The 2021 National Youth Tobacco Survey (NYTS) was conducted among U.S. middle and high school students during the COVID-19 pandemic and revealed that youth tobacco use remains a serious public health concern. About 2.55 million U.S. middle and high school students reported current (past 30-day) use of a tobacco product in 2021, according to new data released in the Morbidity and Mortality Weekly Report.

Because of the implementation of COVID-19 protocols across the country when the 2021 NYTS was conducted (January 18–May 21, 2021), the survey was administered online to allow eligible students to complete the survey at home, school, or somewhere else. While remaining confident in the study results, the reporting of tobacco use might differ by the setting where the survey was completed. Therefore, these results cannot be compared with results from previous NYTS surveys that were primarily conducted on school campuses.

In collaboration with the U.S. Food and Drug Administration, the Centers for Disease Control and Prevention (CDC) analyzed data from the 2021 NYTS. Among middle and high school students who currently used tobacco products about 1 in 3 (860,000) used at least one type of combustible tobacco product, and about 3 in 10 (740,000) used two or more tobacco products.

As previously reported, e-cigarettes were the most common tobacco product currently used among middle and high school students (2.06 million) in 2021. This was followed by cigarettes (410,000), cigars (380,000), smokeless tobacco (240,000), hookahs (220,000), nicotine pouches (200,000), heated tobacco products (170,000), and pipe tobacco (80,000).

“Youth use of tobacco products is unsafe in any form – combustible, smokeless, or electronic,” said Karen Hacker, M.D., M.P.H., director of CDC’s National Center for Chronic Disease Prevention and Health Promotion. “This report provides critical insights needed to combat this serious public health concern and help protect our nation’s youth from the harmful effects of tobacco.”

Disparities Persist Among Subgroups

Among middle and high school students combined, current use of any tobacco product was higher among students who identified as lesbian, gay, or bisexual (14.2 percent) than those who identified as heterosexual (7.9 percent) and those who were “not sure” about their sexual identity (5.5 percent); and higher among students who identified as transgender (18.9 percent) compared to those not transgender (8.2 percent) or not sure (9.1 percent).

Current use of any tobacco product was higher among students who had severe (14.2 percent), moderate (11.2 percent), or mild (9.6 percent) symptoms of psychological distress compared to those with no psychological distress (5.5 percent).

Additionally, among all race and ethnicity groups, non-Hispanic Black students reported the highest prevalence of current combustible tobacco product use (5.2 percent), and specifically cigar use (3.1 percent). While youth use of tobacco products in any form is unsafe, the death and disease from tobacco product use in the United States is primarily caused by combustible tobacco products.

Many Factors Influence Youth

Multiple factors continue to promote tobacco product use and initiation among youth, including flavors, marketing, and misperceptions of harm.

Among the approximately 2.55 million middle and high school students who currently used any tobacco product, most (about 8 in 10 or 1.95 million) reported using flavored tobacco product(s) in the past 30 days.

Approximately 76 percent of students in 2021 reported exposure to tobacco product marketing through traditional media (e.g., newspapers or magazines), and approximately 74 percent of students who used social media had ever seen e-cigarette–related posts or content.

Among students who had ever used e-cigarettes, peer use and curiosity were the most cited reasons for first trying e-cigarettes in 2021. However, among students who currently used e-cigarettes, the most cited reasons for use were feelings of anxiety, stress, or depression and the “high or buzz” associated with nicotine use. Importantly, nicotine withdrawal is commonly accompanied by symptoms of anxiety and depression, and temporary relief of these symptoms through use of a nicotine-containing product might perpetuate continued nicotine use.

Among the approximately 2.55 million students who currently used any tobacco product, 65.3 percent reported that they were seriously thinking about quitting all tobacco products. In addition, 60.2 percent of students who currently used tobacco products reported that they stopped using all tobacco products for one or more days during the past 12 months because they were trying to quit.

“The 2021 NYTS findings include important new information about youth tobacco use behaviors and associated factors that will help the FDA evaluate, design, and implement our tobacco regulatory and educational programs,” said Mitch Zeller, J.D., Director of FDA’s Center for Tobacco Products. “It’s revealing that about two-thirds of current youth users expressed a desire to quit tobacco products and that three-quarters of youth reported having seen or heard a tobacco prevention ad. But the 2021 use data are still concerning and will be valuable for policymakers and educators committed to protecting the next generation from tobacco-related disease and death.”

What Can Be Done To Curtail Use?

Tobacco product use remains the leading cause of preventable disease, disability, and death in the United States. Nearly all tobacco use begins during youth and young adulthood. Nicotine–the addictive drug found in tobacco products–can harm adolescent brain development, which continues into the early to mid-20s. Parents, educators, youth advocates, and health care providers can help protect youth from the harms of tobacco products, including e-cigarettes, and can support and encourage youth to quit.

Strategies to reduce tobacco product use and initiation among all youth include increasing prices of tobacco products; establishing comprehensive clean indoor air policies that deformalize tobacco use and protect persons from exposure to secondhand smoke and e-cigarette aerosol; sustaining media campaigns that warn about the dangers of tobacco product use; reducing youth access to tobacco products, including enforcement of the federal Tobacco 21 policy against retailers who violate the law; and restricting the sales of flavored e-cigarettes.

To learn more about quitting tobacco product use and preventing youth from using tobacco products, visit www.betobaccofree.gov and FDA’s “The Real Cost” campaign.