Cancer Trends Progress Report

Cigarette smoking is the leading preventable cause of disease, disability, and death in the United States. Smoking causes cancers of the lung, esophagus, larynx (voice box), mouth, throat, kidney, bladder, liver, pancreas, stomach, cervix, colon and rectum, as well as acute myeloid leukemia. Tobacco use is initiated and established primarily during adolescence (defined as ages 10-19): nearly 90 percent of adult cigarette smokers in the U.S. first tried cigarettes by age 18, and 98 percent first tried cigarettes by age 26. Each day in the U.S., around 1,600 youth aged 18 or younger smoke their first cigarette and another 200 become daily cigarette smokers.

E-cigarettes (also known as vapes or Electronic Nicotine Delivery Systems [ENDS]) are battery-powered devices that convert a liquid (“e-liquid”) into an aerosol. E-liquids typically contain nicotine, flavorings, vegetable glycerin, propylene glycol, and other chemicals. In addition to nicotine, e-cigarette aerosol may contain heavy metals, volatile organic compounds, and fine and ultrafine particles that can be inhaled deeply into the lungs by both users and bystanders. Nicotine use among youth increases the risk of lifelong tobacco addiction and may also increase the risk for future addiction to other drugs. In August 2016, the FDA finalized a rule extending its regulatory authority to all tobacco products, including e-cigarettes, cigars, and hookah and pipe tobacco.

Teen cigarette smoking prevalence peaked around 1996/1997 but has been declining since.  However, a substantial portion of youth use other tobacco products, including e-cigarettes, cigars, smokeless tobacco, and hookah. According to data from the 2020 National Youth Tobacco Survey (NYTS), 16.2% of middle and high school students reported current use of a tobacco product. Youth use of more than one tobacco product (dual use) is also common.  Since 2014, e-cigarettes have been the most commonly used tobacco product among youth, and, in 2018, former U.S. Surgeon General Jerome Adams issued an advisory calling youth e-cigarette use an epidemic.

According to data from the NYTS, in 2020, more than 3.6 million U.S. youth, including nearly 1 in 5 high school students (19.6%) and 1 in 20 middle school students (4.7%), were current users of e-cigarettes. Moreover, among high school students who reported current e-cigarette use, 38.9% reported using the products frequently (on 20 or more of the past 30 days) and 22.5% reported daily use. The 2021 NYTS data indicated that 11.3% of high schoolers and 2.8% of middle schoolers currently used e-cigarettes. However, NYTS data from 2021 should not be compared with previous years because of differences in data collection due to the COVID-19 pandemic.

There are many factors associated with youth tobacco use, including social, environmental, cognitive, and genetic influences. In addition, Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General, published by the Centers for Disease Control and Prevention in 2012, concluded that tobacco advertising, promotion, and depictions of smoking in movies are causally related to youth tobacco use. Initiation of smoking during adolescence is linked to persistent smoking during adult life and the many adverse health effects caused by smoking.

Understanding trends in youth initiation and use of tobacco products – including cigarettes, e-cigarettes, cigars, and smokeless tobacco – helps policy makers determine how to allocate prevention resources. Effective strategies to reduce youth initiation of tobacco use include federal regulation of tobacco products; significant increases in tobacco prices, including excise taxes; smokefree air laws; restrictions on tobacco advertising and promotion; restricting the availability of tobacco products to youth; mass-media public education campaigns; and full implementation of comprehensive state and community tobacco control programs. On December 20, 2019, the President signed legislation to amend the Federal Food, Drug, and Cosmetic Act, and raise the federal minimum age of sale of tobacco products from 18 to 21 years.