and 2014. CONCLUSIONS: Cigarette smoking exacts a substantial economic burden in the U.S. Continuing efforts to implement proven population-based interventions have been shown to reduce the health and economic burden of cigarette smoking nationally.

Tobacco Product Use Among Middle and High School Students - United States, 2020.

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).

Tobacco Product Use Among Adults - United States, 2019.

Cigarette smoking remains the leading cause of preventable disease and death in the United States (1). The prevalence of current cigarette smoking among U.S. adults has declined over the past several decades, with a prevalence of 13.7% in 2018 (2). However, a variety of combustible, noncombustible, and electronic tobacco products are available in the United States (1,3). To assess recent national estimates of tobacco product use among U.S. adults aged ≥18 years, CDC analyzed data from the 2019 National Health Interview Survey (NHIS). In 2019, an estimated 50.6 million U.S. adults (20.8%) reported currently using any tobacco product, including cigarettes (14.0%), e-cigarettes (4.5%), cigars (3.6%), smokeless tobacco (2.4%), and pipes* (1.0%).† Most current tobacco product users (80.5%) reported using combustible products (cigarettes, cigars, or pipes), and 18.6% reported using two or more tobacco products.§ The prevalence of any current tobacco product use was higher among males; adults aged ≤65 years; non-Hispanic American Indian/Alaska Native (AI/AN) adults; those whose highest level of educational attainment was a General Educational Development (GED) certificate; those with an annual household income <$35,000; lesbian, gay, or bisexual (LGB) adults; uninsured adults and those with Medicaid; those with a disability; or those with mild, moderate, or severe generalized anxiety disorder. E-cigarette use was highest among adults aged 18-24 years (9.3%), with over half (56.0%) of these young adults reporting that they had never smoked cigarettes. Implementing comprehensive, evidence-based, population level interventions (e.g., tobacco price increases, comprehensive smoke-free policies, high-impact antitobacco media campaigns, and barrier-free cessation coverage), in coordination with regulation of the manufacturing, marketing, and sale of all tobacco products, can reduce tobacco-related disease and death in the United States (1,4). As part of a comprehensive approach, targeted interventions are also warranted to reach subpopulations with the highest prevalence of use, which might vary by tobacco product type.

E-cigarette Use Among Middle and High School Students - United States, 2020.

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).

Exposure to Secondhand Smoke in Homes and Vehicles Among US Youths, United States, 2011-2019.

In this study, we report the prevalence of self-reported secondhand smoke (SHS) exposure in homes and vehicles among US middle and high school students in 2019 and changes in SHS exposure over time. Data were from 7 years of the National Youth Tobacco Survey (NYTS; 2011, 2013, and 2015-2019). In 2019, 25.3% (an estimated 6.7 million) of students reported home SHS exposure and 23.3% (6.1 million) reported vehicle SHS exposure. Home and vehicle SHS exposure significantly declined during 2011 through 2018, except for home exposure among non-Hispanic black students. Implementation of smoke-free policies in public and private settings can reduce SHS exposure.

Feasibility of Administering an Electronic Version of the National Youth Tobacco Survey in a Classroom Setting.

INTRODUCTION: The National Youth Tobacco Survey (NYTS) has successfully monitored tobacco product use patterns and correlates since 1999 among US students in grades 6 through 12 using a scannable paper-and-pencil format. We conducted a study to determine the feasibility and potential benefits of administering an electronic version of the NYTS in school settings. METHODS: The pilot survey was administered by using 2 versions. Version 1 mimicked the scannable paper-and-pencil format with respect to design, formatting, and structure, but was administered on a tablet computer. Version 2 used an electronic survey design and formatting capabilities, which included programmed logic skips and tobacco product images. Chi-square and t tests were used to assess subgroup differences. Multivariable-adjusted logistic regression models were used to determine if the odds of ever and current tobacco product use differed between the 2 versions. RESULTS: In total, 2,769 students completed version 1 or version 2. Three-quarters of respondents reported a strong preference for using an electronic device to take the NYTS (74.7%). Compared with version 1, version 2 reduced the mean time to complete the survey by 15% (P < .01), reduced the number of questions students needed to answer by 30% (P < .01), and removed 1.9% of inconsistent survey responses. A significant difference was observed for ever e-cigarette use between versions 1 (22.2%) and 2 (29.5%; P < .0001). No significant differences in ever or current use were observed for other tobacco products. CONCLUSION: An electronic mode of administration is feasible and valid for conducting surveillance of tobacco product use among US youths.

Tobacco-Free Pharmacies and U.S. Adult Smoking Behavior: Evidence From CVS Health's Removal of Tobacco Sales.

INTRODUCTION: Beginning September 3, 2014, CVS Health stopped selling tobacco products in all of its retail stores nationwide. This study assessed the impact of removing tobacco sales from CVS Health on cigarette smoking behaviors among U.S. adult smokers. METHODS: CVS Health retail location data (2012-2016) were linked with data from the Behavioral Risk Factor Surveillance System, a phone-based survey of the non-institutionalized civilian population aged ≥18 years. Using a difference-in-differences regression model, quit attempts and daily versus nondaily smoking were compared between smokers living in counties with CVS stores and counties without CVS stores, before and after CVS's removal of tobacco sales. Control variables included individuals' sociodemographic and health-related variables, state tobacco control variables, and urban status of counties. Analyses were conducted in 2018. RESULTS: During the 2-year period following the removal of tobacco sales from CVS Health, smokers living in counties with high CVS density (≥3.5 CVS stores per 100,000 people) had a 2.21% (95% CI=0.08, 4.33) increase in their quit attempt rates compared with smokers living in counties without CVS stores. This effect was greater in urban areas (marginal effect: 3.03%, 95% CI=0.81, 5.25); however, there was no statistically significant impact in rural areas. Additionally, there was no impact on daily versus nondaily smoking in either urban or rural areas. CONCLUSIONS: Removing tobacco sales in retail pharmacies could help support cessation among U.S. adults who are attempting to quit smoking, particularly in urban areas.

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.

Tobacco Product Use and Cessation Indicators Among Adults - United States, 2018.

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).

Flavored Tobacco Product Use Among Middle and High School Students - United States, 2014-2018.

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).

Social and Physical Environmental Characteristics Associated With Adult Current Cigarette Smoking.

INTRODUCTION: Our objective was to identify social and physical environmental factors associated with current cigarette smoking among adults by metropolitan county in the United States. METHODS: We linked cigarette smoking data from the 2012 Behavioral Risk Factor Surveillance System (BRFSS) Selected Metropolitan Area Risk Trends (SMART) data set to 7 social and physical environmental characteristics: county type (metropolitan designation), primary care physician density, income inequality, percentage of the population that was a racial/ethnic minority, violent crime rate, education, and percentage of county residents with low income and no health insurance, all obtained from several county data sets. Spatial regression and hierarchical logistic regression modeling were performed. RESULTS: Results showed that metropolitan counties with a high proportion of non-Hispanic white adults (P < .001), lower education levels (high school graduate or less) (P < .001), and high violent crime rates (P < .001) had a higher adult cigarette smoking prevalence than other metropolitan counties. Spatial models showed 63.3% of the variability in county cigarette smoking prevalence was explained by these 3 factors as well as county type (based on population size of the of metropolitan area), primary care physician density, and percentage of county residents with low income and no health insurance. At an individual level, results showed that as the density (population) of primary care physicians increased in a county, the odds of being a current smoker decreased (OR, 0.980; P = .02). CONCLUSION: We found a significant association between adult cigarette smoking and county social and physical environmental factors. These place-based factors, especially social environmental characteristics, may reveal tobacco-related disparities to be considered when developing strategies to reduce tobacco use.