Youth and Young Adult Nicotine Consumption and Tobacco Use
Why it Matters
- In 2019 over one in four U.S. high school students and one in ten middle school students currently vape. By contrast, 5.8% of high school students report using conventional cigarettes.1
- A growing body of literature suggests that youths who use e-cigarettes are more likely to smoke conventional cigarettes in the future.2
- The tobacco industry has historically and continues to target youth, especially in and around schools.3
- Exposure to nicotine in adolescence creates measurable changes in brain chemistry and biology. These changes lead to heavier daily use, stronger addictions, and more difficulty quitting tobacco use later in life.4
- Brain changes induced by nicotine exposure can make young people more susceptible to addiction to other substances.5
- National samples of youth e-cigarette users demonstrate that the majority were not aware that the products contain nicotine and believed them to be “not at all addictive”.6
- Youth use of e-cigarettes appears different than adults. Use by adults is highest among those who formerly smoked cigarettes and who had quit within the past year, and use declines with a longer duration of quitting cigarettes among former smokers.7 Youth use is not associated with quitting cigarettes.
- A survey conducted of adolescents and young adults (aged 13-24 years) in May 2020 found that a COVID-19 diagnosis was five times more likely among ever-users of e-cigarettes only, seven times more likely among ever-dual-users, and 6.8 times more likely among past 30-day dual-users. Testing and symptoms were also more likely.8
What We Know About What Works
- The body of research assessing effectiveness of interventions identify several barriers to efforts to assess youth cessation strategies, including:9
- Recruitment—several studies note that they were not able to generate the power anticipated based on recruitment challenges.
- Retention—many studies found it difficult to maintain a sufficient cohort for the duration of the study to yield valid results.
- Compliance—this was a challenge, particularly in pharmacotherapy studies.
- A literature review of material cited in the USPSTF Draft Recommendations Statement on Prevention and Cessation of Tobacco Use in Children and Adolescents: Primary Care Interventions as well as studies published through June 2019 found the following:10
- Four studies assessed the impact of counseling on youth cessation or reduction in smoking levels. Generally, there was a short-term reduction in tobacco use but no long-term impacts.
- Five studies assessed texting as a counseling intervention for youth cessation. Three studies showed reduced use but no impact on cessation. Two studies showed a positive impact on cessation with tailored messages but not general text messages.
- Four nicotine replacement therapy (NRT) studies demonstrated significant impact on abstinence in the short terms but did not maintain an impact over a longer period of time.
- Four studies of bupropion showed a short-term impact on cessation but no long-term impact.
- Two varenicline studies indicated it did not perform better than a placebo among adolescents.
- Four studies of prevention and cessation demonstrated a positive prevention impact but no long-term cessation impact.
- One study on a social branding and media campaign found tobacco use dropped after one year.
- The American Academy of Pediatrics has a study in place aimed at demonstrating providers’ fidelity to guidelines for tobacco cessation counseling and delivery of cessation interventions so adolescents using practice system changes over time. To date, the study has demonstrated the ability to train pediatric providers to delivery tobacco cessation
and social media counseling to adolescents. Youth outcomes are not yet available.11
- Because of the high reliance on the internet by young adults and youth, there is great interest in web-based interventions to support tobacco cessation. Research shows that these interventions are effective for adults and college students; additional research is needed to determine effects for adolescents and young adults.12
- Effective internet-based smoking cessation programs for adolescents usually include combinations of multimedia and interactive features (e.g., videos or stories), content that is tailored to participants’ demographic characteristics, or feedback that reflects participants’ progress and goals.13 Some studies suggest that websites that are interactive or tailored to participants’ demographic characteristics are more effective than sites that are static or more general; other studies suggest equal effects.14
- A recent study found that social media messaging can lead to greater knowledge and beliefs about the harm of e-cigarettes, compared with a control group. Almost four in five (79%) adolescents reported they would share the social media messages, most likely in person and with friends. Message topics for missing out because of lung damage, uncontrolled moods, and ingesting specific harmful chemicals elicited higher intended message reactions.15
- Data from the U.S. National Survey on Drug Use and Health from 2002-2017 found a 43% decline in smoking among youths ages 12-17 and a 27% decline among young adults ages 18-25 after the U.S. ban on flavored cigarettes took effect in September 2009. No similar reduction was found among older people. Menthol cigarettes were not banned, and the study found an increase in smoking of menthol cigarettes among youth right after the ban took effect.16
What’s Relevant in Pennsylvania
- According to the 2019 Pennsylvania Youth Survey, 3.5% of students from 6th–12th grade report using conventional cigarettes, ranging from 0.5% for sixth graders to 7.5% for 12th graders (2019).17
- According to the 2019 Pennsylvania Youth Survey, 19.0% report using e-cigarettes, ranging from 3.8% for sixth graders to 33.1% for 12th graders (2019).18
- According to the 2017 Youth Risk Behavior Survey (YRBS), 18.7% of high school students in Pennsylvania reported current use of any tobacco product, which was defined as one or more days of use of any tobacco product in the past 30 days. E-cigarettes were more likely to be used than cigarettes among high school students (11.3% vs. 8.7%). Use of any tobacco product was higher among male students (22.2%) than among female students (15%) in high schools.19
- Tax rate for e-cigarettes in PA is 40% of the purchase price on e-cigarettes, liquids or substances sold for use in an e-cigarette and e-cigarette devices.
- Young Lungs at Play: In June 2010, the Pennsylvania Department of Health partnered with the Penn State Cooperative Extension to implement Young Lungs at Play. Through the creation of tobacco free parks, community playgrounds and recreational areas, this health policy change initiative aimed to decrease smoking prevalence, teen smoking initiation and exposure to secondhand smoke. YLAP volunteers educated municipal officials, stakeholders
and residents about the health and environmental consequences of tobacco use and promoted policy change through the passage of tobacco free ordinances or resolutions that banned tobacco use in outdoor spaces where children play. YLAP signs were displayed in support of tobacco free ordinances, to increase awareness of tobacco bans. Seventy-eight percent of children under the age of 15 currently lived in municipalities/counties participating in Young Lungs at Play in 2017-2018. https://www.health.pa.gov/topics/Documents/Health%20Planning/3-SHA-Major-Risk-and-Protective-Factors_12-19.pdf
- Tobacco Resistance Unit (TRU) is a movement throughout Pennsylvania to help youth, ages 12–18 stay tobacco and nicotine-free. TRU is managed by the Pennsylvania Alliance to Control Tobacco (PACT) and the Pennsylvania American Lung Association. https://www.livehealthypa.com/data-resources/resources/healthy-living-practices/healthy-living-practices-listing/health-living-practices-details/tobacco-resistance-unit-(tru)
- Effective July 1, 2020, legislation prohibits the sale of any tobacco, nicotine, or related item to anyone under 21 years of age in Pennsylvania.
- National Jewish Health, in partnership with the Pennsylvania Department of Health, has launched an enhanced tobacco and vaping cessation program for teens under age 18 who want to stop using tobacco products, especially electronic cigarettes. The My Life, My Quit program combines best practices for youth tobacco cessation adapted to include vaping and new ways to reach a coach using live text messaging or online chat. https://mylifemyquit.com/
What Other States Are Doing
- Kick Butts Generation youth tobacco initiative in Delaware https://kbgde.org/index.php/home/
- RAZE youth tobacco initiative in West Virginia https://razewv.com/
- FACT teen youth initiative in Wisconsin https://factmovement.org/
- Tobacco Free Rhode Island Tobacco Free Youth http://tobaccofree-ri.org/tobacco-free-youth.htm
- Reality Check of New York http://www.realitycheckofny.com/
References and Resources
- The U.S. Department of Health and Human Services (US DHHS) provides several targeted internet-based smoking cessation interventions, including Smokefree Teen (Smokefree.gov); participants can build individualized quit plans and receive support as part of these programs (Smokefree.gov-Quit Plan).
- Stanford Medicine’s Tobacco Prevention Tool Kit is a compilation of theory-based and evidence-informed resources created by educators, parents, and researchers aimed at preventing middle and high school students’ use of tobacco and nicotine. It contains a number of modules including Smokeless Tobacco, E-Cigs/Vapes/Pod-Based Devices, Hookah etc. It also includes an alternative to suspension curriculum and has Spanish and Chinese translations. http://www.med.stanford.edu/tobaccopreventiontoolkit.html
- Public Health Law Center has created sample language for school policies and evidence-based solutions for alternatives to suspension and expulsion for students being punished for tobacco use. https://www.publichealthlawcenter.org/sites/default/files/resources/Addressing-Student-Commercial-Tobacco-Use-in-Schools-Alternative-Measures-2019-0.pdf
- The American Lung Association offers Intervention for Nicotine Dependence: Education, Prevention, Tobacco and Health (INDEPTH)® as an alternative to suspension or citation for schools. It is available at no cost. https://www.lung.org/quitsmoking/helping-teens-quit/indepth. It is not a cessation program, but participants report that it influenced them to
make a plan to quit.
- American Lung Association’s Vape-Free Schools Initiative was launched in 2020 to help schools navigate the vaping public health emergency with tools to protect and support students impacted by vaping. With your support, we invested in state-of-the-art e-learning to make the trainings virtual—so the programs can be accessed by every school across the country. To be recognized as a Vape Free Schools Initiative member, school staff utilize the training and resources to implement INDEPTH®, Not-On-Tobacco® and a Tobacco-Free School Policy assessment. https://www.lung.org/quitsmoking/helping-teens-quit/vape-free-schools
- For those interested in quitting post-INDEPTH, the American Lung Association offers Not On Tobacco (N-O-T) a program developed with teenagers in mind that provides resources teens need to break nicotine dependency. https://www.lung.org/quit-smoking/helping-teens-quit/not-on-tobacco.
- The Centers for Disease Control and Prevention provides additional guidance in “Best Practices User Guide: Youth Engagement in Tobacco Prevention and Control” https://www.cdc.gov/tobacco/stateandcommunity/bestpractices-youth-engagement/index.html
- The American Academy of Pediatrics has a factsheet providing guidance to pediatricians regarding the use of NRT for adolescent patients, including dosing guidance, the Hooked on Nicotine Checklist for provider use, and a modified Fagerstrom. https://downloads.aap.org/RCE/NRT_and_Adolescents_Pediatrician_Guidance_factsheet.pdf
- University of Colorado Behavioral Health & Wellness program links to a Tobacco Prevention and Cessation for Youth With Mental Illness and Substance Use Disorders report focused on the tobacco cessation needs of youth with mental illnesses and substance abuse disorders, including adolescents (13-17 years old) and young adults (ages 18-25 years old). This report informs the development of effective tobacco control interventions for youth served by the public mental health and substance abuse systems.
- The Regional Pennsylvania Tobacco-Free Coalitions have a resources available to combat the e-cigarette epidemic. These resources include a Secondhand E-cigarette Flyer, as well as a Toolkit For Providers: End the E-cigarette Epidemic.
- The Regional Pennsylvania Tobacco-Free Coalitions also has a document that references all programs that are available to support student lung health. Available in both English and Spanish.
- The Pennsylvania Alliance to Control Tobacco (PACT) has a Tobacco-Free College Campus Program that works to implement comprehensive tobacco-free policies in order to create cleaner air on campuses and protect the lung health of both staff and students. https://pactonline.org/tobacco-free-colleges/. PACT also developed a Tobacco-Free Campus Toolkit.
- African American/Black
- Asian American / Native Hawaiian / Pacific Islander
- Behavioral Health Population
- Chronic Conditions/ Diseases
- Hispanic / Latinx
- People Experiencing Homelessness
- Justice Involved Individuals
- LGBTQA / Sexual Gender Minority (SGM)
- Low Income Individuals
- People in the Military or Veterans
- Older Tobacco Users
- People with Disabilities (PWD)
- Pregnant Women
- Rural Geographic Areas / Amish and Mennonite
- Smokeless Tobacco Products
- Youth and Young Adult Nicotine Consumption and Tobacco Use
- 2019 National Youth Tobacco Survey. https://www.fda.gov/media/132299/download
- US Department of Health and Human Services. Surgeon General’s advisory on e-cigarette use among youth. Washington, DC: US Department of Health and Human Services, Office of the Surgeon General; 2018. https://ecigarettes. surgeongeneral.gov/documents/surgeon-generals-advisory-on-ecigarette-use-among-youth-2018.pdf?mod=article_inline
- Public Health Law Center, Location, Location, Location: Tobacco & E-Cig Point of Sale / Regulating Retailers for Public Health (2019). https://publichealthlawcenter.org/sites/default/files/resources/Location-Tobacco-Ecig-Point-Of-Sale-2019.pdf
- U.S. Dep’t. of Health & Human Servs., The Health Consequences of Smoking — Preventing Tobacco Use Among Youth & Young Adults: A
Report of the Surgeon Gen. (2012). https://www.cdc.gov/tobacco/data_statistics/sgr/2012/index.htm
- The Truth Initiative, The Youth E-Cigarette Epidemic: 5 Important Things to Know (2018). https://truthinitiative.org/research-resources/emerging-tobaccoproducts/youth-e-cigarette-epidemic-5-important-things-know
- Cooper M. et al., Flavorings & Perceived Harm and Addictiveness of E-Cigarettes Among Youth, 2 Tobacco Reg. Sci. 27889 (2016); Jeffrey G.
Willett et al., Recognition, Use and Perceptions of JUUL Among Youth and Young Adults, 28 Tobacco Control 115-16 (2019)
- Villarroel M., Cha A., Vahratian A. Electronic Cigarette Use Among U.S. Adults, 2019. NCHS Data Brief No. 365. April 2020.
- Gaiha S., Cheng J., Halpern-Felsher B. Association Between Youth Smoking, Electronic Cigarette Use, and Coronavirus Disease 2019. Journal
of Adolescent Health. July 2020.
- Segue Consulting Analysis of American Lung Association Annotated Bibliography on Youth Tobacco Cessation Strategies.
- American Lung Association. Annotated Bibliography on Youth Tobacco Cessation Strategies. September 2019.
- Adolescent Health in Pediatric Practice (AHIPP). American Academy of Pediatrics. https://www.aap.org/en-us/professional-resources/Research/PROS/Pages/Adolescent-Health-in-Pediatric-Practice-(AHIPP).aspx
- Taylor GMJ, Dalili MN, Semwal M, Civljak M, Sheikh A, Car J. Internet-based interventions for smoking cessation. Cochrane Database of Systematic Reviews 2017, Issue 9. Art. No.: CD007078. DOI: 10.1002/14651858. CD007078.pub5. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858. CD007078.pub5/full
- Park E, Drake E. Systematic review: internet-based program for youth smoking prevention and cessation. J Nurs Scholarsh. 2015;47(1):43-50. doi:10.1111/jnu.12104. https://pubmed.ncbi.nlm.nih.gov/25130325/
- Taylor GMJ, Dalili MN, Semwal M, Civljak M, Sheikh A, Car J. Internet-based interventions for smoking cessation. Cochrane Database of Systematic Reviews 2017, Issue 9. Art. No.: CD007078. DOI: 10.1002/14651858. CD007078.pub5.
- Lazard A. Social Media Message Designs to Educate Adolescents About E-Cigarettes. Journal of Adolescent Health. May 7, 2020. https://reader.elsevier.com/reader/sd/pii/S1054139X20302809?token=9E5D0EE382B3153EB7CC20BC8DB9B465A428FC76E184C0199A82CAB4F7A9310838588BAD32CA4559236B27ED9C13B0BE
- Rossheim M., Livingston M., Krall J. et.al. Cigarette Use Before and After the 2009 Flavored Cigarette Ban. Journal of Adolescent Health July 13, 2020. https://www.jahonline.org/article/S1054-139X(20)30335-9/fulltext
- 2019 Pennsylvania Youth Survey. https://www.pccd.pa.gov/Juvenile-Justice/Documents/2019%20PAYS/State%20of%20Pennsylvania%20Profile%20Report.Final.pdf