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

Introduction

Tobacco* product use is the leading cause of preventable disease, disability, and death in the United States (1). Preventing tobacco product use among youths is critical to decreasing morbidity and mortality because almost all tobacco product use begins during adolescence or young adulthood; approximately nine in 10 adults who smoke cigarettes started before age 18 years (1–3). In recent years, tobacco products have evolved to include various combusted, smokeless, and electronic products.

The National Youth Tobacco Survey (NYTS), conducted periodically during 1999–2009 and annually since 2011, provides national data on estimates of tobacco product use to support the design, implementation, and evaluation of comprehensive youth tobacco prevention and control programs and to inform tobacco regulatory activities in the United States (4). NYTS is the only nationally representative survey of U.S. middle (grades 6–8) and high school (grades 9–12) students that focuses exclusively on tobacco product use.

This report presents findings from the 2021 NYTS and describes the prevalence of youth tobacco product use and associated factors, including flavored tobacco product use, reasons for use, access to tobacco products, exposure to pro-tobacco and antitobacco product marketing, harm perceptions, urges to use tobacco products, and quitting behaviors. These findings can be used by public health professionals, health care providers, policymakers, parents, and other youth advocates to prevent and reduce tobacco product use among U.S. youths.

Methods

NYTS Sampling Procedures

NYTS is a cross-sectional, school-based, self-administered survey of U.S. middle and high school students (4). The 2021 NYTS sampling frame consisted of all regular public and private schools with students enrolled in grades 6–12 in the 50 U.S. states and the District of Columbia. The sampling frame comprised data obtained from Market Data Retrieval (5) and the National Center for Education Statistics (6,7). Alternative schools, special education schools, U.S. Department of Defense–operated schools, Bureau of Indian Affairs schools, vocational schools, and schools with a combined total of <40 students in grades 6–12 were excluded. Across 16 previous cycles of NYTS, school participation had averaged 80.8% with a low of 49.9%. Student participation had averaged 89.5% with a low of 85.9%. Historical participation rates at both school and student levels guided the sampling design and projected sample sizes. However, a more robust approach was used to calculate the projected sample sizes for the 2021 NYTS by assuming a more conservative overall response rate of 42.5%. The overall number of schools included in the sample was increased to account for higher levels of anticipated school refusals attributable to COVID-19 precautions. NYTS uses a stratified, three-stage cluster sample design (4). All students in the selected classes were eligible to participate in the survey; students who were unable to complete the questionnaire without special assistance were excluded.

Data Collection and Processing

Because of emergency COVID-19 protocols across the United States, the 2021 NYTS was conducted using an online survey to allow eligible students to participate while at school or at home during a designated class period as part of a class activity.^† Participation in NYTS was voluntary at both the school and student levels; parental consent and student assent were required for NYTS participation. Students logged into a secure website from a school-issued or personal Internet-connected device, watched an instructional video, and responded to a question regarding their current location (e.g., classroom, home, or other location) before completing the survey. Data were transmitted directly to a secure server. Data collection procedures were supported by trained, off-site technical assistance providers who maintained regular contact with selected schools and teachers before, during, and after data collection activities. Students or whole classes that were unable to participate during the primary data collection period were asked to take the survey at the next possible opportunity. The 2021 NYTS was reviewed and approved by the Office of Management and Budget, the contracted data collectors’ institutional review board (IRB), and CDC’s IRB.^§

The 2021 survey included 166 questions covering demographic information, tobacco product use behaviors, knowledge of and attitudes toward tobacco use, exposure to protobacco and antitobacco media and advertising, access to tobacco products, nicotine dependence, cessation attempts, exposure to secondhand smoke and e-cigarette aerosol, harm perceptions, exposure to tobacco product health warnings, and other tobacco-related topics. At the beginning of each tobacco product section, a description of the product, including example brands and generic images, was provided. Respondents did not answer all questions because of questionnaire skip patterns. Respondents could skip any question or end the survey at any time.

Survey administration occurred during January 18, 2021–May 21, 2021. The final sample consisted of 508 schools, of which 279 participated (school response rate: 54.9%); 20,413 student questionnaires were completed out of a sample of 25,149 students (student response rate: 81.2%). Student response rates varied by school instructional model; student response rates were 85.8% among schools with in-person instruction (n = 69 participating schools), 77.9% in schools with exclusive distance learning or virtual instruction (n = 68 participating schools), and 81.4% for schools with hybrid instruction (n = 142 participating schools). Hybrid student instructional models define instances in which some educational instruction happened in person and some happened virtually. This included various scenarios, including all students alternating between in-person and virtual learning or a portion of students receiving in-person instruction at all times and the remaining students receiving virtual instruction at all times. The overall response rate for the 2021 NYTS, defined as the product of the school-level and student-level response rates, was 44.6%. After exclusion of outliers, the average survey completion time was approximately 22 minutes. A weighting factor was applied to each student record to adjust for nonresponse and for varying probabilities of selection. Weights were adjusted to ensure that the weighted proportions of students in each grade matched national population proportions. Additional information on the NYTS sampling design, recruitment procedures, and data weighting is available (https://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm).

Measures

Ever and Current Tobacco Product Use

Nine tobacco products were assessed: electronic cigarettes (e-cigarettes), cigarettes, cigars (cigars, cigarillos, and little cigars), smokeless tobacco (chewing tobacco, snuff, dip, snus, and dissolvable tobacco products), hookahs, pipe tobacco, bidis (small brown cigarettes wrapped in a leaf), heated tobacco products (HTPs), and nicotine pouches (pouches containing nicotine powder that comes from tobacco, which users place in their mouth). For each product, ever use was defined as ever using the product, and current use was defined as use on ≥1 day during the past 30 days. Any tobacco product use was defined as use of one or more of the nine tobacco products. Use of two or more tobacco products was defined as use of two or more of the nine tobacco products. Any combustible tobacco product use was defined as use of one or more of the following: cigarettes, cigars, hookahs, pipe tobacco, and bidis.

Demographic Factors

Demographic covariates assessed included sex (female or male), race and ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, or non-Hispanic other race), sexual identity (heterosexual; lesbian, gay, or bisexual [LGB]; or not sure), and whether the respondent identified as transgender (no, yes, not sure, or don’t know what this question is asking).

Social Determinant Indicators

Social determinant indicators included academic status in school (mostly As, Bs, Cs, Ds, or Fs), and speaking a language other than English at home (yes or no). Additionally, a composite scale made up of four questions was used to assess psychological distress: “During the past two weeks, how often have you been bothered by any of the following problems?” 1) “little interest or pleasure in doing things”; 2) “feeling down, depressed, or hopeless”; 3) “feeling nervous, anxious, or on edge”; and 4) “not being able or stop or control worrying.” For each item, response options were numerically coded (not at all = 0; several days = 1; more than half of the days = 2; nearly every day = 3), summed (range: 0–12), and categorized as none (0–2), mild (3–5), moderate (6–8), or severe (9–12). Furthermore, a composite scale made up of four questions was used to assess family affluence. Numeric values were assigned to question responses as follows: 1) “Does your family own a vehicle (such as a car, van, or truck)?” [no = 0; yes, one = 1; yes, two or more = 2]; 2) “Do you have your own bedroom?” [no = 0; yes = 1]; 3) “How many computers (including laptops and tablets, not including game consoles and smartphones) does your family own?” [none = 0; one = 1; two = 2; more than two = 3]; and 4) “During the past 12 months, how many times did you travel on vacation with your family?” [not at all = 0; once = 1; twice = 2; more than twice = 3]. Responses were summed (range: 0–9) and categorized into approximate tertiles based on the weighted distribution of scores in this sample as low (0–5), medium (6–7), and high (8–9).

Frequency of Tobacco Product Use

Respondents who reported ever use of any tobacco product were asked, “During the past 30 days, on how many days did you [use e-cigarettes; smoke cigarettes; smoke cigars, cigarillos, or little cigars; use chewing tobacco, snuff, or dip; use snus; use dissolvable tobacco products; smoke tobacco in a hookah or water pipe; smoke pipes filled with tobacco; use an HTP; or use a nicotine pouch].” Response options ranged between 0 and 30 days. Response options were categorized as 1–5 days, 6–19 days, and 20–30 days. Frequent use was defined as using a product on ≥20 days of the past 30 days.

Flavored Tobacco Product Use

For each tobacco product (excluding cigarettes), current users were asked, “Were any of the [tobacco product] that you used in the past 30 days flavored to taste like menthol, mint, clove or spice, alcoholic drinks, candy, fruit, chocolate, or any other flavor?” Response options were “yes,” “no,” and “don’t know.” Those who responded “yes” were categorized as a current flavored product user. Current flavored tobacco product users were asked, “What flavors were the [tobacco product] that you have used in the past 30 days? (Select one or more).” Response options were “menthol,” “mint,” “clove or spice,” “fruit,” “chocolate,” “alcoholic drinks (such as wine, margarita, or other cocktails),” “candy, desserts, or other sweets,” and “some other flavor not listed here.” Those who selected “some other flavor not listed here” could provide a write-in response; write-in responses corresponding to an original response option were recoded.

For cigarettes, current users were categorized as flavored (menthol) cigarette smokers if they responded “yes” to the question, “Menthol cigarettes are cigarettes that taste like mint. During the past 30 days, were the cigarettes that you usually smoked menthol?” or if they indicated “Kool” or “Newport” as their usual cigarette brand during the past 30 days. Usual cigarette brand was determined based on responses to two questions: “During the past 30 days, what brands of cigarettes did you smoke? (Select one or more)” and “During the past 30 days, what brand of cigarettes did you usually smoke? (Choose only one answer).” If “Kool” or “Newport” was the only brand selected for the first question, or if multiple brands were selected in the first question and “Kool” or “Newport” was selected for the second question, “Kool” or “Newport” was considered the respondent’s usual brand.

E-Cigarette Device Type

Respondents who reported current use of e-cigarettes were asked, “Which of the following best describes the type of e-cigarette you have used in the past 30 days? If you have used more than one type, please think about the one you use most often.” Response options were “A disposable e-cigarette (for example, Puff Bar or Stig),” “An e-cigarette that uses pre-filled or refillable pods or cartridges (for example, Juul, Smok, or Suorin),” “An e-cigarette with a tank that you refill with liquids (including mod systems that can be customized by the user),” and “I don’t know the type.”

Reasons for E-Cigarette Use

Respondents who had ever used e-cigarettes were asked, “Why did you first use an e-cigarette?” Respondents who reported current e-cigarette use were further asked, “Why do you currently use e-cigarettes?” For both questions, respondents could select one or more of 14 specified reasons. Respondents who indicated, “I used/use them for some other reasons” to either question could specify a write-in response; analyses of write-in responses were not included in this report.

Access to Tobacco Products

For each tobacco product, access sources were assessed by two questions: “During the past 30 days, how did you get your [tobacco product]?” (respondents could select one or more of eight specified responses) and “During the past 30 days, where did you buy your [tobacco product]?” (respondents could select one or more of 12 specified responses). Respondents could specify a write-in response; analyses of write-in responses were not included in this report.

Recognition of Public Education Campaigns Against Tobacco Product Use

All respondents were asked two questions regarding public education campaigns against tobacco product use: “In the past 12 months, have you seen or heard The Real Cost, on television, the Internet, social media, or radio as part of ads about tobacco?” (response options were yes, no, or not sure) and “In the past 12 months, have you seen or heard any other ads against tobacco with the following names or slogans on television, the Internet, social media, or on the radio?” Respondents could select one or more of “Truth,” “Tips or Tips from Former Smokers,” “Fresh Empire,” “This Free Life,” or “some other ad” or could select “I haven’t seen or heard any of these ads.” Those who indicated having seen “some other ad” could specify with a write-in response; analyses of write-in responses were not included in this report. A composite of having recognized at least one ad against tobacco product use from a specified response option also was generated.

Exposure to Tobacco Product Marketing

Exposure to tobacco product marketing (advertisements or promotions) was assessed separately for e-cigarettes and cigarettes or other tobacco products for four sources: retail stores; Internet; television, streaming services, or movies; and newspapers or magazines. Respondents were asked, “When you [are using the Internet; read newspapers or magazines; go to a convenience store, supermarket, or gas station; watch television or streaming services (such as Netflix, Hulu, or Amazon Prime), or go to the movies], how often do you see ads or promotions for [e-cigarettes; cigarettes or other tobacco products]?” Respondents were categorized as exposed if they responded “sometimes,” “most of the time,” or “always” or unexposed if they responded “never” or “rarely.” Those who reported “I do not use the Internet,” “I do not read newspapers or magazines,” “I never go to a convenience stores, supermarket, or gas station,” or “I do not watch TV or streaming services or go to the movies” were excluded from the analysis.

E-Cigarette Content on Social Media

All respondents were asked, “How often do you use social media?” Respondents who reported a response other than “never/I don’t use social media” were asked, “When you use social media, how often 1) “do you see posts or content (pictures, videos, or text) related to e-cigarettes?”; 2) “do you post pictures or videos of yourself or someone else using e-cigarettes?”; and 3) “have you liked, commented, or shared posts or content (pictures, videos, or text) related to e-cigarettes?” For each question, response options were “never,” “less than monthly,” “monthly,” “weekly,” or “daily.”

Harm Perceptions

The 2021 NYTS assessed harm perceptions for five tobacco products: e-cigarettes; cigarettes; cigars, cigarillos, or little cigars; smokeless tobacco (chewing tobacco, snuff, dip, snus, or dissolvable tobacco products); and hookahs. All respondents were asked, “How much do you think people harm themselves when they (use e-cigarettes; smoke cigarettes; smoke cigars, cigarillos, or little cigars; use chewing tobacco, snuff, dip, snus, or dissolvable tobacco products; or smoke tobacco in a hookah or water pipe) some days but not every day?” Response options were “no harm,” “little harm,” “some harm,” and “a lot of harm.”

Dependence and Cessation Indicators

Urges to Use Tobacco Products

Students who currently used any tobacco product were asked, “During the past 30 days, have you had a strong craving or felt like you really needed to use a tobacco product of any kind?” (yes or no); and “How soon after you wake up do you want to use a tobacco product of any kind?” Response options were dichotomized as wanting to use a tobacco product within 30 minutes (“within 5 minutes” or “from 6 to 30 minutes,”) or not (“from more than 30 minutes to 1 hour,” “after more than 1 hour but less than 24 hours,” “I rarely want to use tobacco products,” or “I do not want to use tobacco products”).

Quitting Behaviors

Students who currently used any tobacco product were asked, “Are you seriously thinking about quitting the use of all tobacco products?” Responses were dichotomized as yes (“yes, during the next [30 days; 6 months; 12 months]” or “yes, but not during the next 12 months”) or no (“no, I am not thinking about quitting the use of all tobacco products”). Students who currently used any tobacco product were asked, “During the past 12 months, how many times have you stopped using all tobacco products for one day or longer because you were trying to quit all tobacco products for good?” Responses were dichotomized as making a past-year quit attempt (“1 time,” “2 times,” “3–5 times,” “6–9 times,” or “10 or more times”) or not making an attempt (“I did not try to quit all tobacco products during the past 12 months”).

Analyses

Statistical analyses were conducted by using SAS-callable SUDAAN software (version 11.0.1; RTI International) to account for the complex sampling design. Weighted prevalence estimates and 95% CIs were computed for all measures; when applicable, population totals were estimated from probability weights. Results with unweighted denominators <50 or a relative standard error >30% are not reported. Comparisons of estimates from the 2021 NYTS with previous years were not possible because of the modifications to the fielding procedures in 2021 in response to the COVID-19 pandemic. The 20,413 student records were weighted to represent approximately 27.56 million students. On the basis of self-reported grade level, this included 9,763 middle school students (11.97 million) and 10,515 high school students (15.44 million); 135 students with missing information on grade level were excluded from school-level analyses. Overall, 50.8% of student respondents reported completing the survey in a school building or classroom and 49.2% at home or some other place.

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.

Discussion

Public Health Implications

Findings from the 2021 NYTS indicate that approximately one in four students (24.1%), including approximately one in three high school students (34.0%) and one in nine middle school students (11.3%), had ever used a tobacco product. Furthermore, approximately one in 10 students (9.3%), including more than one in eight high school students (13.4%) and one in 25 middle school students (4.0%), had used a tobacco product during the past 30 days. Approximately three in 10 students (29.0%) who currently used any tobacco product reported using two or more tobacco products during the past 30 days; youths who use multiple tobacco products are at higher risk for developing nicotine dependence and might be more likely to continue using tobacco into adulthood (1,2). Most youths who currently use tobacco products are not daily users (8–10). However, even infrequent tobacco product use can lead to symptoms of nicotine dependence (11). Additionally, in 2021, approximately four in 10 youths who currently used e-cigarettes, and more than 20% of youths who currently used cigars, chewing tobacco, snuff, or dip, snus, and HTPs, used them frequently (on ≥20 of the past 30 days). Furthermore, for the first time in 2021, NYTS documented use of nicotine pouches among youths, an emerging tobacco product which contains nicotine powder that dissolves in the mouth without spitting. Nicotine pouches do not contain any tobacco leaf, are available in various flavors, deliver high levels of nicotine by way of nicotine salts, and have had rapidly increasing sales in recent years (12). Although youths’ use of nicotine pouches was low in 2021, these baseline data are needed for future monitoring to inform local, state, and federal public health policy and practice. Youth use of tobacco products in any form is unsafe, regardless of whether the products are combustible, smokeless, or electronic (2,3). Continued efforts are warranted to prevent and reduce all forms of tobacco product use among U.S. youths.

This study highlighted disparities in tobacco product use among U.S. youths. Current use of any tobacco product, overall, was highest among students who were non-Hispanic White, followed by non-Hispanic Black, Hispanic, and students of non-Hispanic other race. However, among all race and ethnicity groups, non-Hispanic Black students reported the highest prevalence of current combustible tobacco product use (5.2%), and specifically cigar use (3.1%). While youth use of tobacco products in any form is unsafe (2), the toll of death and disease from tobacco product use in the United States is primarily caused by cigarettes and other combustible tobacco products (1). In addition, use of any tobacco product was highest among students who identified their sexual identity as LGB than those who identified as heterosexual; among those identifying as transgender than those not transgender; and among those reporting increased symptom severity of psychological distress. Furthermore, although peer use and curiosity were the most commonly cited reasons for initiating e-cigarette use among ever users in 2021, among youths who currently used e-cigarettes, the most commonly cited reasons for use were attributable to feelings of anxiety, stress, or depression and the “high or buzz” associated with nicotine use. This is particularly concerning given the bidirectional association between nicotine use and mental health disorders such as depression and anxiety; studies found that youths with mental health disorders were at increased risk for cigarette smoking, but also that youth nicotine exposure was associated with the development of mental health disorders (3,13). Additionally, nicotine withdrawal is commonly accompanied by symptoms of anxiety and depression, and relief of these symptoms through use of a nicotine-containing tobacco product or nicotine replacement therapy might perpetuate continued nicotine use (1). Thus, the continued implementation of population-based strategies, coupled with tobacco product regulation by FDA, are critical to prevent and reduce the use of all forms of tobacco products among all youths (1–3,14).

Since 2014, e-cigarettes have been the most commonly used tobacco product among U.S. youths (8,15–17). In 2021, youth e-cigarette use remains a serious public health concern, as approximately one in nine high school students (11.3%, 1.72 million) and one in 35 middle school students (2.8%, 320,000) had used e-cigarettes during the past 30 days. While this appears lower than previously reported estimates of e-cigarette use in 2020 (17), any comparison of results between survey years, including the direct attribution of any potential changes in tobacco product use, is not possible because of the modifications to the fielding procedures in 2021 as a result of the COVID-19 pandemic. Specifically, approximately half of students taking the 2021 NYTS reported doing so from outside of a school building or classroom; students participating in a school building or classroom reported a higher prevalence of ever and current use of any tobacco product, including e-cigarettes (18), compared with students participating at home or some other place. However, declines in e-cigarette use during the COVID-19 pandemic compared with a prepandemic period have been observed in other studies of young persons (19,20). Differences in tobacco product use by survey completion setting might be caused by potential underreporting of behaviors, reduced access to tobacco products while at home (19,20), or other unmeasured characteristics among students participating outside of the classroom. Thus, the 2021 NYTS results cannot be compared with previous NYTS survey results that were primarily conducted on school campuses.

The 2021 NYTS offers insights into factors known to influence tobacco product use among youths. Overall, approximately eight in 10 students who used a tobacco product reported using a flavored product, which can increase the appeal and ease of use for youths (2,3). In addition, tobacco product marketing through traditional sources (i.e., media, Internet, print, and point of sale) and social media might prompt tobacco product initiation and use among youths (2,3,21,22); approximately 76% of students in 2021 reported exposure to tobacco product marketing through traditional sources and approximately 74% of students who used social media had seen e-cigarette–related posts or content. However, these data indicate that approximately three in four U.S. students had seen or heard at least one public education campaign against tobacco use during the preceding year, which can be an effective, evidence-based tool to educate youths about the risks of tobacco product use and to prevent initiation (2,23,24). Thus, tailored interventions and services could support cessation behaviors among youths who currently use tobacco products.

Public Health Action

Sustained implementation of population-based strategies, coupled with regulation of tobacco products by FDA, is critical to preventing and reducing all forms of tobacco product use among youths (1–3,14). Strategies to reduce tobacco product use and initiation among all youths include increasing prices of tobacco products; establishing comprehensive clean indoor air policies that denormalize tobacco use and protect persons from exposure to secondhand smoke and e-cigarette aerosol; sustaining media campaigns that warn about the dangers of tobacco product use; reducing youth access to tobacco products, including enforcement of the federal Tobacco 21 policy^¶; and restricting the sales of flavored e-cigarettes (1,14,16,25).

Everyone can help protect youths from the harms of tobacco products, including e-cigarettes (3,14). Parents, educators, and youth advocates can learn about the different types of tobacco products available, including various e-cigarette devices that appeal to youths. They can also set a positive example by being tobacco-free themselves and communicating the harms of tobacco product use for youths, including nicotine’s effects on adolescent brain development and addiction (3). Schools can adopt and enforce tobacco-free campus policies that prohibit use of all tobacco products, including but not limited to e-cigarettes. Also, schools can implement policies to not use tobacco industry–sponsored prevention programs; no tobacco industry–sponsored prevention programs that have been studied have been shown to be effective (2). In addition, health care providers can ask about the use of all tobacco products, including e-cigarettes, when screening patients for tobacco product use and assist those who want to quit using tobacco products (26).

Limitations

The findings in this report are subject to at least three limitations. First, because of the implementation of emergency COVID-19 protocols across the country during the 2021 NYTS fielding, the survey was administered online to allow participation by eligible students at home, school, or somewhere else. Previous research has shown that the prevalence of tobacco use might differ by interview setting (27) and thus the 2021 NYTS results cannot be compared with previous NYTS survey results that were primarily conducted on school campuses. Second, data were self-reported and might be subject to recall and response bias. However, the validity of self-reported tobacco product use is consistently high in population-based studies overall (28). Finally, data were collected only from middle and high school students who attended public or private schools; findings might not be generalizable to youths who are home schooled, have dropped out of school, are in detention centers, or are enrolled in alternative schools. However, data from the Current Population Survey indicate that approximately 96% of U.S. youths aged 10–17 years were enrolled in a traditional school in 2020 (29).

Conclusion

NYTS is the only comprehensive, nationally representative cross-sectional survey of U.S. middle and high school students focused exclusively on tobacco product use behaviors and associated factors. The 2021 NYTS was fully conducted amid the global COVID-19 pandemic, during which time eligible students could participate in classrooms, at home, or some other place. Findings from 2021 NYTS indicate that youth tobacco product use remains a public health threat, with approximately one in four students (24.1%) ever using a tobacco product, and approximately one in 10 students (9.3%) using a tobacco product during the past 30 days. Furthermore, disparities in tobacco product use continue to exist among population subgroups. In 2021, any tobacco product use was higher among students who identified as LGB than heterosexual; among students who identified as transgender than those not transgender; and among students who reported increased symptom severity of psychological distress. Multiple factors continue to promote tobacco product use and initiation among youths, including flavors (such as menthol), marketing, and misperceptions of harm. The comprehensive and sustained implementation of population-level evidence-based tobacco control strategies, combined with FDA’s regulation of tobacco products, is important for preventing and reducing all forms of tobacco product use among all U.S. youths. In addition, as the tobacco product marketplace continues to diversify, surveillance among youths for all forms of tobacco product use and associated factors is important to the development of public health policy and action at the national, state, and community levels.