Abstract
With increasing e-cigarette use among US adolescents and decreasing use of other tobacco products, it is unclear how total use of nicotine products, and its long-term health risks, have changed. The Centers for Disease Control and Prevention's standard measure-any tobacco product use in the past 30 days-considers neither frequency of use nor product risk implications. To investigate how nicotine product use, including frequency of use, and its associated risks have changed among middle school and high school students since 1999. This cross-sectional study used data from the 1999-2020 National Youth Tobacco Survey, an in-school survey of a nationally representative sample of students in grades 6 through 12; each survey recruited between 15 000 and 36 000 participants. Nicotine product use in the past 30 days. Use of nicotine products assessed by nicotine product days (NPDs), the number of days that the average student consumed these products in the past 30 days. Risk-adjusted NPDs account for differential long-term health risks of various products. This study included 16 years of cross-sectional survey data. Each survey recruited between 15 000 and 36 000 participants in grades 6 through 12 (male students: mean, 50.4% [minimum, 48.5%; maximum, 58.4%]; mean age, 14.5 years [minimum, 14.0 years; maximum, 14.7 years]). Nationally representative cross-sectional data for high school students showed that NPDs decreased steadily from 5.6 days per month in 1999 (95% CI, 5.0-6.2 days per month) to 2.2 days per month in 2017 (95% CI, 1.9-2.6 days per month), increased to 4.6 days per month in 2019 (95% CI, 4.1-5.1 days per month), and then decreased to 3.6 days per month in 2020 (95% CI, 3.0-4.1 days per month). For a risk weight of 0.1 for e-cigarettes, compared with combustible products, risk-adjusted NPDs decreased from 2.5 days per month in 2013 (95% CI, 2.2-2.9 days per month) (prior to the popularity of e-cigarettes) to 2.0 days per month in 2019 (95% CI, 1.6-2.5 days per month) and 1.4 days per month in 2020 (95% CI, 1.0-1.8 days per month). However, with a risk weight of 1.0 for e-cigarettes (identical to that of combustible products), risk-adjusted NPDs increased to 5.3 days per month in 2019 (95% CI, 4.4-6.2 days per month) and 3.9 days per month in 2020 (95% CI, 3.1-4.7 days per month). Similar trends were found for middle school students. This study suggests that NPDs represent an improvement, albeit an imperfect one, compared with any 30-day tobacco product use by incorporating the frequency of use of various products. By distinguishing products, NPDs permit consideration of the health consequences associated with different mixes of products over time. Health risks of adolescent nicotine product use could have decreased during vaping's popularity if assessment of the long-term risks associated with vaping compared with those of smoking is low. There is a need to closely monitor youth nicotine and tobacco product use patterns.
Highlights
IntroductionIn the last 2 decades, cigarette smoking has decreased steadily among US adolescents.[1,2] In 2020, 1.6% of middle school students and 4.6% of high school students reported use of cigarettes in the past 30 days, compared with 12.8% of middle school students and 34.8% of high school students in 1999.3-5 In contrast, the popularity of e-cigarettes has increased markedly among adolescents in recent years.[6,7] Since 2014, e-cigarettes have become the most commonly used nicotine or tobacco product among middle school and high school students.[8,9] From 2017 to 2018, current use of e-cigarettes, defined as having vaped in the past 30 days, increased from 11.7% to 20.8% among high school students and from 3.3% to 4.9% among middle school students.[3] The rates grew even higher in 2019, at 27.5% among high school students and 10.5% among middle school students.[10] Vaping decreased substantially in 2020 to 19.6% of high school students and 4.7% of middle school students.[11]
Representative cross-sectional data for high school students showed that nicotine product days (NPDs) decreased steadily from 5.6 days per month in 1999 to 2.2 days per month in 2017, increased to 4.6 days per month in 2019, and decreased to 3.6 days per month in 2020
For a risk weight of 0.1 for e-cigarettes, compared with combustible products, risk-adjusted NPDs decreased from 2.5 days per month in 2013 to 2.0 days per month in 2019 and 1.4 days per month in 2020
Summary
In the last 2 decades, cigarette smoking has decreased steadily among US adolescents.[1,2] In 2020, 1.6% of middle school students and 4.6% of high school students reported use of cigarettes in the past 30 days, compared with 12.8% of middle school students and 34.8% of high school students in 1999.3-5 In contrast, the popularity of e-cigarettes has increased markedly among adolescents in recent years.[6,7] Since 2014, e-cigarettes have become the most commonly used nicotine or tobacco product among middle school and high school students.[8,9] From 2017 to 2018, current use of e-cigarettes, defined as having vaped in the past 30 days, increased from 11.7% to 20.8% among high school students and from 3.3% to 4.9% among middle school students.[3] The rates grew even higher in 2019, at 27.5% among high school students and 10.5% among middle school students.[10] Vaping decreased substantially in 2020 to 19.6% of high school students and 4.7% of middle school students.[11]
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