Aveneu Park, Starling, Australia

Use were obtained from 2015, National Youth Tobacco

Use of Tobacco Among Middle and High School
Students-United States, 2016

Background

Tobacco use is one of the major cause of preventable
death and diseases, it causes almost 443,000 deaths per year in the United
States. The purpose of this paper was to examine tobacco use among middle and
high school students in United States.

Methods

Data were obtained from 2015, National Youth Tobacco
Survey (NYTS), a self-administered school based questionnaire, given to middle
and high school students to get vital information on the results of impact of
tobacco control program and policies. The NYTS is a three-phase cluster
sampling method and a cross-sectional representative sample of students in 6th
to 12th grade. NYTS data were
examined for current use of tobacco according to middle and high school, sex,
race and ethnicity. A two-tailed t-test at p<0.05 was used for statistical significance. Results In 2016, about 20.2% currently use tobacco and 9.6% use more than 2 products of tobacco among high school students. E-cigarettes (11.3%) was the highest, cigarettes (8.0%), cigars (7.7%), smokeless tobacco was 5.8%, hookahs (4.8%), pipe tobacco (1.4%), and bidis (0.5%). Male students had higher use of any tobacco products than females. E-cigarettes was higher among non-Hispanic white (13.7%) and Hispanic (10.3%), while cigars were most commonly used among non-Hispanic black (9.5%). Middle school students currently use 7.2% of any tobacco and 3.1% used more than 2 products of tobacco. E-cigarettes (4.3%) was the highest, cigarettes (2.2%), cigars (2.2%), smokeless tobacco (2.2%), hookahs (2.0%), pipe tobacco was 0.7% and bidis (0.3%). Similarly, male students (8.3%) reported higher use of any tobacco product than females (5.9%). Hispanics had higher tobacco use when compared to others. Conclusion The intervention programs should be maintained to reduce tobacco use among youths in the United States. Introduction       Methods NYTS is a survey administered to middle and high school students in the United States. It is a three-stage cluster sampling method that is representative of students in 6th to 12th grade attending public and private schools. The data for this study were obtained from 2016 NYTS. The size of the sample and rate of response for this study was estimated to be 20,675 (71.6%). The students that participated in the study were asked questions on current use of different tobacco products: cigarette use, cigars, smokeless tobacco, e-cigarettes, hookahs (water pipes used to smoke tobacco), pipe tobacco, and bidis. It was stated that current use of tobacco was the use of each product for more than one day in the last 30 days. Furthermore, participant current use of one or more tobacco products was defined as the use of any tobacco product and 2 or more tobacco products use was stated as current use of more than 2 tobacco products. Moreover, the use of any type of combustible tobacco product was stated as current use of cigarettes, cigars, hookahs, pipe tobacco, and bidis. Weighted data were used for the complex survey design and modified for participants that did not respond to the questions, prevalence estimates at the national level, 95% confidence intervals, and estimated population estimates were rounded down to the nearest 10,000. Participants current use of tobacco products were estimated for middle and high school in 2016 by selected demographics. The results were estimated for linear and quadratic trends in 2016 after race/ethnicity, sex, and school grade were adjusted. T-tests was conducted to determine differences of the outcome in each variable for a statistical significant of p<0.05.   Results In 2016, the percentage of students in high school that reported on the current use of any tobacco product were 20.2%, including 9.6% who reported current use of two or more tobacco products. E-cigarettes were the most frequently tobacco product used among high school students (about 11.3% of current users), cigarettes (8.0%)was the second highest tobacco product used among the participants, 7.7% use cigars, smokeless tobacco users were 5.8%, hookahs (4.8%), pipe tobacco (1.4%), and bidis (0.5%) was the least used tobacco product among high school students (Table). Furthermore, the male students reported a higher use of any tobacco product, two or more tobacco products and any combustible tobacco product when compared to the female students. The non-Hispanic white (13.7%) and the Hispanic high school students (10.3%) had a higher use of e-cigarettes when compared to the non-Hispanic black (6.2%). Furthermore, it was estimated that 9.5% of non-Hispanic black use cigars when compared to non-Hispanic white (7.9%) and Hispanic (7.2%). The non-Hispanic white (7.4%) use more smokeless tobacco than the Hispanic (4.4%) and non-Hispanic black (2.1%). Similarly, the Hispanic (6.4%) reported use of hookah more than any other race and ethnicity (Table 1). About 7.2% of the middle school students reported current use of any tobacco product, and 3.1% of the students (0.36 million; 42.4% of current tobacco users) use more than two tobacco products (Table). The most frequently used tobacco product among middle school students was e-cigarettes (4.3%), cigarettes (2.2%) was the secondly commonly used tobacco product, cigars and smokeless tobacco were 2.2%, hookahs (2.0%), pipe tobacco (0.7%), and bidis (0.3%) was the least used tobacco product. The male students (8.3%) had a higher tobacco product use than the female middle school students (5.9%). Hispanics had more use of any tobacco product, two or more tobacco products, hookahs than non-Hispanic white students (Table). Furthermore, the Hispanic (5.6%) had higher current use of e-cigarette than non-Hispanic black (4.0%) and non-Hispanic white (3.7%). Cigar was the most commonly used tobacco product among non-Hispanic black (4.5%) when compared to Hispanic (2.8%) and non-Hispanic white (1.4%). Hookah use was higher among Hispanic (3.7%) middle school student followed by non-Hispanic black (2.8%) and least reported use among non-Hispanic white (0.9%) (Table 1).   Discussion This research is very important because of its input to research on tobacco and strategies for control policy by using the NYTS data to examine tobacco product use among middle and high school students in the U.S (HHS ART). Furthermore, this study cross-examined data on students in middle and high school in the U.S. (HHS ART). The analyses revealed that non-Hispanic white and the Hispanic students had a higher use of tobacco product when compared to the non-Hispanic black among the high school students with the exception of cigars (HHS). Moreover, Hispanics in the middle school use more tobacco products than non-Hispanic white and non-Hispanic black students in the same category (HHS).  Tobacco product use decreases among middle and high school student in 2016, which contrasts with report of previous years that showed reduction in the use of cigarettes and cigars. Moreover, a simultaneous increase was observed in the use of other tobacco products including e-cigarettes and hookahs during the decline leading to non-observable change in the use of tobacco product in the previous years as reported. It was estimated that 3.9 million students in middle and high school in the United States currently take any tobacco product and 1.8 million students reported the use of 2 or more tobacco products. In addition, youths that uses several tobacco products have higher nicotine dependence than youths with single tobacco product use (4). There are certain limitations that affected this study which include non-representation of total population because the participants according to the data (NYTS) were from public and private school excluding students that dropped out of school, home-schooled youths and students in detention centers. In addition, the study can have response and recall bias because data were self-reported. Finally, the restructuring in the survey questions about e-cigarettes, hookahs and pipe tobacco in the previous years had effect on the outcome of the reported use. In general, the trends were the same with those found in other surveys represented at the national level despite all these limitations (6,7).   The decline in tobacco products use including e-cigarettes among youths recently was due to the preventive and control measures that was implemented in the whole of United States (2). There are several preventive methods that was implemented to resolve tobacco products use among youths in United States, which include policies that encourage smoke-free environment, restriction on youth easy access to tobacco products and campaign on the media that warn about the health consequences associated with tobacco use among youths. In February of 2014, the first national media campaign on tobacco education titled The Real Cost, the campaign targeted youths between 12 and 17 years in the U.S. The impact of the campaign was evaluated, and the outcome revealed that 348,398 youths in the U.S did not smoke cigarette between February 2014 and March 2016 (5). The sustenance of these preventive methods will help reduce the use of any tobacco products among youths in the United States (1–3). Preventing youths from tobacco use can be achieved by implementing strong policies that are against the use of tobacco product. FDA received autonomy in August 8, 2016 to monitor tobacco products including e-cigarettes, cigars, pipe tobacco, and hookah tobacco (8). The comprehensive tobacco control programs are very efficient in reducing tobacco products use among youths in the United States, but it receives insufficient funds from the government to achieve its goals (8, cdc 2011). Furthermore, the control of production, sharing and sales of tobacco products by FDA coupled with the full implementation of CDC comprehensive tobacco control and prevention strategies (9), will help reduce the initiation and use of tobacco products among youths in the United States (1,2,9). Another method of reducing tobacco use among youths is by raising the price and tax on all tobacco products and strong national media campaign and limitations against tobacco use in public places and raising the age of access to tobacco products to 21 years and above (9,10). It is very important to maintain the supervision of tobacco use among youths in order to determine the trend of its use over time. Conclusion                     Tobacco product            Sex % (95% CI)          Race/Ethnicity % (95% CI)     Total       Female       Male   White, non-Hispanic   Black, non-Hispanic       Hispanic   Other, non-Hispanic     % (95% CI)   Estimated no. of users High school students   Electronic cigarettes 9.5 (7.8–11.5) 13.1 (11.4–14.9) 13.7 (11.9–15.7) 6.2 (4.8–7.9)      10.3 (8.2–12.8) 5.4 (3.6–8.0) 11.3 (9.9–12.9) 1,680,000 Cigarettes 6.9 (5.4–8.8) 9.1 (7.6–11.0) 9.9 (8.2–11.8) 3.9 (2.9–5.3) 6.4 (4.9–8.4)      4.8 (3.1–7.6) 8.0 (6.7–9.6) 1,180,000 Cigars 5.6 (4.3–7.2)      9.0 (8.6–11.2) 7.9 (6.5–9.6) 9.5 (7.8–11.5) 7.2 (5.7–9.1) 3.7 (2.4–5.7) 7.7 (6.6–8.9) 1,130,000 Smokeless tobacco 3.3 (2.4–4.4) 8.3 (6.8–10.1) 7.4 (6.0–9.1) 2.1 (1.5–3.1) 4.4 (3.4–5.7) 3.8 (2.1–6.8) 5.8 (4.8–7.0) 860,000 Hookah 5.1 (4.1–6.3) 4.5 (3.8–5.4) 4.5 (3.7–5.4) 4.1 (3.2–5.3) 6.4 (4.8–8.3) 3.4 (2.1–5.5) 4.8 (4.1–5.7) 700,000 Pipe tobacco 0.9 (0.7–1.2) 1.8 (1.5–2.4) 1.4 (1.1–1.8) 1.2 (0.7–2.0) 1.2 (0.9–1.8)      - —§ 0.5 (0.3–0.7) 190,000 Bidis 0.3 (0.2–0.6) 0.7 (0.5–0.9) 0.4 (0.2–0.7) — 0.6 (0.4–1.1) — 0.5 (0.3–0.7) 70,000 Any tobacco product¶ 17.0 (14.9–19.3) 23.5 (21.3–25.8) 23.0 (20.7–25.6) 16.4 (14.1–18.9 18.3 (15.8–21.0) 11.3 (8.7–14.5) 20.2 (18.4–22.3) 3,050,000 ?2 tobacco products** 7.8 (6.3–9.7) 11.4 (9.9–13.0) 11.3 (9.6–13.2) 6.1 (5.2–7.3) 8.9 (7.1–11.2) 5.0 (3.2–7.7) 9.6 (8.3–11.1) 1,440,000 Any combustible tobacco product†† 12.4 (10.7–14.4) 15.3 (13.7–17.1) 15.1 (13.1–17.3) 12.9 (11.0–15.1) 12.9 (11.1–14.9) 8.1 (5.9–11.1) 13.8 (12.3–15.5) 2,080,000 Middle school students   Electronic cigarettes 3.4 (2.7–4.3) 5.1 (4.2–6.1) 3.7 (3.0–4.7) 4.0 (2.6–6.0) 5.6 (4.3–7.4) — 4.3 (3.7–4.9) 500,000 Cigarettes 1.8 (1.3–2.5) .5 (1.8–3.4) 1.9 (1.4–2.6) — 2.5 (1.8–3.5) — 2.2 (1.7–2.7) 250,000 Cigars 1.7 (1.1–2.4)      2.7 (1.9–3.9) 1.4 (0.9–2.2) 4.5 (2.8–7.1) .8 (1.9–4.2) — 2.2 (1.7–2.9) 260,000 Smokeless tobacco 1.5 (0.9–2.4) 3.0 (2.2–4.0) 2.1 (1.5–3.0) — 3.0 (2.1–3.4) — 2.2 (1.6–3.1) 260,000 Hookah 1.9 (1.5–2.5) 2.1 (1.5–2.9) 0.9 (0.6–1.4) 2.8 (1.8–4.4) 3.7 (3.0–4.7) — 2.0 (1.6–2.5) 230,000 Pipe tobacco 0.6 (0.3–1.0) 0.8 (0.5–1.3) — — 1.7 (1.1–2.6) — 0.7 (0.5–1.0) 70,000 Bidis — 0.4 (0.2–0.7) — — 0.6 (0.4–1.1) — 0.3 (0.2–0.5) 30,000 Any tobacco product¶ .9 (4.9–7.3) 8.3 (6.8–9.9) 5.9 (4.7–7.3) 7.5 (5.5–10.1) 9.5 (7.5–11.8) — 7.2 (6.1–8.4) 850,000 ?2 tobacco products** 2.5 (1.8–3.4) 3.6 (2.7–4.7) 2.3 (1.7–3.0) 3.0 (2.0–4.3) 4.5 (3.3–6.1) — 3.1 (2.5–3.8) 360,000 Any combustible tobacco product†† 3.9 (3.0–5.0)      4.6 (3.4–6.2) 2.9 (2.2–3.7) 5.8 (4.0–8.3) 6.1 (4.7–7.9) — 4.3 (3.5–5.2) 510,000 Source: National Youth Tobacco Survey, United States, 2015 Abbreviation: CI = confidence interval. * The last 30-day use of electronic cigarettes was examined by asking, "During the last thirty days, on the number of days did you use electronic cigarettes or e-cigarettes?" Last thirty days use of cigarettes was examined by asking, "During the last 30 days, on number of days did you smoke cigarettes?" Past 30-day use of cigars was evaluated by asking, "During the last 30 days, the number of days did you use cigars, cigarillos, or little cigars?" The last 30-day use of hookahs was evaluated by asking, "In the last 30 days, on the number of days did you smoke tobacco in a hookah or waterpipe?" The definition of smokeless tobacco was the use of chewing tobacco, snuff, dip and snus. The last 30-day use of smokeless tobacco was examined by asking questions on chewing tobacco, snuff, and dip: "In the last 30 days, number of days chewing tobacco was used, snuff, or dip?," and the question on use of snus: "In the last thirty days, which tobacco products was used on at least one day: snus, dissolvable tobacco products?." Feedback from the questions were combined to obtain the total smokeless tobacco use. The last thirty day use of pipe tobacco and bidis were evaluated by asking, "For the past thirty days, which of the tobacco products have you used for at least a day: pipe filled with tobacco (not waterpipe) and bidis?" † The total number of tobacco product users was rounded down to the nearest 10,000 persons. § Data was not statistically significant because the sample size was less than 50 or relative standard error was  more than 0.3. ¶ The use of any tobacco product can be defined as the use of any of the following tobacco products: electronic cigarettes, cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco, and/or bidis for at least a day in the last thirty days. ** Definition of 2 or more tobacco product use is the use of two or more tobacco products including electronic cigarettes, cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco, and/or bidis for at least one day in the last thirty days. †† Any combustible tobacco use can be defined as the use of tobacco products (cigarettes, cigars, hookahs, pipe tobacco, and/or bidis) on at least one day in the last thirty days.