Trends in Nicotine Product Use Among US Adolescents, 1999-2020

Question How has exposure to nicotine products and their associated risk among US adolescents changed owing to the popularity of e-cigarettes? Findings This cross-sectional study, which included 16 years of survey data for between 15 000 and 36 000 students in grades 6 through 12 per year, found that exposure to nicotine products, as assessed by nicotine product days, decreased prior to the popularity of e-cigarettes. This decrease slowed and then reversed owing to the upsurge of vaping; however, adjusting for differential long-term risks of nicotine products, risk-adjusted nicotine product days may have decreased if the risk associated with vaping is sufficiently low compared with that of smoking. Meaning This study suggests that whether the health risks associated with nicotine product use among US adolescents have increased owing to the popularity of e-cigarettes depends on one's assessment of the risks associated with vaping. This cross-sectional study uses data from the National Youth Tobacco Survey to investigate how nicotine product use and its associated risks have changed among middle school and high school students since 1999. IMPORTANCE With increasing e-cigarette use among US adolescents and decreasing use of other tobacco products, it is unclear how total use of nicotine products, and its long-term health risks, have changed. The Centers for Disease Control and Prevention's standard measure-any tobacco product use in the past 30 days-considers neither frequency of use nor product risk implications. OBJECTIVE To investigate how nicotine product use, including frequency of use, and its associated risks have changed among middle school and high school students since 1999. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used data from the 1999-2020 National Youth Tobacco Survey, an in-school survey of a nationally representative sample of students in grades 6 through 12; each survey recruited between 15 000 and 36 000 participants. EXPOSURES Nicotine product use in the past 30 days. MAIN OUTCOMES AND MEASURES Use of nicotine products assessed by nicotine product days (NPDs), the number of days that the average student consumed these products in the past 30 days. Risk-adjusted NPDs account for differential long-term health risks of various products. RESULTS This study included 16 years of cross-sectional survey data. Each survey recruited between 15 000 and 36 000 participants in grades 6 through 12 (male students: mean, 50.4% [minimum, 48.5%; maximum, 58.4%]; mean age, 14.5 years [minimum, 14.0 years; maximum, 14.7 years]). Nationally representative cross-sectional data for high school students showed that NPDs decreased steadily from 5.6 days per month in 1999 (95% CI, 5.0-6.2 days per month) to 2.2 days per month in 2017 (95% CI, 1.9-2.6 days per month), increased to 4.6 days per month in 2019 (95% CI, 4.1-5.1 days per month), and then decreased to 3.6 days per month in 2020 (95% CI, 3.0-4.1 days per month). For a risk weight of 0.1 for e-cigarettes, compared with combustible products, risk-adjusted NPDs decreased from 2.5 days per month in 2013 (95% CI, 2.2-2.9 days per month) (prior to the popularity of e-cigarettes) to 2.0 days per month in 2019 (95% CI, 1.6-2.5 days per month) and 1.4 days per month in 2020 (95% CI, 1.0-1.8 days per month). However, with a risk weight of 1.0 for e-cigarettes (identical to that of combustible products), risk-adjusted NPDs increased to 5.3 days per month in 2019 (95% CI, 4.4-6.2 days per month) and 3.9 days per month in 2020 (95% CI, 3.1-4.7 days per month). Similar trends were found for middle school students. CONCLUSIONS AND RELEVANCE This study suggests that NPDs represent an improvement, albeit an imperfect one, compared with any 30-day tobacco product use by incorporating the frequency of use of various products. By distinguishing products, NPDs permit consideration of the health consequences associated with different mixes of products over time. Health risks of adolescent nicotine product use could have decreased during vaping's popularity if assessment of the long-term risks associated with vaping compared with those of smoking is low. There is a need to closely monitor youth nicotine and tobacco product use patterns.

Automated summary

This study indicates that the exposure to nicotine products and their associated risks among US adolescents have changed due to the popularity of e-cigarettes, with the decrease in exposure prior to vaping's rise and a subsequent reversal. The study suggests that the health risks of adolescent nicotine product use could have decreased during the popularity of vaping if the assessment of the risks associated with vaping compared with those of smoking is low. There is a need for continued monitoring of youth nicotine and tobacco product use patterns.