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Adolescents and Tobacco: Trends

Approximately 4.9 million middle and high school students were current tobacco users in 2018.1 Although tobacco use by adolescents has declined substantially in the last 40 years, in 2018, less than one in 25 high school seniors was a daily smoker.2 Substantial racial/ethnic and regional differences in smoking rates exist. Among high school students, white teens are more likely to smoke than their black or Hispanic peers.3 Smoking rates are typically higher in nonmetropolitan areas, and in the Southern and Midwestern regions of the country.4

Figure 1: 30 Day Prevalence of Daily Use of Cigarettes, by Grade, 1976-2018In 2018, 0.8 of 8th graders, 1.8 of 10th graders, and 3.6 percent of 12th graders used cigarettes daily in the past 30 days.

Source: Johnston, L. D., Miech, R. A., O’Malley, P. M., Bachman, J. G., Schulenberg, J. E., & Patrick, M. E. (2019). Monitoring the Future national survey results on drug use 1975-2018: Overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, University of Michigan. Retrieved from http://www.monitoringthefuture.org/pubs/monographs/mtf-overview2018.pdf.

Table 1: Percent of students who report smoking cigarettes daily, by grade, 1976-2018

Year collected 8th Grade 10th Grade 12th Grade
1976     28.8
1977     28.8
1978     27.5
1979     25.4
1980     21.3
1981     20.3
1982     21.1
1983     21.2
1984     18.7
1985     19.5
1986     18.7
1987     18.7
1988     18.1
1989     18.9
1990     19.1
1991 7.2 12.6 18.5
1992 7.0 12.3 17.2
1993 8.3 14.2 19.0
1994 8.8 14.6 19.4
1995 9.3 16.3 21.6
1996 10.4 18.3 22.2
1997 9.0 18.0 24.6
1998 8.8 15.8 22.4
1999 8.1 15.9 23.1
2000 7.4 14.0 20.6
2001 5.5 12.2 19.0
2002 5.1 10.1 16.9
2003 4.5 8.9 15.8
2004 4.4 8.3 15.6
2005 4.0 7.5 13.6
2006 4.0 7.6 12.2
2007 3.0 7.2 12.3
2008 3.1 5.9 11.4
2009 2.7 6.3 11.2
2010 2.9 6.6 10.7
2011 2.4 5.5 10.3
2012 1.9 5.0 9.3
2013 1.8 4.4 8.5
2014 1.4 3.2 6.7
2015 1.3 3.0 5.5
2016 0.9 1.9 4.8
2017 0.6 2.2 4.2
2018 0.8 1.8 3.6

Products used by adolescents include cigarettes (both store-bought and hand-rolled), cigars, pipes, hookahs, smokeless tobacco, and newer oral products such as e-cigarettes, pouches, lozenges, strips, and sticks:

  • Tobacco cigarettes: Nearly 90 percent of adult smokers began smoking before age 18, and 9.7 percent of high school seniors reported smoking in the last month.2
  • Smokeless tobacco: Use of smokeless tobacco among adolescents is less common than cigarette smoking. 
  • Hookahs: Hookahs are no safer than other forms of tobacco smoking and may deliver even higher levels of toxic substances. 
  • Flavored little cigars: Of middle and high school students who used tobacco products in 2014, more than 60 percent smoked flavored little cigars.5
  • E-cigarettes: From 2011 to 2016, the percentage of 12th-grade students who had ever used an e-cigarette increased from 4.7 to 13 percent, down from a peak in 2015 of 16 percent.2 For the first time in 2014, more teenagers used e-cigarettes or vaped nicotine than smoked cigarettes—a trend that continues. In 2017, 11 percent of high school students reported vaping nicotine at least once in the past 30 days.17

Many adolescents use more than one tobacco product. In 2017, 9 percent of high school students and two percent of middle school students reported the current use of two or more types of tobacco.18

Tobacco Cigarettes

In 2018, less than a quarter of high school seniors reported ever having smoked a cigarette.2 However, in 2018, almost one in 20 students in 12th grade (five percent) was a regular, daily smoker—a number that has declined dramatically from its recent peak of 25 percent in 1997 (see Figure 2).2 Cigarette smoking by adolescents (measured as use in the past month) in grades eight, 10, and 12 combined has declined by more than half since its most recent peak in the late 1990s. In 2014, about one in twelve (eight percent) reported smoking cigarettes in the past month, compared with more than one in four (28 percent) in 1996-97 (see Figure 2).2

Figure 2: Percent of adolescents who report smoking cigarettes in the past month, 1996-1997, 2014, 2016, and 2018The percent of adolescents who reported smoking cigarettes in the past month dropped from 28% in 1996 to 5% in 2018.

Source: Johnston, L. D., Miech, R. A., O’Malley, P. M., Bachman, J. G., Schulenberg, J. E., & Patrick, M. E. (2019). Monitoring the Future national survey results on drug use 1975-2018: Overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, University of Michigan. Retrieved from http://www.monitoringthefuture.org/pubs/monographs/mtf-overview2018.pdf.

Table 2: Percent of adolescents who report smoking cigarettes in the past month, 1996-1997, 2014, 2015, 2016, 2017, 2018

Year collected Percentage
1996-97 28%
2014 8%
2015 7%
2016 6%
2017 5%
2018 5%

Although we may not know all of the factors playing a role in this decline, the 1990s were years when funds from tobacco companies (the result of a legal settlement between the tobacco companies and the federal government) supported a number of local, state, and national anti-tobacco campaigns.7 In addition, during this time, new restrictions on tobacco advertising were instituted, smoke-free laws and policies were widely implemented, and additional taxes were placed on cigarettes, which inhibited demand.8 However, after 2002, most states did not allocate funds to maintain the proven anti-tobacco efforts shown to deter adolescent tobacco use.9

Smokeless tobacco

Use of smokeless tobacco products (e.g., snuff, chewing tobacco) among adolescents is less common than cigarette smoking. However, adolescents increased their use of smokeless tobacco between 2008 and 2010. Rates remained fairly steady from 2010 to 2018.2 Although four percent of 12th graders used smokeless tobacco in the past 30 days (in 2018), this is not as high as during the mid-1990s, when use peaked at 12 percent (in 1995). Adolescents increased their use of smokeless tobacco between 2008 and 2011, however, this trend has slowed and even reversed, particularly for older adolescents (see Figure 3).2 Approximately equal proportions of male and female adolescents smoke tobacco cigarettes, but users of smokeless tobacco products are nearly all male.2

Figure 3: Percent of students who report using smokeless tobacco in the last 30 days, by grade, 1993-2018

 

The percentage of 8th, 10th, and 12th graders who report using smokeless tobacco in the last 30 days has decreased.

Source: Johnston, L. D., Miech, R. A., O’Malley, P. M., Bachman, J. G., Schulenberg, J. E., & Patrick, M. E. (2019). Monitoring the Future national survey results on drug use 1975-2018: Overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, University of Michigan. Retrieved from http://www.monitoringthefuture.org/pubs/monographs/mtf-overview2018.pdf.

Table 3: Percent of students who report using smokeless tobacco in the last 30 days, by grade, 1993-2018

Year collected 8th Grade 10th Grade 12th Grade
1993 6.6 10.4 10.7
1994 7.7 10.5 11.1
1995 7.1 9.7 12.2
1996 7.1 8.6 9.8
1997 5.5 8.9 9.7
1998 4.8 7.5 8.8
1999 4.5 6.5 8.4
2000 4.2 6.1 7.6
2001 4.0 6.9 7.8
2002 3.3 6.1 6.5
2003 4.1 5.3 6.7
2004 4.1 4.9 6.7
2005 3.3 5.6 7.6
2006 3.7 5.7 6.1
2007 3.2 6.1 6.6
2008 3.5 5.0 6.5
2009 3.7 6.5 8.4
2010 4.1 7.5 8.5
2011 3.5 6.6 8.3
2012 2.8 6 8
2013 2.8 6.1 8.4
2014 3.0 5.3 8.4
2015 3.2 4.9 6.1
2016 2.5 3.5 6.6
2017 1.7 3.8 4.9
2018 2.1 3.9 4.2

Hookahs

Hookahs (water pipes) are popular among some adolescents and are typically used in groups and sometimes in "hookah lounges." When used in groups, the hookah mouthpiece is passed around from person to person. Hookahs are no less addictive than other forms of tobacco smoking, and are at least as toxic as cigarette smoking.10

A typical hookah smoking session is one hour, during which the user inhales 100 to 200 times the amount of smoke they would inhale from a single conventional cigarette.11 Because users smoke for a prolonged period of time, they may absorb more of the nicotine and toxic chemicals associated with cigarette smoking.11 However, the dangers of hookah smoking are not well known among some adolescents.12 Analysis of a national survey found that 24 percent of those ages 18 to 24 believed that hookahs were less harmful than smoking cigarettes.12

Older teens have decreased their use of hookahs in recent years. Between 2014 and 2018, the percentage of high school seniors who had used a hookah in the last year decreased from 20 percent to 8 percent.2 Among adolescents and young adults, hookah use is highest among those ages 19-20, and those who live in cities. It is less common in suburban and rural areas.10

E-Cigarettes

Electronic cigarettes, or e-cigarettes, are battery-powered devices designed to deliver nicotine, flavor, and other chemicals. E-cigarettes heat a liquid containing highly addictive nicotine and other chemicals to become an aerosol that is then inhaled by the user. The variety of flavors available, such as strawberry, cinnamon, and chocolate, are a primary reason for use among young e-cigarette users.13

Prior to 2016, e-cigarettes not marketed for therapeutic purposes were unregulated by the Food and Drug Administration (FDA). This changed with a new rule that expanded the FDA’s authority. The percent of high school seniors who had used an e-cigarette in the past 30 days increased from 1.5 percent in 2010 to 26.7 percent in 2018.2,6

The same trend is observed in younger adolescents. Use among 8th grade students also more than doubled (in 2018, 10 percent had used one in the past 30 days). Overall, among younger adolescents (those in 8th and 10th grades), more than twice as many reported using e-cigarettes than those who reported smoking cigarettes in 2018. This is less true for older adolescents and young adults; the discrepancy may be due to the relatively recent emergence of e-cigarettes.2

The parallel use of e-cigarettes with conventional cigarettes also is common. In 2014, approximately one out of four 8th and 10th grade students who used an e-cigarette in the past 30 days had also smoked a conventional cigarette; looking at those in 12th grade, that figure rises to more than half.16

There is concern that e-cigarettes represent a gateway to the use of traditional cigarettes and other tobacco products. Eighth grade students who use e-cigarettes are 10 times more likely than their peers who do not use e-cigarettes to eventually smoke tobacco cigarettes. This trend continues to a slightly lesser degree for older adolescents. Tenth and 12th grade students who use e-cigarettes are eight and six times more likely, respectively, than their peers to smoke tobacco cigarettes. This suggests that adolescents who use e-cigarettes are likely to become tobacco cigarette smokers as they age.14

Adolescent use of e-cigarettes is becoming increasingly common.15 An emerging trend among adolescents is to use e-cigarettes to vaporize liquid marijuana or hash oil, which contain concentrated THC (tetrahydrocannabinol), the principal psychoactive ingredient in marijuana.15 This practice can produce a higher-potency high that can be damaging during crucial years in the brain’s development.

Other Oral Tobacco Products

Newer forms of oral tobacco products—pouches, lozenges, strips, snus, and sticks—also are cause for concern. Most of these are designed to dissolve in the user's mouth, and are offered in candy-like flavors; however, they all contain potent toxins that can lead to cancer and other serious diseases. Unfortunately, there are currently no reliable data on how many adolescents use these newer products.


 


Footnotes


1 Gentzke, A.S., Creamer, M., Cullen, K.A., et al. Vital Signs: Tobacco Product Use Among Middle and High School Students — United States, 2011–2018. MMWR Morb Mortal Wkly Rep 2019;68:157–164. DOI: http://dx.doi.org/10.15585/mmwr.mm6806e1.
2 Johnston, L. D., Miech, R. A., O’Malley, P. M., Bachman, J. G., Schulenberg, J. E., & Patrick, M. E. (2019). Monitoring the Future national survey results on drug use 1975-2018: Overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, University of Michigan. Retrieved from http://www.monitoringthefuture.org/pubs/monographs/mtf-overview2018.pdf.
3 Kann, L., McManus, T., Harris, W. A., Shanklin, S. L., Flint, K. H., Queens, B., … Ethier, K. A. (2018). Youth Risk Behavior Surveillance – United States, 2017. Surveillance Summaries, 67(8), 1-114. Retrieved from https://www.cdc.gov/mmwr/volumes/67/ss/ss6708a1.htm?s_cid=hy-yrbs2017-mmwr.
4Center for Behavioral Health Statistics and Quality. (2017). 2016 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf
5Corey, C. G., Ambrose, B. K., Apelberg, B. J. & King, B. A. (2015). Flavored tobacco product use among middle and high school students – United States, 2014. Morbidity and Mortality Weekly Report, 64(38), 1066-1070. Retrieved from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6438a2.htm.
6 Singh, T., Arrazola, R. A., Corey, C. G., Husten, C. G, Neff, N. J., Homa, D., M., & King, B. A. (2016). Tobacco use among middle and high school students — United States, 2011–2015. Morbidity and Mortality Weekly Report, 65(14), 361–367. Retrieved from: http://www.cdc.gov/mmwr/volumes/65/wr/mm6514a1.htm.
7 Jones, W.J., & Silvestri, G.A. (2010). The Master Settlement Agreement and its impact on tobacco use 10 years later: Lessons for physicians about health policy making. Chest, 137(3), 692–700.
8 U.S. Department of Health and Human Services. (2014). The health consequences of smoking—50 years of progress: A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Retrieved from http://www.surgeongeneral.gov/library/reports/50-years-of-progress/exec-summary.pdf.
9 U.S. Department of Health and Human Services. (2012). Preventing tobacco use among youth and young adults: A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Retrieved from http://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/full-report.pdf.
10 National Institute on Drug Abuse. (2016). Hookah isn’t harmless. Retrieved from https://teens.drugabuse.gov/blog/post/hookah-isn-t-harmless.
11 U.S. Food and Drug Administration. (2016). Hookah tobacco (shisha or waterpipe tobacco). Retrieved from https://www.fda.gov/tobacco-products/products-ingredients-components/hookah-tobacco-shisha-or-waterpipe-tobacco.
12 Wackowski, O. A. & Delnevo, C. D. (2016). Young adults’ risk perceptions of various tobacco products relative to cigarettes: Results From the National Young Adult Health Survey. Health Education & Behavior, 43(3); 328-336. Retrieved from http://heb.sagepub.com/content/43/3/328.
13 U.S. Food and Drug Administration. (2016). Vaporizers, e-cigarettes, and other electronic nicotine delivery systems (ENDS). Retrieved from http://www.fda.gov/tobaccoproducts/labeling/productsingredientscomponents/ucm456610.htm.
14 Miech, R. A., O’Malley, P. M., Johnston, L., & Patrick, M. E. (2016). E-cigarettes and the drug use patterns of adolescents. Nicotine and Tobacco Research, 18(5), 654-659. Retrieved from http://ntr.oxfordjournals.org/content/18/5/654.
15 Morean, M. E., Kong, G., Camenga, D. R., Cavallo, D. A., & Krishnan-Sarin, S. (2015). High school students’ use of electronic cigarettes to vaporize cannabis. Pediatrics 136(4). Retrieved from http://pediatrics.aappublications.org/content/early/2015/09/01/peds.2015-1727.
16 Warner, K. E. (2016). Frequency of e-cigarette use and cigarette smoking by American students in 2014. American Journal of Preventive Medicine 51(2). Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26821834.
17  Johnston, L. D., Miech, R. A., O’Malley, P. M., Bachman, J. G., Schulenberg, J. E., & Patrick, M. E. (2018). Monitoring the Future national survey results on drug use: 1975-2017: Overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, The University of Michigan. Retrieved from http://www.monitoringthefuture.org/pubs/monographs/mtf-overview2017.pdf.
18 Wang, T. W., Gentzke, A., Sharapova, S., Cullen, K. A., Ambrose, B. K., & Jamal, A. (2018, June 8). Tobacco product use among middle and high school students – United States, 2011-2017. Morbidity and Mortality Weekly Report, 67(22), 629-633. Retrieved from https://www.cdc.gov/mmwr/volumes/67/wr/mm6722a3.htm?s_cid=mm6722a3_e.
Content created by Office of Adolescent Health
Content last reviewed on May 1, 2019