Tobacco Product Use and Associated Factors Among Middle and High School Students — National Youth Tobacco Survey, United States, 2021

Results

Ever Tobacco Product Use

In 2021, among U.S. middle and high school students, 24.1% (6.6 million) reported ever use of a tobacco product (high school: 34.0%, 5.22 million; middle school: 11.3%, 1.34 million) (Table 1). Among students who ever used a tobacco product, 49.4% (3.2 million) had ever used a combustible tobacco product and 41.5% (2.74 million) had ever used two or more tobacco product types. E-cigarettes were the most commonly ever used tobacco product overall (19.4%; 5.3 million), followed by cigarettes (8.1%), cigars (5.2%), smokeless tobacco (3.6%), hookahs (2.8%), nicotine pouches (1.9%), HTPs (1.8%), and pipe tobacco (1.0%). Ever use of any tobacco product was reported by 28.0% of middle and high school students who reported taking the survey in a school or classroom and 20.5% of middle and high school students who reported taking the survey at home or some other place (data not shown).

Current Tobacco Product Use

Overall, among middle and high school students, 9.3% (2.55 million) reported current (past 30-day) use of any tobacco product (Table 2). Among students who currently used any tobacco product, 34.4% (860,000) currently used any combustible tobacco product and 29.0% (740,000) currently used two or more tobacco product types. E-cigarettes were the most commonly used tobacco product overall (7.6%; 2.06 million), followed by cigarettes (1.5%), cigars (1.4%), smokeless tobacco (0.9%), hookahs and nicotine pouches (both 0.8%), HTPs (0.7%), and pipe tobacco (0.3%). Current use of any tobacco product was reported by 11.7% of middle and high school students who reported taking the survey in a school or classroom and 6.9% of middle and high school students who reported taking the survey at home or some other place.

Among high school students, 13.4% (2.06 million) reported current use of any tobacco product (Figure 1). Among high school students who currently used tobacco products, 32.8% (660,000) currently used any combustible tobacco product and 28.4% (580,000) currently used two or more tobacco product types. Among high school students, e-cigarettes were the most commonly used tobacco product (11.3%; 1.72 million), followed by cigars (2.1%), cigarettes (1.9%), hookahs and smokeless tobacco (both 1.2%), nicotine pouches (1.1%), HTPs (0.8%), and pipe tobacco (0.4%).

Among middle school students, 4.0% (470,000) reported current use of any tobacco product. Among middle school students who currently used tobacco products, 40.0% (190,000) currently used any combustible tobacco product and 32.5% (150,000) currently used two or more tobacco product types. Among middle school students, e-cigarettes were the most commonly used tobacco product (2.8%; 320,000), followed by cigarettes (1.0%), cigars and smokeless tobacco (both 0.6%), hookahs and HTPs (both 0.4%), nicotine pouches (0.3%), and pipe tobacco (0.2%).

Social Determinant Indicators

Ever Tobacco Product Use

By race and ethnicity, ever use of any tobacco product was reported by 26.7% of students who were non-Hispanic White, 22.4% of students who were Hispanic, 21.9% of students who were non-Hispanic Black, and 16.1% of students who were non-Hispanic other race (Table 1). Ever use of any combustible tobacco product was reported by 14.0% of students who were non-Hispanic Black, 12.6% of students who were non-Hispanic White, 10.4% of students who were Hispanic, and 8.3% of students who were non-Hispanic other race.

Ever use of any tobacco product was reported by 35.4% of students identifying as LGB, 22.8% of those identifying as heterosexual, and 14.4% of those who were not sure (Table 3) and 37.9% of those identifying as transgender, 23.4% of those identifying as not transgender, and 26.4% of those who were not sure.

For psychological distress, prevalence of ever use of any tobacco product ranged from 16.6% (none) to 37.8% (severe) (Table 3). Prevalence was similar for low (24.4%), medium (22.3%), and high (24.0%) family affluence. Prevalence of ever use of any tobacco product increased as self-reported grades in school declined (mostly As: 18.3% to mostly Fs: 41.7%). Ever use was 24.5% for students who spoke English at home and 20.5% for those who spoke another language at home.

Current Tobacco Product Use

By race and ethnicity, current use of any tobacco product was reported by 11.0% of students who were non-Hispanic White, 8.2% of students who were non-Hispanic Black, 7.4% of students who were Hispanic, and 5.4% of students who were non-Hispanic other race (Table 2). Current use of any combustible tobacco product was reported by 5.2% of students who were non-Hispanic Black, 3.1% of students who were non-Hispanic White, and 2.8% of students who were Hispanic.

Overall, current use of any tobacco product was reported by 14.2% of students identifying as LGB, 7.9% of those identifying as heterosexual, and 5.5% of those who were not sure (Table 3) and 18.9% of those identifying as transgender, 8.2% of those identifying as not transgender, and 9.1% of those who were not sure.

By psychological distress, prevalence of current use of any tobacco product ranged from 5.5% (none) to 14.2% (severe) (Table 3). Current use was similar for low (9.2%), medium (7.7%), and high (8.8%) family affluence. Prevalence of current use of any tobacco product increased with declining self-reported grades in school (mostly As: 5.5% to mostly Fs: 17.3%). Current use of any tobacco product was 9.2% for students who spoke English in the home and 6.4% for those spoke another language at home.

Frequency of Tobacco Product Use

Among students who currently used each tobacco product, frequent use (on ≥20 of the past 30 days) was 39.4% (810,000) for e-cigarettes, 29.5% (50,000) for chewing tobacco, snuff, or dip, 26.1% (20,000) for snus, 22.1% (30,000) for HTPs, 20.7% (80,000) for cigars, 19.9% (40,000) for hookahs, 18.9% (70,000) for cigarettes, and 17.2% (30,000) for nicotine pouches (Table 4). For nearly all tobacco products, more than half of students who currently used the products reported using them on 1–5 days of the past 30 days.

Flavored Tobacco Product Use

Among students who currently used any tobacco product, 79.1% (high school: 80.2%; middle school: 74.6%) reported using flavored tobacco product(s) in the past 30 days (Table 5). Among students who currently used each tobacco product, use of a flavored product was 84.7% for e-cigarettes, 70.1% for smokeless tobacco, 61.6% for nicotine pouches, 46.6% for hookahs, 44.4% for cigars, 44.0% for HTPs, 38.8% for cigarettes (menthol only), and 34.4% for pipe tobacco.

Among students who currently used each flavored tobacco product, fruit was the most commonly reported flavor type for e-cigarettes (71.6%), hookahs (73.5%), cigars (65.0%), and HTPs (46.4%) (Figure 2) (Supplementary Table 1; https://stacks.cdc.gov/view/cdc/114659); mint was the most commonly reported flavor type for smokeless tobacco (69.2%) and nicotine pouches (53.5%). Menthol use was reported as 50.2% for nicotine pouches, 38.8% for cigarettes, 38.2% for smokeless tobacco, 28.8% for e-cigarettes, 26.5% for HTPs, 21.0% for cigars, and 17.0% for hookahs.

E-Cigarette Device Type

Among students who currently used e-cigarettes, disposable e-cigarettes were the most commonly used device type (overall: 53.7%, 1.08 million; high school: 55.8%, 940,000; middle school: 43.8%, 130,000), followed by prefilled or refillable pods or cartridges (overall: 28.7%, 570,000; high school: 28.9%, 480,000; middle school: 27.8%, 80,000), and tanks or mod systems (overall: 9.0%, 180,000; high school: 7.5%, 120,000; middle school: 15.6%, 40,000) (Figure 3). Estimates of e-cigarette device type by sex and race or ethnicity are provided (Supplementary Table 2; https://stacks.cdc.gov/view/cdc/114659).

Reasons for E-Cigarette Use

Among students who ever used e-cigarettes, the most common reasons for first use were “a friend used them” (57.8%), “I was curious about them” (47.6%), “I was feeling anxious, stressed, or depressed” (25.1%), and “to get a high or buzz from nicotine” (23.3%) (Table 6). The most commonly reported reason for first use among high school students was “a friend used them” (60.6%) and was “I was curious about them” (49.4%) for middle school students.

Among students who currently used e-cigarettes, the most common reasons for current use were “I am feeling anxious, stressed, or depressed” (43.4%), “to get a high or buzz from nicotine” (42.8%), “a friend uses them” (28.3%), and “I can use them to do tricks” (20.0%) (Table 6). The most commonly reported reason for current use was “to get a high or buzz from nicotine” (45.3%) among high school students and “I am feeling anxious, stressed, or depressed” (45.0%) among middle school students.

Access to Tobacco Products

Among students who currently used any tobacco product, during the past 30 days, 32.8% got their products from a friend, 31.3% bought the products themselves, 28.8% had someone else buy the products for them, and 26.3% had someone offer the products to them (Table 7).

By purchase locations, 22.5% of students who currently used tobacco products reported purchasing from another person (friend, family member, or someone else), 20.2% from vape shops or tobacco shops, and 19.6% from gas stations or convenience stores; 48.6% of current tobacco product users did not purchase the products they used in the past 30 days.

Recognition of Public Education Campaigns Against Tobacco Product Use

Among all students, 75.2% (high school: 79.4%; middle school: 69.8%) had seen or heard at least one public education campaign against tobacco product use within the past year (Table 8). Recognition was 78.3% among males, 71.9% among females, and ranged from 67.6% among students who were non-Hispanic other race to 79.2% among students who were non-Hispanic White. Recognition was 60.9% for “The Real Cost,” 39.7% for “Truth,” 19.8% for “Tips” or “Tips from Former Smokers,” 6.9% for “Fresh Empire,” 4.8% for “This Free Life,” and 11.7% for “some other ad.”

Exposure to Tobacco Product Marketing

Among students who reported contact with a potential source of tobacco product marketing, 75.7% (high school: 79.6%; middle school: 70.7%) reported exposure to any tobacco product marketing from one or more of these sources (Table 9). The prevalence of exposure was 65.4% among students who reported going to retail stores, 43.9% among those who reported using the Internet, 34.0% among those who reported reading newspapers or magazines, and 30.3% among those who reported watching television or streaming services or going to the movies. Overall, 70.3% of middle and high school students reported exposure to e-cigarette marketing specifically, whereas 59.1% reported exposure to cigarette or other tobacco product marketing.

E-Cigarette Content on Social Media

In total, 91.5% (23.06 million) of U.S. middle and high school students reported using social media. Among all social media users, 73.5% (high school: 80.0%; middle school: 64.5%) reported ever seeing e-cigarette-related posts or content; 13.7% (high school: 16.3%; middle school: 10.1%) reported seeing e-cigarette–related content daily (Table 10). An estimated 14.4% of social media users in middle and high school reported posting pictures or videos of e-cigarette use by themselves or others; 26.1% reported otherwise engaging (liking, commenting, or sharing) with e-cigarette–related content on social media.

Harm Perceptions

Among all students, the percentage who reported that intermittent use of tobacco products causes a lot of harm was highest for smokeless tobacco (48.3%), followed by cigarettes (47.0%), hookahs (42.0%), e-cigarettes (41.8%), and cigars (41.5%) (Figure 4). The percentage of students who reported that intermittent use causes no harm or little harm was highest for e-cigarettes (16.6%) and lowest for cigarettes (9.6%). Estimates of harm perceptions for each tobacco product by school level are provided (Supplementary Table 3; https://stacks.cdc.gov/view/cdc/114659).

Dependence and Cessation Indicators

Among students who currently used any tobacco product, 27.2% (high school: 27.1%; middle school: 28.1%) reported experiencing cravings for tobacco product of any kind during the past 30 days (Table 11). Overall, 19.5% (high school: 21.8%; middle school: 9.4%) of students who currently used any tobacco product reported wanting to use a tobacco product within 30 minutes of waking.

Among students who currently used any tobacco product, 65.3% (high school: 64.9%; middle school: 67.6%) reported that they were seriously thinking about quitting all tobacco products. In addition, 60.2% (high school: 58.2%; middle school: 68.4%) of current tobacco product users overall reported that they stopped using all tobacco products for ≥1 day during the past 12 months because they were trying to quit.