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

MMWR Introduction

Commercial tobacco product¹ use² is the leading cause of preventable disease, disability, and death in the United States. Most tobacco product use begins during adolescence.

CDC and the Food and Drug Administration (FDA) analyzed data from the 2021 National Youth Tobacco Survey (NYTS), a cross-sectional, self-administered, nationally representative survey of U.S. middle (grades 6–8) and high (grades 9–12) school students.

This surveillance summary provided estimates on:

• Youth tobacco product use (ever and current use).
• Demographic factors.
• Social determinant indicators.
• Frequency of use.
• Flavored tobacco product use.
• E-cigarette device type.
• Reasons for e-cigarette use.
• Access to tobacco products.
• Exposure to tobacco product marketing.
• Recognition of public education campaigns against tobacco product use.
• Harm perceptions of tobacco product use.
• Urges to use tobacco products.
• Quitting behaviors.

The continued monitoring of all forms of youth tobacco product use and associated factors through surveillance efforts, including NYTS, is important to the development of public health policy and action at national, state, and local levels. In addition, the comprehensive and ongoing use of evidence-based tobacco control strategies, combined with FDA’s regulation of tobacco products, is important for reducing all forms of tobacco product use among U.S. youths.

MMWR Highlights

Current (Past 30-day) Tobacco Product Use Among High School Students, 2021

• Any tobacco product, 13.4%.
• E-cigarettes, 11.3%.
• Cigars, 2.1%.
• Cigarettes, 1.9%.
• Smokeless tobacco, 1.2%.
• Hookahs, 1.2%.
• Nicotine pouches, 1.1%.
• Heated tobacco products, 0.8%.
• Pipe tobacco, 0.4%.

Current (Past 30-day) Tobacco Product Use Among Middle School Students, 2021

• Any tobacco product, 4.0%.
• E-cigarettes, 2.8%.
• Cigarettes, 1.0%.
• Cigars, 0.6%.
• Smokeless tobacco, 0.6%.
• Heated tobacco products, 0.4%.
• Hookahs, 0.4%.
• Nicotine pouches, 0.3%.
• Pipe tobacco, 0.2%.

Demographic and Social Determinant Indicators

• The demographic and social determinants reported in this study included race and ethnicity, sexual identity and gender identity, psychological distress, family affluence, performance in school (grades), and a language other than English spoken at home.
• Current use of any tobacco product was higher among middle and high school students who identified as lesbian/gay/bisexual (14.2%; 490,000) than those who identified as heterosexual (7.9%; 1.46 million), and among those identifying as transgender (18.9%; 80,000) than those not transgender (8.2%; 1.83 million).
• The prevalence of current use of any tobacco product increased with increasing symptom severity of psychological distress, from 5.5% (none) to 14.2% (severe).
• Overall, current use of any tobacco product was highest among middle and high school students who were non-Hispanic White (11.0%), followed by non-Hispanic Black (8.2%), Hispanic (7.4%), and students of non-Hispanic other race (5.4%).
• However, current use of combustible tobacco products was highest among students who were non-Hispanic Black (5.2%) followed by non-Hispanic White (3.1%) and Hispanic (2.8%). Specifically, use of cigars was highest among students who were non-Hispanic Black (3.1%), followed by non-Hispanic White (1.4%) and Hispanic (0.9%).

Additional Findings

• Flavored Product Use: Among the approximately 2.55 million students who currently used any tobacco product, 79.1% (1.95 million) reported using flavored tobacco product(s) in the past 30 days.
• E-cigarette Product Type: Among the approximately 2.06 million students who currently used e-cigarettes, disposable e-cigarettes were the most commonly used device type (53.7%; 1.08 million) followed by prefilled or refillable pods or cartridges (28.7%; 570,000) and tanks or mod systems (9.0%; 180,000).
• Harm Perceptions: The percentage of students who reported that intermittent use (use on some days but not every day) 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%).
• Marketing Exposure: Among students who reported contact with a potential source of tobacco product marketing, 75.7% (19.21 million) reported any exposure to advertisements or promotions for e-cigarettes, cigarettes, or other tobacco products.
• Campaign Exposure: Approximately 3 in 4 US students (75.2%; 19.56 million) had seen or heard at least one public education campaign against tobacco use within the past year.
• Reasons for Use: Among students who currently used e-cigarettes, the most commonly cited reasons for use were feelings of anxiety, stress, or depression and the “high” or “buzz” associated with nicotine use.
• Cessation Indicators: Among the approximately 2.55 million students who currently used any tobacco product, 65.3% (1.32 million) reported that they were seriously thinking about quitting all tobacco products. In addition, 60.2% (1.20 million) of students who currently used tobacco products reported that they stopped using all tobacco products for 1 or more days during the past 12 months because they were trying to quit.

¹This report includes findings on the use of nine tobacco products: bidis (small brown cigarettes wrapped in a leaf), electronic cigarettes (e-cigarettes), cigars, cigarettes, heated tobacco products, hookahs, nicotine pouches, pipe tobacco, and smokeless tobacco.

²Tobacco product use in this document refers to the use of commercial tobacco and not the sacred and traditional use of tobacco by some American Indian communities.

NOTE: The 2021 NYTS—administered January 18–May 21, 2021—was fully conducted amid the COVID-19 pandemic. Because of the COVID-19 protocols implemented across the country at that time, the survey was administered online to allow eligible students to complete the survey at home, school, or elsewhere. The reporting of tobacco use might differ by survey completion setting and thus, the 2021 NYTS results cannot be compared with previous NYTS survey results, which were primarily conducted on school campuses.