Tobacco use is the leading cause of preventable disease and death in the United States; nearly all tobacco product use begins during youth and young adulthood ( 1 , 2 ). CDC and the Food and Drug Administration (FDA) analyzed data from the 2019 and 2020 National Youth Tobacco Surveys (NYTS) to determine changes in the current (past 30-day) use of seven tobacco products among U.S. middle (grades 6–8) and high (grades 9–12) school students. In 2020, current use of any tobacco product was reported by 16.2% (4.47 million) of all students, including 23.6% (3.65 million) of high school and 6.7% (800,000) of middle school students. Electronic cigarettes (e-cigarettes) were the most commonly used tobacco product among high school (19.6%; 3.02 million) and middle school (4.7%; 550,000) students. From 2019 to 2020, decreases in current use of any tobacco product, any combustible tobacco product, multiple tobacco products, e-cigarettes, cigars, and smokeless tobacco occurred among high school and middle school students; these declines resulted in an estimated 1.73 million fewer current youth tobacco product users in 2020 than in 2019 (6.20 million) ( 3 ). From 2019 to 2020, no significant change occurred in the use of cigarettes, hookahs, pipe tobacco, or heated tobacco products. The comprehensive and sustained implementation of evidence-based tobacco control strategies at the national, state, and local levels, combined with tobacco product regulation by FDA, is warranted to help sustain this progress and to prevent and reduce all forms of tobacco product use among U.S. youths ( 1 , 2 ). NYTS is a cross-sectional, voluntary, school-based, self-administered electronic survey of U.S. middle and high school students. A stratified three-stage cluster sampling procedure generated a nationally representative sample of U.S. students attending public and private schools in grades 6–12. Participants complete the survey in classrooms using a tablet computer.* In 2020, data collection occurred during January 16–March 16, 2020. † In total, 14,531 students (participation rate = 87.4%) from 180 schools (participation rate = 49.9%) participated, yielding an overall response rate of 43.6% in 2020. Detailed information about NYTS is available elsewhere. § Prevalence, with 95% confidence intervals, of current use of seven tobacco products (e-cigarettes, cigarettes, cigars, smokeless tobacco, ¶ hookahs, pipe tobacco,** and heated tobacco products †† ) was reported; current use was defined as use on one or more days during the past 30 days. Three composite measures of current use (any tobacco product, §§ any combustible tobacco product, ¶¶ and multiple tobacco products***) also were reported. National weighted prevalence estimates and population totals ††† in 2020 were reported among all students and separately by school level. Estimates were reported overall and by selected demographic characteristics. Differences between the prevalence of current use in 2020 and that in 2019 (19,018 participants in 2019; student participation rate = 85.8%; school participation rate = 77.2%; overall response rate = 66.3%) were estimated using t-tests; p-values 30% or an unweighted denominator of 30%. ** In 2020, any tobacco product use was defined as use of any tobacco product (e-cigarettes, cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco, bidis [small brown cigarettes wrapped in a leaf], or heated tobacco products) on ≥1 day during the past 30 days. †† Any combustible tobacco product use was defined as use of cigarettes, cigars, hookahs, pipe tobacco, or bidis on ≥1 day during the past 30 days. §§ In 2020, multiple tobacco product use was defined as use of two or more tobacco products (e-cigarettes, cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco, bidis, or heated tobacco products) on ≥1 day during the past 30 days. Among middle school students, 6.7% (800,000) reported current use of any tobacco product, 3.4% (400,000; 50.7% of any tobacco product users) reported current use of any combustible tobacco product, and 2.8% (340,000; 41.8% of any tobacco product users) reported current use of multiple tobacco products. By type of product, current use among middle school students was highest for e-cigarettes (4.7%), followed by cigarettes (1.6%), cigars (1.5%), hookahs (1.3%), heated tobacco products (1.3%), smokeless tobacco (1.2%), and pipe tobacco (0.4%). Among middle school students, any tobacco product use was reported by 6.8% of females and 6.6% of males; by 9.4% of Hispanic, 6.7% of non-Hispanic Black, and 5.7% of non-Hispanic White students; and by 16.5% of those identifying as lesbian, gay, or bisexual, 5.5% of those identifying as heterosexual, and 6.4% of those reporting “not sure” about their sexual identity. From 2019 to 2020, among high school (Figure 1) and middle school students (Figure 2), significant declines (p 30% or unweighted denominator <50. § In 2020, any tobacco product use was defined as use of any tobacco product (e-cigarettes, cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco, bidis [small brown cigarettes wrapped in a leaf], or heated tobacco products) on ≥1 day during the past 30 days. In 2019, consistent with previously published estimates, any tobacco product use was defined as use of any tobacco product (e-cigarettes, cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco, or bidis) on ≥1 day during the past 30 days. ¶ Any combustible tobacco product use was defined as use of cigarettes, cigars, hookahs, pipe tobacco, or bidis on ≥1 day during the past 30 days. ** In 2020, multiple tobacco product use was defined as use of two or more tobacco products (e-cigarettes, cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco, bidis, or heated tobacco products) on ≥1 day during the past 30 days. In 2019, consistent with previously published estimates, multiple tobacco product use was defined as use of two or more tobacco products (e-cigarettes, cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco, or bidis) on ≥1 day during the past 30 days. †† During 2019–2020, significant declines in the use of any tobacco product (p<0.001), any combustible tobacco product (p = 0.013), multiple tobacco products (p = 0.025), e-cigarettes (p<0.001), cigars (p = 0.012), and smokeless tobacco (p = 0.038) were observed. No significant change in use of cigarettes, hookahs, or heated tobacco products occurred. Because of the suppression of the pipe tobacco estimate in 2019, no comparison was made during 2019–2020. The figure is a bar chart showing the percentage of current use of selected tobacco products, any tobacco product, any combustible tobacco product, and multiple tobacco products among middle school students in the United States during 2019 and 2020 according to the National Youth Tobacco Survey. Discussion Use of any tobacco product by youths declined by an estimated 1.73 million from 6.20 million in 2019 ( 3 ) to 4.47 million in 2020. Despite this decline, in 2020 nearly one in four U.S. high school students and approximately one in 15 middle school students still reported current use of any tobacco product. Continued efforts are warranted to sustain this progress and to prevent and reduce all forms of tobacco product use among U.S. youths ( 1 , 2 ). Among both middle and high school students, current use of e-cigarettes declined from 2019 to 2020, reversing previous trends and returning current e-cigarette use to levels similar to those observed in 2018 ( 4 ). Declines in current cigar smoking and smokeless tobacco product use also occurred, as did youths’ use of any combustible tobacco products and multiple tobacco products. Together, these changes contributed to an overall reduction in any tobacco product use by youths during 2019–2020. These declines were likely attributable to multiple factors at the national, state, and local level. For example, in December 2019, the federal minimum age of sale of all tobacco product types increased from 18 to 21 years ( 5 ). Under the authority of the 2009 Family Smoking Prevention and Tobacco Control Act, FDA issued guidance in January 2020 to prioritize enforcement against certain flavored e-cigarette products that appeal to youths, including mint and fruit flavors ( 6 ). Several states and communities also recently restricted the sale of flavored tobacco products, including e-cigarettes. §§§ In addition, public health efforts to address the multistate outbreak of e-cigarette, or vaping, product use–associated lung injury (EVALI) might have contributed to these declines in youth e-cigarette use ( 7 ). Furthermore, targeted actions to address the youth e-cigarette epidemic occurred, including FDA’s public education campaign to reduce youth e-cigarette, smokeless tobacco, and cigarette use. ¶¶¶ Despite declines in youths’ use of combustible tobacco products since 2011 ( 4 ), no change in current cigarette smoking occurred during 2019–2020. Among all students who currently used any tobacco product, approximately 42% (1.87 million) reported smoking combustible tobacco products in 2020. However, a decline in current cigar smoking did occur during 2019–2020. Continued actions are warranted to help ensure sustained progress in preventing and reducing youths’ use of all forms of tobacco products, including those that are combustible, noncombustible, and electronic. The findings in this report are subject to at least three limitations. First, the data collection period was truncated because of the coronavirus disease 2019 pandemic, resulting in a lower school participation rate (49.9%) compared with recent NYTS cycles (average across 2011–2019 NYTS cycles = 78.2%). However, the 2020 NYTS student participation rate (87.4%) was high, and the weighted sample yielded nationally representative estimates.**** Second, these data were self-reported and might be subject to recall and response biases. Finally, these findings might not be generalizable to youths who are homeschooled, have dropped out of school, are in detention centers, or are enrolled in alternative schools. In 2020, approximately one in six U.S. middle and high school students, or approximately 4.47 million youths overall, reported current use of any tobacco product. The comprehensive and sustained implementation of evidence-based tobacco control strategies at the national, state, and local levels, combined with tobacco product regulation by FDA, is warranted for continuing progress toward reducing and preventing all forms of tobacco product use among U.S. youths. Such strategies include increasing prices of tobacco products, protecting persons from exposure to secondhand smoke and e-cigarette aerosol, sustaining hard-hitting media campaigns that warn about the dangers of tobacco product use, restricting youth access to tobacco products, prohibiting the sale of all flavored tobacco products, and development of regulations to reduce youth appeal and addictiveness of tobacco products ( 1 – 3 , 8 – 10 ). In addition, as the tobacco product landscape continues to diversify, surveillance for all forms of tobacco product use, including novel products, by youths is important to inform public health policy and practice at the local, state, and national levels. Summary What is already known? Tobacco use is the leading cause of preventable disease and death in the United States; nearly all tobacco use begins during youth and young adulthood. What is added by this report? In 2020, 23.6% (3.65 million) of high school and 6.7% (800,000) of middle school students reported current (past 30-day) use of any tobacco product. From 2019 to 2020, decreases among high school and middle school students occurred in current use of any tobacco product, combustible tobacco products, multiple tobacco products, e-cigarettes, cigars, and smokeless tobacco. What are the implications for public health? The comprehensive and sustained implementation of evidence-based tobacco control strategies, combined with tobacco product regulation by the Food and Drug Administration, is warranted to help sustain this progress and prevent and reduce all forms of tobacco product use among U.S. youths.
