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A Sea Change in US Youth Tobacco Use

Economic and Health Policy Research, American Cancer Society

US high school students are now using e-cigarettes at a higher rate than combustible cigarettes, according to the 2014 National Youth Tobacco Survey, published April 16, 2015 in Morbidity and Mortality Weekly Report (MMWR).

The survey’s findings demonstrate distinct changes in the patterns of youth tobacco use from previous years that reinforce the country’s need for decisive regulatory action.

The changes in high school student tobacco use prevalence from the National Youth Tobacco Survey shown in the graph below were compiled from US Centers for Disease Control and Prevention (CDC) MMWR articles for the following years: 2000, 2006, 2009, 2011-2012, 2013, and 2014.

We can split the survey’s findings into three parts: Good News, Bad News, and Confusing News. And as always with The Tobacco Atlas, Fifth Edition, we will provide a clear Call To Action.

Good News

US high school students are using cigarettes at the lowest rate on record. The proportion of high school students who reported using cigarettes in the past 30 days in 2014 is a third of the proportion who used cigarettes in 2000.

Cigarettes are quite possibly the most deadly consumer product sold on the market in the United States. Moreover, most cigarette smokers begin smoking while in their teenage years. If youth cigarette use continues to decline, and if these teenagers can stay away from cigarettes as adults, we will see a massive improvement in the health of the public in the US.

Public health researchers and proponents can certainly attribute much of the long decline in cigarette use to the success of a continuing set of key tobacco control policies, including:

But progress in these policy areas has slowed in the US over the past few years, which suggests that other dynamics are at play in the drop in cigarette use among young people.

In other good news, cigar and pipe use are also down sharply from 2013. But, this finding is not as straightforward as it may seem, a point we’ll discuss more in Confusing News.

Bad News

The percent of high school students using any tobacco product is not decreasing along with the cigarette use rate, which is cause for concern. The reason behind this is clear: E-cigarette use is now more common among high school students than the smoking of combustible cigarettes.

We show the data only from 2011 through 2014 in the figure below to illustrate how fast e-cigarette use has grown and because 2011 was the first year that high school students were asked if they used e-cigarettes and hookah.

Many high school students are gravitating toward e-cigarettes, which is a worrisome finding to The Tobacco Atlas team and much of the US public health community because the e-cigarette market is not being regulated in any meaningful way by the US federal government or by most state governments.

Confusing News

Hookah use in 2014 was found to be as common as combustible cigarette use among high school students, representing a near doubling of hookah use from 2013. It is not clear what changed in the US water pipe tobacco market that would have caused such a large shift. For example, there were no important new products released, and the number of water pipe cafes does not appear to have increased meaningfully. There were also no changes in tax rates that would have driven an increase in water pipe use while driving down the prevalence of pipe tobacco smoking. Ma’assel for water pipes and traditional (from the American perspective) pipe tobacco are taxed at the identical rates by the federal government and almost every state government.

A small change in the survey question methodology for hookah (noted in the MMWR article) and a relatively recent addition of a new meaning of the word “hookah,” might explain some of this dramatic shift. We are concerned that the students surveyed could have mistakenly reported that they used hookah (a tobacco burning water pipe) when they actually meant to report that they used e-hookah or hookah pens, which are new common names for e-cigarettes (example product and example article). If our concern is true, then the 2014 NYTS could have underestimated the true prevalence of e-cigarette use (and overestimated actual combustible hookah use). It is worth further inquiry to determine if there was any confusion in terms in the 2014 survey, and if so, how to avoid this source of error in future surveys. While we should be concerned about increased hookah use regardless, if this change in the survey questioning had no effect, we might need to consider even more strongly the dramatic changes in hookah use.

Call To Action

The US Food and Drug Administration needs to exercise regulatory authority over e-cigarettes and all other tobacco products.

Any way that you read these survey results, US youth are clearly taking up e-cigarette use in large numbers. The fact that this is happening at the same time that cigarette use is dropping might suggest that these two products are acting as substitutes for one another. However, if the proportion of the population that is still consuming nicotine products is staying steady, while the proportion of tobacco products being consumed that are not under the regulatory authority of the FDA is growing, then the tobacco market will remain subject to the goals and preferences of the tobacco industry instead of public health authorities.

The tobacco industry controls many or even most facets of the tobacco products market and if they want consumers to shift their consumption to e-cigarettes, they have enormous power to make this happen.

Likewise, if the tobacco industry wants consumers to continue to use combustible cigarettes, they can deeply affect those behaviors, too.

We can only be certain that the tobacco industry will do what is best for their bottom line. They are the same as any corporate entity in any industry in that they are driven principally by their profits, as part of their fiduciary duty to their shareholders.

We cannot say with any certainty that the tobacco industry’s goal to improve its financial bottom line will line up with the public health community’s goals to protect the health of the public. In fact, evidence from previous behaviors would predict quite the opposite.

Therefore, the public health community must do what is best to protect the health of the public. In order to fulfill this overarching goal, government regulatory agencies with mandates to protect the public health need to be setting the policies that guide the tobacco products market.


This post was authored by Alex Liber with contributions from Evan Blecher, John Daniel, Jeffrey Drope, Elizabeth Mendes, and Michal Stoklosa. This post was last updated on April 22,2015.

Note: We recognize that highlighting an individual survey’s results might appear to contradict our previous statements regarding our intent to rely upon the IHME’s data synthesis efforts. In the case of mapping the prevalence of use of non-cigarette tobacco products, the Tobacco Atlas reports the estimates of single surveys (see Smokeless Tobacco and Water Pipes) and we will continue to do so until prevalence estimates of non-cigarette tobacco products from multiple surveys are available as a combined single prevalence estimate. We will endeavor, however, as we have done here, to cast a critical eye on the methodologies and findings of single and multiple-survey sources alike.

ACS Staff

Economic and Health Policy Research, American Cancer Society

The Economic and Health Policy Research program seeks to address cancer worldwide by conducting research on the economic and policy aspects of risk factors to cancer, including in the areas of tobacco, nutrition, physical activity and harmful alcohol use. We also examine issues around the economics of health equity, including access to care.