• Report Finds Fewer American Youths Use Tobacco Products

    Despite Declines, E-cigarettes Remain Popular

    January 21, 2021, 12:40 pm Michael Devitt — A new report from the CDC and the FDA revealed mixed results in the use of tobacco products by U.S. middle school and high school students. The report, published Dec. 18, 2020, in Morbidity and Mortality Weekly Report, found that while use of e-cigarettes, cigars and smokeless tobacco declined in these age groups between 2019 and 2020, about one-sixth of all students — just under 4.5 million — still used some type of tobacco product last year.

    young man vaping

    “While I am encouraged that tobacco use is declining among middle school and high school students, there are still too many who become addicted to nicotine and will be at risk for long-term complications,” Lynn Fisher, M.D., a member of the AAFP’s Commission on Health of the Public and Science, told AAFP News. “We have to continue to make addressing tobacco use a priority in our practices.”

    Study Methods

    The study authors compared data from the 2019 and 2020 National Youth Tobacco Surveys, a voluntary, cross-sectional, school-based electronic survey of U.S. middle and high school students enrolled in public and private schools. While data for the 2019 survey was collected over a four-month period, the COVID-19 pandemic resulted in 2020 survey data being collected from Jan. 16 through March 16, 2020.

    A total of 14,531 eligible students completed the survey in classrooms using a tablet computer. The surveys tracked current use of seven tobacco products: e-cigarettes, cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco and heated tobacco products (a new category considered separate from e-cigarettes and defined as products that heat tobacco sticks or capsules to produce a vapor). Current use was defined as use of a product on one or more days in the last 30 days.

    In addition to use of heated tobacco products, the study also presented survey data for the first time on the use of tobacco products by sexual identity.

    Story Highlights


    Overall use of any tobacco product declined from 6.2 million in 2019 to 4.47 million in 2020. Among both groups of students, statistically significant declines were seen across a wide range of tobacco products, including

    • e-cigarettes,
    • cigars,
    • smokeless tobacco,
    • use of multiple tobacco products,
    • use of any tobacco product and
    • use of any combustible tobacco product.

    On the other hand, there was no significant increase or decrease in the current use of cigarettes, hookahs, pipe tobacco or heated tobacco products.

    Despite the declines, about 23.6% of high school students and 6.7% of middle school students — or 16.2% combined — still reported current use of one or more tobacco products. In middle school, a slightly higher percentage of female students used tobacco products (6.8% vs. 6.6% of males), whereas in high school, a higher percentage of male students used tobacco products (24.7% vs. 22.5% of females). In both age groups, e-cigarettes were the most popular tobacco product used, followed in high school students by cigars and cigarettes, and in middle school students by cigarettes and cigars.

    In terms of sexual identity, 30.9% of high school students and 16.5% of middle school students who self-identified as lesbian, gay or bisexual reported current use of tobacco products compared with 22% of high school students and 5.5% of middle school students who identified as heterosexual. Another 20.4% of high school students and 6.4% of middle school students who reported being unsure of their sexual identity currently used tobacco products.

    The authors attributed the decline in tobacco product use to several factors, such as the December 2019 federal increase in the minimum age of sale for all tobacco products from 18 to 21 and FDA guidance issued in January 2020 that emphasized enforcement against certain types of flavored e-cigarette products that appeal to youth, as well as various state and local initiatives.

    “Continued actions are warranted to help ensure sustained progress in preventing and reducing youths’ use of all forms of tobacco products, including those that are combustible, noncombustible and electronic,” they wrote.

    It should be noted that the Academy recently revised its own position paper on preventing and treating nicotine dependence and tobacco use.

    Talking About Tobacco Use: Family Physician Perspective

    Fisher, who also serves as an assistant professor in the Department of Family and Community Medicine at the University of Kansas School of Medicine-Wichita, said he was surprised to read that the use of cigarettes did not decrease given the recent emphasis on Tobacco 21 legislation and the wide range of other tobacco products available. As such, he emphasized the importance of educating youth about the harms of tobacco use early on.

    “I think that we need to provide that education before students are given the opportunity to start using tobacco,” Fisher said. “Hopefully if students hear a consistent message from their teachers, their parents and their physicians about the harms of tobacco, they will be less inclined to start using.”

    Fisher also outlined some of the strategies he uses. For example, when asked about counseling youth on using e-cigarettes, he said, “You can’t just simply ask students if they are using tobacco. I recently learned that there are many names for specific brands and types of e-cigarettes. It is important to specifically ask about the use of those, as students might not realize that what they are using is a form of an e-cigarette.”

    The AAFP recommends universal screening for tobacco and nicotine use, especially for those in high-risk populations. Significant research has been done on the disproportionate harmful health effects caused by higher rates of tobacco and nicotine use among certain adult populations, including lesbian, gay, bisexual and transgender individuals. Given the findings that also showed higher tobacco use among youth who identified as lesbian, gay or bisexual, these early opportunities for education and intervention are especially important. Fisher added that he takes a nonjudgmental approach when discussing tobacco use or any other health issue.

    “It is important that we create a culturally competent, inclusive way of reaching out to youth, especially LGBTQIA youth,” said Fisher. “I want youth who are marginalized to know that they can talk to me without judgement. I listen to understand. I want to be a trusted source of information about tobacco use and any other issue that affects health. I always ask if there is anything I can do to assist stopping any behavior that may be harmful and would keep the youth from their full potential.”

    For AAFP members who want more information on tobacco cessation and decreasing tobacco use, Fisher noted that several tools and resources are available on the Academy’s website, including the Quit Smoking Guide and the Treating Tobacco Dependence Practice Manual.

    Fisher also suggested that FPs consult their individual state’s tobacco cessation quitline, and noted that several smartphone apps are available for patients to assist with tobacco cessation.