Flavored Tobacco Product Use Among Middle and High School Students — United States, 2014–2018

Karen A. Cullen, PhD; Sherry T. Liu, PhD; Jennifer K. Bernat, PhD; Wendy I. Slavit, MPH; Michael A. Tynan; Brian A. King, PhD; Linda J. Neff, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(39):839-844. 

In This Article

Abstract and Introduction

Introduction

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]

NYTS is an annual cross-sectional, school-based, self-administered, pencil-and-paper questionnaire administered to U.S. middle and high school students. A three-stage cluster sampling procedure was used to generate a nationally representative sample of U.S. students attending public or private schools in grades 6–12. This report uses data from five NYTS waves (2014–2018). Sample sizes and response rates were 22,007 (73.3%) in 2014; 17,711 (63.4%) in 2015; 20,675 (71.6%) in 2016; 17,872 (68.1%) in 2017; and 20,189 (68.2%) in 2018.

Participants were asked about current (≥1 day during the past 30 days) use of cigarettes, e-cigarettes, hookahs, cigars, pipe tobacco, smokeless tobacco, snus, dissolvable tobacco products, and bidis. Current cigarette smoking was determined by asking "During the past 30 days, on how many days did you smoke cigarettes?" Current use of cigars was determined by asking "During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?" Current use of smokeless tobacco was determined by asking "During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip?" Current use of e-cigarettes was determined by asking "During the last 30 days, on how many days did you use e-cigarettes?" Current use of hookahs was determined by asking "During the past 30 days, on how many days did you smoke tobacco in a hookah or waterpipe?" Current use of pipe tobacco (not hookahs), snus, dissolvable tobacco, and bidis were determined by asking "In the past 30 days, which of the following products have you used on at least one day?" "Any tobacco" use was defined as current use of one or more tobacco products. "Any smokeless tobacco" use was defined as current use of smokeless tobacco (chewing tobacco, snuff, or dip), snus, or dissolvables. Participants were also asked about any current use of tobacco products that were "flavored to taste like menthol (mint), alcohol (wine, cognac), candy, fruit, chocolate, or any other flavors." Participants could select from a list of flavored tobacco products, including each noncigarette tobacco product type. Among students who reported current use of each product, those who selected the flavored product were categorized as flavored tobacco product users. Among current cigarette smokers, menthol smokers were categorized as those who reported "Yes" to the question "During the past 30 days, were the cigarettes that you usually smoked menthol," or who reported "Newport" or "Kool" as the usual cigarette brand because these brands produce menthol cigarettes exclusively or predominantly.

Data were weighted to account for the complex survey design and adjusted for nonresponse; national prevalence estimates were calculated with 95% confidence intervals. Current flavored product use estimates for 2018 were assessed for any tobacco product and for each product individually, by school type, sex, and race/ethnicity. Use of flavored bidis was first included in the survey in 2016, so 2014–2015 data do not include bidis. For each school type, presence of linear and nonlinear (i.e., quadratic) trends were assessed during 2014–2018.§ For all analyses, p-values <0.05 were considered statistically significant. Analyses were conducted using SAS (version 9.4; SAS Institute) and SUDAAN (version 11.0.3; RTI International).

In 2018, 27.1% of high school students and 7.2% of middle school students reported current use of any tobacco product, corresponding to an estimated 4.92 million middle and high school students who use at least one tobacco product. Among current users of any tobacco product, 64.1% reported using at least one flavored tobacco product in the past 30 days. The percentage of current tobacco users who reported flavored product use in the past 30 days was 65.2% for e-cigarettes, 45.7% for menthol cigarettes, 43.6% for cigars, 38.9% for bidis, 37.5% for any smokeless tobacco, 26.5% for tobacco in pipes, and 26.1% for hookah (Table).

Among high school tobacco product users, a significant nonlinear decrease occurred during 2014–2018 in use of any flavored tobacco product (from 73.0% to 67.4%) (Figure). By product, a significant nonlinear increase in use of flavored e-cigarettes (from 65.1% to 67.8%) occurred; a significant nonlinear decrease in use of flavored smokeless tobacco (from 64.7% to 40.1%) occurred. Significant linear decreases in use of menthol cigarettes (from 54.5% to 46.1%), flavored hookah tobacco (from 63.8% to 27.9%), flavored cigars (from 64.7% to 44.5%), and flavored pipe tobacco (from 44.0% to 27.3%) occurred. Among middle school tobacco product users (Figure), a significant linear decrease in flavored hookah tobacco use (from 44.3% to 18.3%) occurred during 2014–2018. The use of flavored e-cigarettes decreased from 55.1% to 39.2% during 2014–2015 and then increased during 2015–2018 to 51.5%, comparable with the 2014 estimate. No significant change in use of any flavored tobacco, flavored smokeless tobacco, cigars, pipe tobacco, or menthol cigarettes among middle school students occurred during 2014–2018.

Figure.

Figure: Percentage of current tobacco product*,† users in high school and middle school who reported using flavored products during the preceding 30 days, by tobacco product — National Youth Tobacco Survey, United States, 2014–2018
* For 2014–2015, any tobacco is use of cigarettes, cigars, smokeless tobacco, e-cigarettes, hookahs, pipe tobacco, snus, or dissolvables on ≥1 day in the preceding 30 days. For 2016–2018, any tobacco is use of cigarettes, cigars, smokeless tobacco, e-cigarettes, hookahs, pipe tobacco, snus, dissolvables, or bidis on ≥1 day in the preceding 30 days. Exclusion of bidis from any tobacco use for 2016, 2017, and 2018 did not change the estimates.
Use of flavored bidis was only asked beginning in 2016, so estimates of flavored bidi use are not available for 2014–2015. For middle school estimates, use of flavored pipe tobacco and bidis are not shown because the individual estimates needed to be suppressed as a result of small sample size, relative standard error >30%, or both.

* Family Smoking Prevention and Tobacco Control Act [Pub. L. No. 111–31, H.R. 1256 (2009)]. https://www.govinfo.gov/content/pkg/PLAW-111publ31/html/PLAW-111publ31.htm.
https://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm.

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