Tobacco Product Use and Associated Factors Among Middle and High School Students — National Youth Tobacco Survey, United States, 2021

Morbidity and Mortality Weekly Report

Surveillance Summaries / Vol. 71 / No. 5 March 11, 2022

Tobacco Product Use and Associated Factors

Among Middle and High School Students —

National Youth Tobacco Survey, United States, 2021

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

Surveillance Summaries

The MMWR series of publications is published by the Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC),

U.S. Department of Health and Human Services, Atlanta, GA 30329-4027.

Suggested citation: [Author names; first three, then et al., if more than six.] [Title]. MMWR Surveill Summ 2022;71(No. SS-#):[inclusive page numbers].

Centers for Disease Control and Prevention

Rochelle P. Walensky, MD, MPH, Director

Debra Houry, MD, MPH, Acting Principal Deputy Director

Daniel B. Jernigan, MD, MPH, Deputy Director for Public Health Science and Surveillance

Rebecca Bunnell, PhD, MEd, Director, Office of Science

Jennifer Layden, MD, PhD, Deputy Director, Office of Science

Leslie Dauphin, PhD, Director, Center for Surveillance, Epidemiology, and Laboratory Services

MMWR Editorial and Production Staff (Serials)

Charlotte K. Kent, PhD, MPH, Editor in Chief

Christine G. Casey, MD, Editor

Mary Dott, MD, MPH, Online Editor

Terisa F. Rutledge, Managing Editor

David C. Johnson, Lead Technical Writer-Editor

Jeffrey D. Sokolow, MA, Project Editor

Martha F. Boyd, Lead Visual Information Specialist

Alexander J. Gottardy, Maureen A. Leahy,

Julia C. Martinroe, Stephen R. Spriggs,Tong Yang,

Visual Information Specialists

Quang M. Doan, MBA, Phyllis H. King,

Terraye M. Starr, Moua Yang,

Information Technology Specialists

MMWR Editorial Board

Timothy F. Jones, MD, Chairman

Matthew L. Boulton, MD, MPH

Carolyn Brooks, ScD, MA

Jay C. Butler, MD

Virginia A. Caine, MD

Jonathan E. Fielding, MD, MPH, MBA

David W. Fleming, MD

William E. Halperin, MD, DrPH, MPH

Jewel Mullen, MD, MPH, MPA

Jeff Niederdeppe, PhD

Celeste Philip, MD, MPH

Patricia Quinlisk, MD, MPH

Patrick L. Remington, MD, MPH

Carlos Roig, MS, MA

William Schaffner, MD

Nathaniel Smith, MD, MPH

Morgan Bobb Swanson, BS

Abbigail Tumpey, MPH

Ian Branam, MA,

Acting Lead Health Communication Specialist

Shelton Bartley, MPH, Leslie Hamlin,

Lowery Johnson, Amanda Ray,

Health Communication Specialists

Will Yang, MA,

Visual Information Specialist

CONTENTS

Introduction ............................................................................................................2

Methods

....................................................................................................................3

Results

.......................................................................................................................6

Discussion

............................................................................................................. 11

Limitations

............................................................................................................ 13

Conclusion

............................................................................................................ 13

References

............................................................................................................. 14

Surveillance Summaries

MMWR / March 11, 2022 / Vol. 71 / No. 5 1

US Department of Health and Human Services/Centers for Disease Control and Prevention

Tobacco Product Use and Associated Factors Among Middle and

High School Students — National Youth Tobacco Survey,

United States, 2021

Andrea S. Gentzke, PhD

; Teresa W. Wang, PhD

; Monica Cornelius, PhD

; Eunice Park-Lee, PhD

; Chunfeng Ren, PhD

; Michael D. Sawdey, PhD

;

Karen A. Cullen, PhD

; Caitlin Loretan, MPH

; Ahmed Jamal, MBBS

; David M. Homa, PhD

Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC;

Center for Tobacco Products,

Food and Drug Administration

Abstract

Problem/Condition: Commercial tobacco use is the leading cause of preventable disease, disability, and death in the United States.

Most tobacco product use begins during adolescence. In recent years, tobacco products have evolved to include various combusted,

smokeless, and electronic products.

Period Covered: 2021.

Description of System: The National Youth Tobacco Survey (NYTS) is an annual, cross-sectional, school-based, self-administered

survey of U.S. middle school (grades 6–8) and high school (grades 9–12) students. A three-stage cluster sampling procedure

is used to generate a nationally representative sample of U.S. students attending public and private schools. NYTS is the only

nationally representative survey of U.S. middle and high school students that focuses exclusively on tobacco use patterns and

associated factors. NYTS provides data to support the design, implementation, and evaluation of comprehensive youth tobacco use

prevention and control programs and to guide tobacco regulatory activities. Since 2019, NYTS has been administered electronically

via tablet computers. Because of emergency COVID-19 protocols that were in place across the United States during the 2021

NYTS fielding window (January 18–May 21, 2021), the 2021 survey was administered using a web URL to allow participation

by eligible students learning under varying instructional models (in-person, distance/virtual, and hybrid). In total, 50.8% of

student respondents reported completing the survey in a school building or classroom and 49.2% at home or some other place.

CDC and the Food and Drug Administration (FDA) analyzed data from the 2021 NYTS to assess tobacco product use patterns

and associated factors among U.S. middle and high school students. Overall, 20,413 students (out of 25,149 sampled students;

student response rate: 81.2%) completed the questionnaire from 279 schools (out of 508 sampled schools; school response rate:

54.9%). The overall response rate, defined as the product of the student and school response rates, was 44.6%. The sample was

weighted to represent approximately 11.97 million middle school students and 15.44 million high school students. Students with

missing information about grade level were excluded from the school-level analyses (n = 135).

Results: In 2021, an estimated 34.0% of high school students (5.22 million) and 11.3% of middle school students (1.34 million)

reported ever using a tobacco product (i.e., electronic cigarettes [e-cigarettes], cigarettes, cigars, smokeless tobacco, hookahs, pipe

tobacco, heated tobacco products, nicotine pouches, and bidis [small brown cigarettes wrapped in a leaf ]). Current (past 30-day)

use of a tobacco product was 13.4% for high school students (2.06 million) and 4.0% for middle school students (470,000).

E-cigarettes were the most commonly currently used tobacco product, cited by 11.3% of high school students (1.72 million)

and 2.8% of middle school students (320,000), followed by cigarettes, cigars, smokeless tobacco, hookahs, nicotine pouches,

heated tobacco products, and pipe tobacco. Current use of any tobacco product was reported by 14.2% of students identifying as

lesbian, gay, or bisexual (LGB) (versus 7.9% of heterosexual); 18.9% of students identifying as transgender (versus 8.2% of not

transgender); and 14.2% of students reporting severe psychological distress (versus 5.5% with no distress). Among students who

currently used each respective tobacco product, frequent use (on ≥20 days of the past 30 days) ranged from 17.2% for nicotine

pouches to 39.4% for e-cigarettes. Among current users of any tobacco product, 79.1% reported using a flavored tobacco product;

by product, e-cigarettes were the most commonly used flavored tobacco product. Among current users of any tobacco product,

the most commonly reported source of access was from a friend

(32.8%). Among students who currently used e-cigarettes,

53.7% used a disposable device, 28.7% used a prefilled/refillable

pod or cartridge device, 9.0% used a tank or mod system

(a system that can be customized by the user), and 8.6% did

Corresponding author: Andrea Gentzke, PhD, National Center for

Chronic Disease Prevention and Health Promotion, CDC. Telephone:

404-498-1795; E-mail: [email protected].

Surveillance Summaries

2 MMWR / March 11, 2022 / Vol. 71 / No. 5

US Department of Health and Human Services/Centers for Disease Control and Prevention

not know the device type. Among students who had ever used e-cigarettes, the most common reason for first trying them was “a

friend used them” (57.8%); among current e-cigarette users, the most commonly cited reason for current use was “I am feeling

anxious, stressed, or depressed” (43.4%). Among all middle and high school students, 75.2% reported past-year recognition of

any antitobacco public education campaign ads. Exposure to marketing or advertising for any tobacco product was reported by

75.7% of students who had contact with an assessed potential source of tobacco product advertisements or promotions (going to a

convenience store, supermarket, or gas station; using the Internet; watching television or streaming services or going to the movies;

or reading newspapers or magazines). Among students who reported using social media, 73.5% had ever seen e-cigarette–related

content. Among all students, perceiving “no” or “little” harm from intermittent tobacco product use was highest for e-cigarettes

(16.6%) and lowest for cigarettes (9.6%). Among students who currently used any tobacco product, 27.2% had experienced

cravings during the past 30 days; 19.5% reported wanting to use a tobacco product within 30 minutes of waking. Moreover,

65.3% of students who currently used tobacco products were seriously thinking about quitting the use of all products, and 60.2%

had stopped using all products for ≥1 day because they were trying to quit during the past 12 months.

Interpretation: In 2021, approximately one in 10 U.S. middle and high school students (9.3%) had used a tobacco product during

the preceding 30 days. By school level, this represented more than one in eight high school students (13.4%) and approximately

one in 25 middle school students (4.0%). E-cigarettes were the most commonly used tobacco product in 2021. Tobacco product

use was higher among certain subpopulations, such as those identifying as LGB or transgender, or those reporting psychological

distress. Importantly, approximately two thirds of students who currently used tobacco products were seriously thinking about

quitting. However, factors that might continue to promote tobacco product use among U.S. youths, such as the availability of

flavors, access to tobacco products, exposure to tobacco product marketing, and misperceptions about harm from tobacco product

use, remained prevalent in 2021.

Public Health Action: The continued monitoring of all forms of youth tobacco product use and associated factors through

surveillance efforts including NYTS is important to the development of public health policy and action at national, state, and local

levels. The 2021 NYTS was successfully administered during the COVID-19 pandemic using a web URL to allow participation

by eligible students learning under varying instructional models. As a result of these modifications to the fielding procedures,

any comparison of results between 2021 NYTS findings with previous years, including the direct attribution of any potential

changes in tobacco product use, is not possible. Parents, educators, youth advocates, and health care providers can help protect

youths from the harms of tobacco products, including e-cigarettes. In addition, the comprehensive and sustained implementation

of evidence-based tobacco control strategies, combined with FDA’s regulation of tobacco products, is important for reducing all

forms of tobacco product use among U.S. youths.

Introduction

Tobacco* product use is the leading cause of preventable

disease, disability, and death in the United States (1).

Preventing tobacco product use among youths is critical to

decreasing morbidity and mortality because almost all tobacco

product use begins during adolescence or young adulthood;

approximately nine in 10 adults who smoke cigarettes started

before age 18 years (1–3). In recent years, tobacco products

have evolved to include various combusted, smokeless, and

electronic products.

The National Youth Tobacco Survey (NYTS), conducted

periodically during 1999–2009 and annually since 2011,

provides national data on estimates of tobacco product use

* The term “tobacco” as used in this report refers to commercial tobacco products

and not to sacred and traditional use of tobacco by some American Indian

communities.

to support the design, implementation, and evaluation of

comprehensive youth tobacco prevention and control programs

and to inform tobacco regulatory activities in the United States

(4). NYTS is the only nationally representative survey of U.S.

middle (grades 6–8) and high school (grades 9–12) students

that focuses exclusively on tobacco product use.

This report presents findings from the 2021 NYTS and

describes the prevalence of youth tobacco product use and

associated factors, including flavored tobacco product use,

reasons for use, access to tobacco products, exposure to pro-

tobacco and antitobacco product marketing, harm perceptions,

urges to use tobacco products, and quitting behaviors. These

findings can be used by public health professionals, health care

providers, policymakers, parents, and other youth advocates to

prevent and reduce tobacco product use among U.S. youths.

Surveillance Summaries

MMWR / March 11, 2022 / Vol. 71 / No. 5 3

US Department of Health and Human Services/Centers for Disease Control and Prevention

Methods

NYTS Sampling Procedures

NYTS is a cross-sectional, school-based, self-administered

survey of U.S. middle and high school students (4). The 2021

NYTS sampling frame consisted of all regular public and

private schools with students enrolled in grades 6–12 in the

50 U.S. states and the District of Columbia. The sampling

frame comprised data obtained from Market Data Retrieval

(5) and the National Center for Education Statistics (6,7).

Alternative schools, special education schools, U.S. Department

of Defense–operated schools, Bureau of Indian Affairs schools,

vocational schools, and schools with a combined total of

<40 students in grades 6–12 were excluded. Across 16 previous

cycles of NYTS, school participation had averaged 80.8%

with a low of 49.9%. Student participation had averaged

89.5% with a low of 85.9%. Historical participation rates at

both school and student levels guided the sampling design

and projected sample sizes. However, a more robust approach

was used to calculate the projected sample sizes for the 2021

NYTS by assuming a more conservative overall response rate of

42.5%. The overall number of schools included in the sample

was increased to account for higher levels of anticipated school

refusals attributable to COVID-19 precautions. NYTS uses

a stratified, three-stage cluster sample design (4). All students

in the selected classes were eligible to participate in the survey;

students who were unable to complete the questionnaire

without special assistance were excluded.

Data Collection and Processing

Because of emergency COVID-19 protocols across the

United States, the 2021 NYTS was conducted using an

online survey to allow eligible students to participate while

at school or at home during a designated class period as part

of a class activity.

†

Participation in NYTS was voluntary at

both the school and student levels; parental consent and

student assent were required for NYTS participation. Students

logged into a secure website from a school-issued or personal

Internet-connected device, watched an instructional video,

and responded to a question regarding their current location

(e.g., classroom, home, or other location) before completing

†

In 2019, NYTS transitioned from a paper and pencil questionnaire to an

electronic survey. The 2019 and 2020 NYTS were conducted offline using

provided tablet computers in schools; data collection was supported by trained

survey administrators (4). This methodology was not feasible for the 2021

NYTS because of the implementation of emergency COVID-19 protocols across

the country, including various school instructional models (in-person, distance/

virtual, and hybrid), restricted visitor access at schools, travel restrictions, and

other factors.

the survey. Data were transmitted directly to a secure server.

Data collection procedures were supported by trained, off-site

technical assistance providers who maintained regular contact

with selected schools and teachers before, during, and after

data collection activities. Students or whole classes that were

unable to participate during the primary data collection period

were asked to take the survey at the next possible opportunity.

The 2021 NYTS was reviewed and approved by the Office

of Management and Budget, the contracted data collectors’

institutional review board (IRB), and CDC’s IRB.

The 2021 survey included 166 questions covering

demographic information, tobacco product use behaviors,

knowledge of and attitudes toward tobacco use, exposure to

protobacco and antitobacco media and advertising, access to

tobacco products, nicotine dependence, cessation attempts,

exposure to secondhand smoke and e-cigarette aerosol, harm

perceptions, exposure to tobacco product health warnings, and

other tobacco-related topics. At the beginning of each tobacco

product section, a description of the product, including

example brands and generic images, was provided. Respondents

did not answer all questions because of questionnaire skip

patterns. Respondents could skip any question or end the

survey at any time.

Survey administration occurred during January 18, 2021–

May 21, 2021. The final sample consisted of 508 schools,

of which 279 participated (school response rate: 54.9%);

20,413 student questionnaires were completed out of a

sample of 25,149 students (student response rate: 81.2%).

Student response rates varied by school instructional model;

student response rates were 85.8% among schools with

in-person instruction (n = 69 participating schools), 77.9% in

schools with exclusive distance learning or virtual instruction

(n = 68 participating schools), and 81.4% for schools with

hybrid instruction (n = 142 participating schools). Hybrid

student instructional models define instances in which some

educational instruction happened in person and some happened

virtually. This included various scenarios, including all students

alternating between in-person and virtual learning or a portion

of students receiving in-person instruction at all times and the

remaining students receiving virtual instruction at all times. The

overall response rate for the 2021 NYTS, defined as the product

of the school-level and student-level response rates, was 44.6%.

After exclusion of outliers, the average survey completion time

was approximately 22 minutes. A weighting factor was applied

to each student record to adjust for nonresponse and for varying

probabilities of selection. Weights were adjusted to ensure that

the weighted proportions of students in each grade matched

45 C.F.R. part 46; 21 C.F.R. part 56.

Surveillance Summaries

4 MMWR / March 11, 2022 / Vol. 71 / No. 5

US Department of Health and Human Services/Centers for Disease Control and Prevention

national population proportions. Additional information

on the NYTS sampling design, recruitment procedures, and

data weighting is available (https://www.cdc.gov/tobacco/

data_statistics/surveys/nyts/index.htm).

Measures

Ever and Current Tobacco Product Use

Nine tobacco products were assessed: electronic cigarettes

(e-cigarettes), cigarettes, cigars (cigars, cigarillos, and little

cigars), smokeless tobacco (chewing tobacco, snuff, dip, snus,

and dissolvable tobacco products), hookahs, pipe tobacco, bidis

(small brown cigarettes wrapped in a leaf ), heated tobacco

products (HTPs), and nicotine pouches (pouches containing

nicotine powder that comes from tobacco, which users place

in their mouth). For each product, ever use was defined as

ever using the product, and current use was defined as use on

≥1 day during the past 30 days. Any tobacco product use was

defined as use of one or more of the nine tobacco products.

Use of two or more tobacco products was defined as use of

two or more of the nine tobacco products. Any combustible

tobacco product use was defined as use of one or more of the

following: cigarettes, cigars, hookahs, pipe tobacco, and bidis.

Demographic Factors

Demographic covariates assessed included sex (female or

male), race and ethnicity (non-Hispanic White, non-Hispanic

Black, Hispanic, or non-Hispanic other race), sexual identity

(heterosexual; lesbian, gay, or bisexual [LGB]; or not sure), and

whether the respondent identified as transgender (no, yes, not

sure, or don’t know what this question is asking).

Social Determinant Indicators

Social determinant indicators included academic status in

school (mostly As, Bs, Cs, Ds, or Fs), and speaking a language

other than English at home (yes or no). Additionally, a

composite scale made up of four questions was used to assess

psychological distress: “During the past two weeks, how often

have you been bothered by any of the following problems?”

1) “little interest or pleasure in doing things”; 2) “feeling down,

depressed, or hopeless”; 3) “feeling nervous, anxious, or on

edge”; and 4) “not being able or stop or control worrying.”

For each item, response options were numerically coded (not

at all=0; several days=1; more than half of the days=2;

nearly every day=3), summed (range: 0–12), and categorized

as none (0–2), mild (3–5), moderate (6–8), or severe (9–12).

Furthermore, a composite scale made up of four questions was

used to assess family affluence. Numeric values were assigned

to question responses as follows: 1) “Does your family own a

vehicle (such as a car, van, or truck)?” [no=0; yes, one=1;

yes, two or more=2]; 2) “Do you have your own bedroom?”

[no=0; yes=1]; 3) “How many computers (including laptops

and tablets, not including game consoles and smartphones)

does your family own?” [none=0; one=1; two=2; more

than two=3]; and 4) “During the past 12 months, how many

times did you travel on vacation with your family?” [not at

all=0; once=1; twice=2; more than twice=3]. Responses

were summed (range: 0–9) and categorized into approximate

tertiles based on the weighted distribution of scores in this

sample as low (0–5), medium (6–7), and high (8–9).

Frequency of Tobacco Product Use

Respondents who reported ever use of any tobacco product

were asked, “During the past 30 days, on how many days did

you [use e-cigarettes; smoke cigarettes; smoke cigars, cigarillos,

or little cigars; use chewing tobacco, snuff, or dip; use snus;

use dissolvable tobacco products; smoke tobacco in a hookah

or water pipe; smoke pipes filled with tobacco; use an HTP;

or use a nicotine pouch].” Response options ranged between

0 and 30 days. Response options were categorized as 1–5 days,

6–19 days, and 20–30 days. Frequent use was defined as using

a product on ≥20 days of the past 30 days.

Flavored Tobacco Product Use

For each tobacco product (excluding cigarettes), current

users were asked, “Were any of the [tobacco product] that

you used in the past 30 days flavored to taste like menthol,

mint, clove or spice, alcoholic drinks, candy, fruit, chocolate,

or any other flavor?” Response options were “yes,” “no,” and

“don’t know.” Those who responded “yes” were categorized

as a current flavored product user. Current flavored tobacco

product users were asked, “What flavors were the [tobacco

product] that you have used in the past 30 days? (Select one

or more).” Response options were “menthol,” “mint,” “clove

or spice,” “fruit,” “chocolate,” “alcoholic drinks (such as wine,

margarita, or other cocktails),” “candy, desserts, or other

sweets,” and “some other flavor not listed here.” Those who

selected “some other flavor not listed here” could provide a

write-in response; write-in responses corresponding to an

original response option were recoded.

For cigarettes, current users were categorized as flavored

(menthol) cigarette smokers if they responded “yes” to the

question, “Menthol cigarettes are cigarettes that taste like mint.

During the past 30 days, were the cigarettes that you usually

smoked menthol?” or if they indicated “Kool” or “Newport”

as their usual cigarette brand during the past 30 days. Usual

cigarette brand was determined based on responses to two

questions: “During the past 30 days, what brands of cigarettes

did you smoke? (Select one or more)” and “During the past

30 days, what brand of cigarettes did you usually smoke?

Surveillance Summaries

MMWR / March 11, 2022 / Vol. 71 / No. 5 5

US Department of Health and Human Services/Centers for Disease Control and Prevention

(Choose only one answer).” If “Kool” or “Newport” was the

only brand selected for the first question, or if multiple brands

were selected in the first question and “Kool” or “Newport”

was selected for the second question, “Kool” or “Newport”

was considered the respondent’s usual brand.

E-Cigarette Device Type

Respondents who reported current use of e-cigarettes were

asked, “Which of the following best describes the type of

e-cigarette you have used in the past 30 days? If you have used

more than one type, please think about the one you use most

often.” Response options were “A disposable e-cigarette (for

example, Puff Bar or Stig),” “An e-cigarette that uses pre-filled

or refillable pods or cartridges (for example, Juul, Smok, or

Suorin),” “An e-cigarette with a tank that you refill with liquids

(including mod systems that can be customized by the user),”

and “I don’t know the type.”

Reasons for E-Cigarette Use

Respondents who had ever used e-cigarettes were asked,

“Why did you first use an e-cigarette?” Respondents who

reported current e-cigarette use were further asked, “Why do

you currently use e-cigarettes?” For both questions, respondents

could select one or more of 14 specified reasons. Respondents

who indicated, “I used/use them for some other reasons” to

either question could specify a write-in response; analyses of

write-in responses were not included in this report.

Access to Tobacco Products

For each tobacco product, access sources were assessed by

two questions: “During the past 30 days, how did you get your

[tobacco product]?” (respondents could select one or more of

eight specified responses) and “During the past 30 days, where

did you buy your [tobacco product]?” (respondents could select

one or more of 12 specified responses). Respondents could

specify a write-in response; analyses of write-in responses were

not included in this report.

Recognition of Public Education Campaigns

Against Tobacco Product Use

All respondents were asked two questions regarding public

education campaigns against tobacco product use: “In the

past 12 months, have you seen or heard The Real Cost, on

television, the Internet, social media, or radio as part of ads

about tobacco?” (response options were yes, no, or not sure)

and “In the past 12 months, have you seen or heard any other

ads against tobacco with the following names or slogans

on television, the Internet, social media, or on the radio?”

Respondents could select one or more of “Truth,” “Tips or

Tips from Former Smokers,” “Fresh Empire,” “This Free Life,”

or “some other ad” or could select “I haven’t seen or heard any

of these ads.” Those who indicated having seen “some other

ad” could specify with a write-in response; analyses of write-in

responses were not included in this report. A composite of

having recognized at least one ad against tobacco product use

from a specified response option also was generated.

Exposure to Tobacco Product Marketing

Exposure to tobacco product marketing (advertisements

or promotions) was assessed separately for e-cigarettes and

cigarettes or other tobacco products for four sources: retail

stores; Internet; television, streaming services, or movies; and

newspapers or magazines. Respondents were asked, “When

you [are using the Internet; read newspapers or magazines;

go to a convenience store, supermarket, or gas station; watch

television or streaming services (such as Netflix, Hulu, or

Amazon Prime), or go to the movies], how often do you see

ads or promotions for [e-cigarettes; cigarettes or other tobacco

products]?” Respondents were categorized as exposed if they

responded “sometimes,” “most of the time,” or “always” or

unexposed if they responded “never” or “rarely.” Those who

reported “I do not use the Internet,” “I do not read newspapers

or magazines,” “I never go to a convenience stores, supermarket,

or gas station,” or “I do not watch TV or streaming services or

go to the movies” were excluded from the analysis.

E-Cigarette Content on Social Media

All respondents were asked, “How often do you use social

media?” Respondents who reported a response other than

“never/I don’t use social media” were asked, “When you

use social media, how often 1) “do you see posts or content

(pictures, videos, or text) related to e-cigarettes?”; 2) “do

you post pictures or videos of yourself or someone else

using e-cigarettes?”; and 3) “have you liked, commented, or

shared posts or content (pictures, videos, or text) related to

e-cigarettes?” For each question, response options were “never,”

“less than monthly,” “monthly,” “weekly,” or “daily.”

Harm Perceptions

The 2021 NYTS assessed harm perceptions for five tobacco

products: e-cigarettes; cigarettes; cigars, cigarillos, or little

cigars; smokeless tobacco (chewing tobacco, snuff, dip, snus,

or dissolvable tobacco products); and hookahs. All respondents

were asked, “How much do you think people harm themselves

when they (use e-cigarettes; smoke cigarettes; smoke cigars,

cigarillos, or little cigars; use chewing tobacco, snuff, dip,

snus, or dissolvable tobacco products; or smoke tobacco in a

hookah or water pipe) some days but not every day?” Response

options were “no harm,” “little harm,” “some harm,” and “a

lot of harm.”

Surveillance Summaries

6 MMWR / March 11, 2022 / Vol. 71 / No. 5

US Department of Health and Human Services/Centers for Disease Control and Prevention

Dependence and Cessation Indicators

Urges to Use Tobacco Products

Students who currently used any tobacco product were

asked, “During the past 30 days, have you had a strong craving

or felt like you really needed to use a tobacco product of any

kind?” (yes or no); and “How soon after you wake up do you

want to use a tobacco product of any kind?” Response options

were dichotomized as wanting to use a tobacco product within

30 minutes (“within 5 minutes” or “from 6 to 30 minutes,”) or

not (“from more than 30 minutes to 1 hour,” “after more than

1 hour but less than 24 hours,” “I rarely want to use tobacco

products,” or “I do not want to use tobacco products”).

Quitting Behaviors

Students who currently used any tobacco product were

asked, “Are you seriously thinking about quitting the use of all

tobacco products?” Responses were dichotomized as yes (“yes,

during the next [30 days; 6 months; 12 months]” or “yes, but

not during the next 12 months”) or no (“no, I am not thinking

about quitting the use of all tobacco products”). Students who

currently used any tobacco product were asked, “During the

past 12 months, how many times have you stopped using

all tobacco products for one day or longer because you were

trying to quit all tobacco products for good?” Responses were

dichotomized as making a past-year quit attempt (“1 time,”

“2 times,” “3–5 times,” “6–9 times,” or “10 or more times”)

or not making an attempt (“I did not try to quit all tobacco

products during the past 12 months”).

Analyses

Statistical analyses were conducted by using SAS-callable

SUDAAN software (version 11.0.1; RTI International) to

account for the complex sampling design. Weighted prevalence

estimates and 95% CIs were computed for all measures; when

applicable, population totals were estimated from probability

weights. Results with unweighted denominators <50 or a relative

standard error >30% are not reported. Comparisons of estimates

from the 2021 NYTS with previous years were not possible

because of the modifications to the fielding procedures in 2021

in response to the COVID-19 pandemic. The 20,413 student

records were weighted to represent approximately 27.56 million

students. On the basis of self-reported grade level, this included

9,763 middle school students (11.97 million) and 10,515 high

school students (15.44 million); 135 students with missing

information on grade level were excluded from school-level

analyses. Overall, 50.8% of student respondents reported

completing the survey in a school building or classroom and

49.2% at home or some other place.

Results

Ever Tobacco Product Use

In 2021, among U.S. middle and high school students,

24.1% (6.6 million) reported ever use of a tobacco product

(high school: 34.0%, 5.22 million; middle school: 11.3%,

1.34 million) (Table 1). Among students who ever used

a tobacco product, 49.4% (3.2 million) had ever used a

combustible tobacco product and 41.5% (2.74 million) had

ever used two or more tobacco product types. E-cigarettes

were the most commonly ever used tobacco product overall

(19.4%; 5.3 million), followed by cigarettes (8.1%), cigars

(5.2%), smokeless tobacco (3.6%), hookahs (2.8%), nicotine

pouches (1.9%), HTPs (1.8%), and pipe tobacco (1.0%). Ever

use of any tobacco product was reported by 28.0% of middle

and high school students who reported taking the survey in

a school or classroom and 20.5% of middle and high school

students who reported taking the survey at home or some other

place ( data not shown).

Current Tobacco Product Use

Overall, among middle and high school students, 9.3%

(2.55 million) reported current (past 30-day) use of any

tobacco product (Table 2). Among students who currently

used any tobacco product, 34.4% (860,000) currently used any

combustible tobacco product and 29.0% (740,000) currently

used two or more tobacco product types. E-cigarettes were

the most commonly used tobacco product overall (7.6%;

2.06 million), followed by cigarettes (1.5%), cigars (1.4%),

smokeless tobacco (0.9%), hookahs and nicotine pouches

(both 0.8%), HTPs (0.7%), and pipe tobacco (0.3%). Current

use of any tobacco product was reported by 11.7% of middle

and high school students who reported taking the survey in

a school or classroom and 6.9% of middle and high school

students who reported taking the survey at home or some

other place.

Among high school students, 13.4% (2.06 million) reported

current use of any tobacco product (Figure 1). Among high

school students who currently used tobacco products, 32.8%

(660,000) currently used any combustible tobacco product and

28.4% (580,000) currently used two or more tobacco product

types. Among high school students, e-cigarettes were the most

commonly used tobacco product (11.3%; 1.72 million),

followed by cigars (2.1%), cigarettes (1.9%), hookahs and

smokeless tobacco (both 1.2%), nicotine pouches (1.1%),

HTPs (0.8%), and pipe tobacco (0.4%).

Among middle school students, 4.0% (470,000) reported

current use of any tobacco product. Among middle school

Surveillance Summaries

MMWR / March 11, 2022 / Vol. 71 / No. 5 7

US Department of Health and Human Services/Centers for Disease Control and Prevention

FIGURE 1. Percentage of middle and high school students who reported current (past 30-day) use of select tobacco products,* any tobacco product,

†

any combustible tobacco product,

or two or more tobacco product types,

by school level** and overall — National Youth Tobacco Survey,

United States, 2021

100

Overall High school Middle school

Percentage

School level

Any tobacco product

Any combustible tobacco product

≥2 tobacco products

E-cigarettes

Cigarettes

Cigars

Smokeless tobacco

Hookahs

Nicotine pouches

Heated tobacco products

Pipe tobacco

Abbreviation: e-cigarettes = electronic cigarettes.

* Past 30-day use of e-cigarettes was determined by asking, “During the past 30 days, on how many days did you use e-cigarettes?” Past 30-day use of cigarettes was

determined by asking, “During the past 30 days, on how many days did you smoke cigarettes?” Past 30-day use of cigars was determined by asking, “During the

past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?” Smokeless tobacco was defined as use of chewing tobacco, snuff, dip, snus, or

dissolvable tobacco products. Past 30-day use of smokeless tobacco was determined by asking, “During the past 30 days, on how many days did you use [chewing

tobacco, snuff, or dip /snus/dissolvable tobacco products]?” Responses from these questions were combined to derive overall smokeless tobacco use. Past 30-day

use of hookahs was determined by asking, “During the past 30 days, on how many days did you smoke tobacco in a hookah or water pipe?” Past 30-day use of

nicotine pouches was determined by asking, “During the past 30 days, on how many days did you use nicotine pouches?” Past 30-day use of heated tobacco

products was determined by asking, “During the past 30 days, on how many days did you use heated tobacco products?” Past 30-day use of pipe tobacco (not

hookahs) was determined by asking, “In the past 30 days, on how many days did you smoke pipes filled with tobacco?” Because of missing data on the past 30-day

use questions, denominators for each tobacco product might be different. For each product, current use was defined as self-reported use on ≥1 day during the

past 30 days.

†

Any tobacco product use was defined as use of any tobacco product (e-cigarettes, cigarettes, cigars [cigars, cigarillos, or little cigars], smokeless tobacco [chewing

tobacco, snuff, dip, snus, or dissolvable tobacco products], hookahs, pipe tobacco, heated tobacco products, nicotine pouches, or bidis [small brown cigarettes

wrapped in a leaf]) on ≥1 day during the past 30 days.

Any combustible tobacco product use was defined as use of cigarettes, cigars (cigars, cigarillos, or little cigars), hookahs, pipe tobacco, or bidis on ≥1 day during

the past 30 days.

Defined as use of two or more tobacco products (e-cigarettes, cigarettes, cigars [cigars, cigarillos, or little cigars], smokeless tobacco [chewing tobacco, snuff, dip,

snus, or dissolvable tobacco products], hookahs, pipe tobacco, heated tobacco products, nicotine pouches, or bidis) on ≥1 day during the past 30 days.

** Overall estimates were reported among 20,413 U.S. middle and high school students. School level was determined by self-reported grade level: high school

(grades 9–12; n = 10,515) and middle school (grades 6–8; n = 9,763).

students who currently used tobacco products, 40.0%

(190,000) currently used any combustible tobacco product

and 32.5% (150,000) currently used two or more tobacco

product types. Among middle school students, e-cigarettes were

the most commonly used tobacco product (2.8%; 320,000),

followed by cigarettes (1.0%), cigars and smokeless tobacco

(both 0.6%), hookahs and HTPs (both 0.4%), nicotine

pouches (0.3%), and pipe tobacco (0.2%).

Social Determinant Indicators

Ever Tobacco Product Use

By race and ethnicity, ever use of any tobacco product was

reported by 26.7% of students who were non-Hispanic White,

22.4% of students who were Hispanic, 21.9% of students who

were non-Hispanic Black, and 16.1% of students who were

non-Hispanic other race (Table 1). Ever use of any combustible

tobacco product was reported by 14.0% of students who

Surveillance Summaries

8 MMWR / March 11, 2022 / Vol. 71 / No. 5

US Department of Health and Human Services/Centers for Disease Control and Prevention

were non-Hispanic Black, 12.6% of students who were non-

Hispanic White, 10.4% of students who were Hispanic, and

8.3% of students who were non-Hispanic other race.

Ever use of any tobacco product was reported by 35.4% of

students identifying as LGB, 22.8% of those identifying as

heterosexual, and 14.4% of those who were not sure (Table 3)

and 37.9% of those identifying as transgender, 23.4% of those

identifying as not transgender, and 26.4% of those who were

not sure.

For psychological distress, prevalence of ever use of any

tobacco product ranged from 16.6% (none) to 37.8% (severe)

(Table 3). Prevalence was similar for low (24.4%), medium

(22.3%), and high (24.0%) family affluence. Prevalence of ever

use of any tobacco product increased as self-reported grades

in school declined (mostly As: 18.3% to mostly Fs: 41.7%).

Ever use was 24.5% for students who spoke English at home

and 20.5% for those who spoke another language at home.

Current Tobacco Product Use

By race and ethnicity, current use of any tobacco product

was reported by 11.0% of students who were non-Hispanic

White, 8.2% of students who were non-Hispanic Black,

7.4% of students who were Hispanic, and 5.4% of students

who were non-Hispanic other race (Table 2). Current use of

any combustible tobacco product was reported by 5.2% of

students who were non-Hispanic Black, 3.1% of students

who were non-Hispanic White, and 2.8% of students who

were Hispanic.

Overall, current use of any tobacco product was reported

by 14.2% of students identifying as LGB, 7.9% of those

identifying as heterosexual, and 5.5% of those who were not

sure (Table 3) and 18.9% of those identifying as transgender,

8.2% of those identifying as not transgender, and 9.1% of

those who were not sure.

By psychological distress, prevalence of current use of any

tobacco product ranged from 5.5% (none) to 14.2% (severe)

(Table 3). Current use was similar for low (9.2%), medium

(7.7%), and high (8.8%) family affluence. Prevalence of

current use of any tobacco product increased with declining

self-reported grades in school (mostly As: 5.5% to mostly Fs:

17.3%). Current use of any tobacco product was 9.2% for

students who spoke English in the home and 6.4% for those

spoke another language at home.

Frequency of Tobacco Product Use

Among students who currently used each tobacco product,

frequent use (on ≥20 of the past 30 days) was 39.4% (810,000)

for e-cigarettes, 29.5% (50,000) for chewing tobacco, snuff,

or dip, 26.1% (20,000) for snus, 22.1% (30,000) for HTPs,

20.7% (80,000) for cigars, 19.9% (40,000) for hookahs,

18.9% (70,000) for cigarettes, and 17.2% (30,000) for nicotine

pouches (Table 4). For nearly all tobacco products, more than

half of students who currently used the products reported using

them on 1–5 days of the past 30 days.

Flavored Tobacco Product Use

Among students who currently used any tobacco product,

79.1% (high school: 80.2%; middle school: 74.6%) reported

using flavored tobacco product(s) in the past 30 days (Table 5).

Among students who currently used each tobacco product,

use of a flavored product was 84.7% for e-cigarettes, 70.1%

for smokeless tobacco, 61.6% for nicotine pouches, 46.6%

for hookahs, 44.4% for cigars, 44.0% for HTPs, 38.8% for

cigarettes (menthol only), and 34.4% for pipe tobacco.

Among students who currently used each flavored tobacco

product, fruit was the most commonly reported flavor type

for e-cigarettes (71.6%), hookahs (73.5%), cigars (65.0%),

and HTPs (46.4%) (Figure 2) (Supplementary Table 1;

https://stacks.cdc.gov/view/cdc/114659); mint was the most

commonly reported flavor type for smokeless tobacco (69.2%)

and nicotine pouches (53.5%). Menthol use was reported as

50.2% for nicotine pouches, 38.8% for cigarettes, 38.2% for

smokeless tobacco, 28.8% for e-cigarettes, 26.5% for HTPs,

21.0% for cigars, and 17.0% for hookahs.

E-Cigarette Device Type

Among students who currently used e-cigarettes, disposable

e-cigarettes were the most commonly used device type (overall:

53.7%, 1.08 million; high school: 55.8%, 940,000; middle

school: 43.8%, 130,000), followed by prefilled or refillable

pods or cartridges (overall: 28.7%, 570,000; high school:

28.9%, 480,000; middle school: 27.8%, 80,000), and tanks

or mod systems (overall: 9.0%, 180,000; high school: 7.5%,

120,000; middle school: 15.6%, 40,000) (Figure 3). Estimates

of e-cigarette device type by sex and race or ethnicity are

provided (Supplementary Table 2; https://stacks.cdc.gov/view/

cdc/114659).

Reasons for E-Cigarette Use

Among students who ever used e-cigarettes, the most

common reasons for first use were “a friend used them”

(57.8%), “I was curious about them” (47.6%), “I was feeling

anxious, stressed, or depressed” (25.1%), and “to get a high or

buzz from nicotine” (23.3%) (Table 6). The most commonly

reported reason for first use among high school students was

“a friend used them” (60.6%) and was “I was curious about

them” (49.4%) for middle school students.

Surveillance Summaries

MMWR / March 11, 2022 / Vol. 71 / No. 5 9

US Department of Health and Human Services/Centers for Disease Control and Prevention

FIGURE 2. Flavor types* used among middle and high school students who reported current (past 30-day) use of flavored tobacco products,

by product

†,§,¶

— National Youth Tobacco Survey, United States, 2021

100

E-cigarettes Cigars Smokeless tobacco Hookahs Heated tobacco products Nicotine pouches

Percentage

Tobacco product

Fruit

Candy/Desserts/Sweets

Mint

Menthol

Some other avor

Alcoholic drinks

Chocolate

Clove/Spice

Abbreviation: e-cigarettes = electronic cigarettes.

* For each respective tobacco product excluding cigarettes (e-cigarettes, cigars [cigars, cigarillos, or little cigars], smokeless tobacco [chewing tobacco, snuff, or dip;

snus; dissolvable tobacco products], hookahs, pipe tobacco, heated tobacco products, nicotine pouches), current (past 30-day) users were asked, “Were any of the

[tobacco product] that you used in the past 30 days flavored to taste like menthol, mint, clove or spice, alcohol (wine, cognac), candy, fruit, chocolate, or any other

flavor?” (response options were “yes,” “no,” or “don’t know”). Those who responded yes were then asked, “What flavors were the [tobacco product] that you have used

in the past 30 days? (Select one or more).” Response options were menthol, mint, clove or spice, alcoholic drinks (such as wine, cognac, margarita, or other cocktails),

candy, desserts, or other sweets, fruit, chocolate, and some other flavor not listed here (write-in responses). Write-in responses were examined and recoded to a

prespecified response option where applicable.

†

For cigarettes, flavored use refers to menthol cigarette use only. All other flavor types for cigarettes are not applicable. Menthol cigarette use is omitted from this figure.

For smokeless tobacco, flavor types were assessed separately among flavored chewing tobacco, snuff, or dip; snus; and dissolvable tobacco product users. Flavor

types were then assessed as a composite among current users of chewing, snuff, dip, snus or dissolvable tobacco products.

Data are not shown as they were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%: smokeless tobacco: clove or

spice; hookahs: some other flavor, alcoholic drinks, chocolate, clove or spice; heated tobacco products: mint, some other flavor, alcoholic drinks, chocolate, clove or

spice; nicotine pouches: fruit; candy, desserts, or sweets; some other flavor; alcoholic drinks; chocolate; or clove or spice. All estimates of flavor types used for pipe

tobacco were statistically unreliable and are omitted from this figure.

Among students who currently used e-cigarettes, the most

common reasons for current use were “I am feeling anxious,

stressed, or depressed” (43.4%), “to get a high or buzz from

nicotine” (42.8%), “a friend uses them” (28.3%), and “I can

use them to do tricks” (20.0%) (Table 6). The most commonly

reported reason for current use was “to get a high or buzz

from nicotine” (45.3%) among high school students and

“I am feeling anxious, stressed, or depressed” (45.0%) among

middle school students.

Access to Tobacco Products

Among students who currently used any tobacco product,

during the past 30 days, 32.8% got their products from a

friend, 31.3% bought the products themselves, 28.8% had

someone else buy the products for them, and 26.3% had

someone offer the products to them (Table 7).

By purchase locations, 22.5% of students who currently

used tobacco products reported purchasing from another

person (friend, family member, or someone else), 20.2% from

vape shops or tobacco shops, and 19.6% from gas stations or

convenience stores; 48.6% of current tobacco product users

did not purchase the products they used in the past 30 days.

Surveillance Summaries

10 MMWR / March 11, 2022 / Vol. 71 / No. 5

US Department of Health and Human Services/Centers for Disease Control and Prevention

FIGURE 3. E-cigarette device types* reported among middle and high school students who reported current (past 30-day) use of e-cigarettes,

overall and by school level — National Youth Tobacco Survey, United States, 2021

100

Disposable e-cigarette Prelled or rellable

pod or cartridge

Tank or mod system Don't know

Percentage

E-cigarette device type

Overall High school Middle school

Abbreviation: e-cigarettes = electronic cigarettes.

* Device type among current e-cigarette users was assessed by the question, “Which of the following best describes the type of e-cigarette you have used in the

past 30 days? If you have used more than one type, please think about the one you use most often. Response options included the following: “a disposable

e-cigarette (for example, Puff Bar or Stig),” “an e-cigarette that uses pre-filled or refillable pods or cartridges (for example, Juul, Smok, or Suorin),” “an e-cigarette

with a tank that you refill with liquids (including mod systems that can be customized by the user),” and “I don’t know the type.”

†

Past 30-day use of e-cigarettes was determined by asking, “During the past 30 days, on how many days did you use e-cigarettes?” Those indicating use on ≥1 day

of the past 30 days were considered current user of the respective product.

Recognition of Public Education

Campaigns Against Tobacco Product Use

Among all students, 75.2% (high school: 79.4%; middle

school: 69.8%) had seen or heard at least one public education

campaign against tobacco product use within the past year

(Table 8). Recognition was 78.3% among males, 71.9% among

females, and ranged from 67.6% among students who were

non-Hispanic other race to 79.2% among students who were

non-Hispanic White. Recognition was 60.9% for “The Real

Cost,” 39.7% for “Truth,” 19.8% for “Tips” or “Tips from

Former Smokers,” 6.9% for “Fresh Empire,” 4.8% for “This

Free Life,” and 11.7% for “some other ad.”

Exposure to Tobacco Product Marketing

Among students who reported contact with a potential

source of tobacco product marketing, 75.7% (high school:

79.6%; middle school: 70.7%) reported exposure to any

tobacco product marketing from one or more of these sources

(Table 9). The prevalence of exposure was 65.4% among

students who reported going to retail stores, 43.9% among

those who reported using the Internet, 34.0% among those

who reported reading newspapers or magazines, and 30.3%

among those who reported watching television or streaming

services or going to the movies. Overall, 70.3% of middle and

high school students reported exposure to e-cigarette marketing

specifically, whereas 59.1% reported exposure to cigarette or

other tobacco product marketing.

Surveillance Summaries

MMWR / March 11, 2022 / Vol. 71 / No. 5 11

US Department of Health and Human Services/Centers for Disease Control and Prevention

E-Cigarette Content on Social Media

In total, 91.5% (23.06 million) of U.S. middle and high

school students reported using social media. Among all social

media users, 73.5% (high school: 80.0%; middle school:

64.5%) reported ever seeing e-cigarette-related posts or

content; 13.7% (high school: 16.3%; middle school: 10.1%)

reported seeing e-cigarette–related content daily (Table 10).

An estimated 14.4% of social media users in middle and high

school reported posting pictures or videos of e-cigarette use

by themselves or others; 26.1% reported otherwise engaging

(liking, commenting, or sharing) with e-cigarette–related

content on social media.

Harm Perceptions

Among all students, the percentage who reported that

intermittent use of tobacco products causes a lot of harm was

highest for smokeless tobacco (48.3%), followed by cigarettes

(47.0%), hookahs (42.0%), e-cigarettes (41.8%), and cigars

(41.5%) (Figure 4). The percentage of students who reported

that intermittent use causes no harm or little harm was highest

for e-cigarettes (16.6%) and lowest for cigarettes (9.6%).

Estimates of harm perceptions for each tobacco product by

school level are provided (Supplementary Table 3; https://

stacks.cdc.gov/view/cdc/114659).

Dependence and Cessation Indicators

Among students who currently used any tobacco product,

27.2% (high school: 27.1%; middle school: 28.1%) reported

experiencing cravings for tobacco product of any kind during

the past 30 days (Table 11). Overall, 19.5% (high school:

21.8%; middle school: 9.4%) of students who currently used

any tobacco product reported wanting to use a tobacco product

within 30 minutes of waking.

Among students who currently used any tobacco product,

65.3% (high school: 64.9%; middle school: 67.6%) reported

that they were seriously thinking about quitting all tobacco

products. In addition, 60.2% (high school: 58.2%; middle

school: 68.4%) of current tobacco product users overall reported

that they stopped using all tobacco products for ≥1 day during

the past 12 months because they were trying to quit.

Discussion

Public Health Implications

Findings from the 2021 NYTS indicate that approximately

one in four students (24.1%), including approximately one in

three high school students (34.0%) and one in nine middle

school students (11.3%), had ever used a tobacco product.

Furthermore, approximately one in 10 students (9.3%),

including more than one in eight high school students (13.4%)

and one in 25 middle school students (4.0%), had used a

tobacco product during the past 30 days. Approximately

three in 10 students (29.0%) who currently used any tobacco

product reported using two or more tobacco products during

the past 30 days; youths who use multiple tobacco products are

at higher risk for developing nicotine dependence and might

be more likely to continue using tobacco into adulthood (1,2).

Most youths who currently use tobacco products are not daily

users (8–10). However, even infrequent tobacco product use can

lead to symptoms of nicotine dependence (11). Additionally,

in 2021, approximately four in 10 youths who currently used

e-cigarettes, and more than 20% of youths who currently used

cigars, chewing tobacco, snuff, or dip, snus, and HTPs, used

them frequently (on ≥20 of the past 30 days). Furthermore,

for the first time in 2021, NYTS documented use of nicotine

pouches among youths, an emerging tobacco product which

contains nicotine powder that dissolves in the mouth without

spitting. Nicotine pouches do not contain any tobacco leaf,

are available in various flavors, deliver high levels of nicotine

by way of nicotine salts, and have had rapidly increasing sales

in recent years (12). Although youths’ use of nicotine pouches

was low in 2021, these baseline data are needed for future

monitoring to inform local, state, and federal public health

policy and practice. Youth use of tobacco products in any form

is unsafe, regardless of whether the products are combustible,

smokeless, or electronic (2,3). Continued efforts are warranted

to prevent and reduce all forms of tobacco product use among

U.S. youths.

This study highlighted disparities in tobacco product use

among U.S. youths. Current use of any tobacco product,

overall, was highest among students who were non-Hispanic

White, followed by non-Hispanic Black, Hispanic, and

students of non-Hispanic other race. However, among all race

and ethnicity groups, non-Hispanic Black students reported

the highest prevalence of current combustible tobacco product

use (5.2%), and specifically cigar use (3.1%). While youth use

of tobacco products in any form is unsafe (2), the toll of death

and disease from tobacco product use in the United States is

primarily caused by cigarettes and other combustible tobacco

products (1). In addition, use of any tobacco product was

highest among students who identified their sexual identity

as LGB than those who identified as heterosexual; among

those identifying as transgender than those not transgender;

and among those reporting increased symptom severity of

psychological distress. Furthermore, although peer use and

curiosity were the most commonly cited reasons for initiating

e-cigarette use among ever users in 2021, among youths who

Surveillance Summaries

12 MMWR / March 11, 2022 / Vol. 71 / No. 5

US Department of Health and Human Services/Centers for Disease Control and Prevention

FIGURE 4. Harm perceptions of intermittent use* of select tobacco products among middle and high school students — National Youth

Tobacco Survey, United States, 2021

0 10 20 30 40 50 60 70 80 90 100

Hookahs

Smokeless

tobacco

Cigars, cigarillos,

little cigars

Cigarettes

E-cigarettes

Percentage

No harmLittle harmSome harmA lot of harm

Tobacco product

Abbreviation: e-cigarettes = electronic cigarettes.

* Assessed by the questions, “How much do you think people harm themselves when they [use e-cigarettes; smoke cigarettes; smoke cigars, cigarillos, or little cigars;

use chewing tobacco, snuff, dip, snus, or dissolvable tobacco products; or smoke tobacco in a hookah or water pipe] some days but not every day?” Response options

included “no harm,” “little harm,” “some harm,” and “a lot of harm” for each of the five tobacco products assessed. Harm perceptions of intermittent use of other

tobacco products were not assessed in the 2021 National Youth Tobacco Survey.

currently used e-cigarettes, the most commonly cited reasons for

use were attributable to feelings of anxiety, stress, or depression

and the “high or buzz” associated with nicotine use. This is

particularly concerning given the bidirectional association

between nicotine use and mental health disorders such as

depression and anxiety; studies found that youths with mental

health disorders were at increased risk for cigarette smoking,

but also that youth nicotine exposure was associated with the

development of mental health disorders (3,13). Additionally,

nicotine withdrawal is commonly accompanied by symptoms

of anxiety and depression, and relief of these symptoms through

use of a nicotine-containing tobacco product or nicotine

replacement therapy might perpetuate continued nicotine use

(1). Thus, the continued implementation of population-based

strategies, coupled with tobacco product regulation by FDA,

are critical to prevent and reduce the use of all forms of tobacco

products among all youths (1–3,14).

Since 2014, e-cigarettes have been the most commonly

used tobacco product among U.S. youths (8,15–17). In

2021, youth e-cigarette use remains a serious public health

concern, as approximately one in nine high school students

(11.3%, 1.72 million) and one in 35 middle school students

(2.8%, 320,000) had used e-cigarettes during the past 30 days.

While this appears lower than previously reported estimates

of e-cigarette use in 2020 (17), any comparison of results

between survey years, including the direct attribution of any

potential changes in tobacco product use, is not possible

because of the modifications to the fielding procedures in

2021 as a result of the COVID-19 pandemic. Specifically,

approximately half of students taking the 2021 NYTS reported

doing so from outside of a school building or classroom;

students participating in a school building or classroom

reported a higher prevalence of ever and current use of any

tobacco product, including e-cigarettes (18), compared with

students participating at home or some other place. However,

Surveillance Summaries

MMWR / March 11, 2022 / Vol. 71 / No. 5 13

US Department of Health and Human Services/Centers for Disease Control and Prevention

declines in e-cigarette use during the COVID-19 pandemic

compared with a prepandemic period have been observed in

other studies of young persons (19,20). Differences in tobacco

product use by survey completion setting might be caused

by potential underreporting of behaviors, reduced access to

tobacco products while at home (19,20), or other unmeasured

characteristics among students participating outside of the

classroom. Thus, the 2021 NYTS results cannot be compared

with previous NYTS survey results that were primarily

conducted on school campuses.

The 2021 NYTS offers insights into factors known to

influence tobacco product use among youths. Overall,

approximately eight in 10 students who used a tobacco product

reported using a flavored product, which can increase the

appeal and ease of use for youths (2,3). In addition, tobacco

product marketing through traditional sources (i.e., media,

Internet, print, and point of sale) and social media might

prompt tobacco product initiation and use among youths

(2,3,21,22); approximately 76% of students in 2021 reported

exposure to tobacco product marketing through traditional

sources and approximately 74% of students who used social

media had seen e-cigarette–related posts or content. However,

these data indicate that approximately three in four U.S.

students had seen or heard at least one public education

campaign against tobacco use during the preceding year,

which can be an effective, evidence-based tool to educate

youths about the risks of tobacco product use and to prevent

initiation (2,23,24). Thus, tailored interventions and services

could support cessation behaviors among youths who currently

use tobacco products.

Public Health Action

Sustained implementation of population-based strategies,

coupled with regulation of tobacco products by FDA, is critical

to preventing and reducing all forms of tobacco product use

among youths (1–3,14). Strategies to reduce tobacco product

use and initiation among all youths include increasing prices

of tobacco products; establishing comprehensive clean indoor

air policies that denormalize 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

; and

restricting the sales of flavored e-cigarettes (1,14,16,25).

On December 20, 2019, the Federal Food, Drug, and Cosmetic Act was

amended to raise the federal minimum age of sale for tobacco products from

18 to 21 years. This legislation (known as “Tobacco 21” or “T21”) became

effective immediately, making it illegal for a retailer to sell any tobacco product

to anyone aged <21 years.

Everyone can help protect youths from the harms of tobacco

products, including e-cigarettes (3,14). Parents, educators,

and youth advocates can learn about the different types of

tobacco products available, including various e-cigarette devices

that appeal to youths. They can also set a positive example

by being tobacco-free themselves and communicating the

harms of tobacco product use for youths, including nicotine’s

effects on adolescent brain development and addiction (3).

Schools can adopt and enforce tobacco-free campus policies

that prohibit use of all tobacco products, including but not

limited to e-cigarettes. Also, schools can implement policies

to not use tobacco industry–sponsored prevention programs;

no tobacco industry–sponsored prevention programs that have

been studied have been shown to be effective (2). In addition,

health care providers can ask about the use of all tobacco

products, including e-cigarettes, when screening patients for

tobacco product use and assist those who want to quit using

tobacco products (26).

Limitations

The findings in this report are subject to at least three

limitations. First, because of the implementation of emergency

COVID-19 protocols across the country during the 2021

NYTS fielding, the survey was administered online to allow

participation by eligible students at home, school, or somewhere

else. Previous research has shown that the prevalence of tobacco

use might differ by interview setting (27) and thus the 2021

NYTS results cannot be compared with previous NYTS survey

results that were primarily conducted on school campuses.

Second, data were self-reported and might be subject to recall

and response bias. However, the validity of self-reported

tobacco product use is consistently high in population-based

studies overall (28). Finally, data were collected only from

middle and high school students who attended public or

private schools; findings might not be generalizable to youths

who are home schooled, have dropped out of school, are

in detention centers, or are enrolled in alternative schools.

However, data from the Current Population Survey indicate

that approximately 96% of U.S. youths aged 10–17 years were

enrolled in a traditional school in 2020 (29).

Conclusion

NYTS is the only comprehensive, nationally representative

cross-sectional survey of U.S. middle and high school students

focused exclusively on tobacco product use behaviors and

associated factors. The 2021 NYTS was fully conducted

amid the global COVID-19 pandemic, during which time

Surveillance Summaries

14 MMWR / March 11, 2022 / Vol. 71 / No. 5

US Department of Health and Human Services/Centers for Disease Control and Prevention

eligible students could participate in classrooms, at home, or

some other place. Findings from 2021 NYTS indicate that

youth tobacco product use remains a public health threat,

with approximately one in four students (24.1%) ever using a

tobacco product, and approximately one in 10 students (9.3%)

using a tobacco product during the past 30 days. Furthermore,

disparities in tobacco product use continue to exist among

population subgroups. In 2021, any tobacco product use

was higher among students who identified as LGB than

heterosexual; among students who identified as transgender

than those not transgender; and among students who reported

increased symptom severity of psychological distress. Multiple

factors continue to promote tobacco product use and initiation

among youths, including flavors (such as menthol), marketing,

and misperceptions of harm. The comprehensive and sustained

implementation of population-level evidence-based tobacco

control strategies, combined with FDA’s regulation of tobacco

products, is important for preventing and reducing all forms

of tobacco product use among all U.S. youths. In addition,

as the tobacco product marketplace continues to diversify,

surveillance among youths for all forms of tobacco product

use and associated factors is important to the development

of public health policy and action at the national, state, and

community levels.

Conflicts of Interest

All authors have completed and submitted the International Com-

mittee of Medical Journal Editors form for disclosure of potential

conicts of interest. No potential conicts of interest were disclosed.

References

1. US Department of Health and Human Services. The health consequences

of smoking: 50 years of progress. a report of the Surgeon General.

Atlanta, GA: US Department of Health and Human Services, CDC,

National Center for Chronic Disease Prevention and Health Promotion,

Office on Smoking and Health. 2014. https://www.ncbi.nlm.nih.gov/

books/NBK179276/pdf/Bookshelf_NBK179276.pdf

2. US Department of Health and Human Services. Preventing tobacco use

among youth and young adults: a report of the Surgeon General.

Atlanta, GA: US Department of Health and Human Services, CDC,

National Center for Chronic Disease Prevention and Health Promotion,

Office on Smoking and Health; 2012. https://www.ncbi.nlm.nih.gov/

books/NBK99237/pdf/Bookshelf_NBK99237.pdf

3. US Department of Health and Human Services. E-cigarette use among

youth and young adults: a report of the Surgeon General. Atlanta, GA:

US Department of Health and Human Services, CDC, National Center

for Chronic Disease Prevention and Health Promotion, Office on

Smoking and Health; 2016. https://www.cdc.gov/tobacco/data_

statistics/sgr/e-cigarettes/pdfs/2016_sgr_entire_report_508.pdf

4. CDC. National Youth Tobacco Survey. Atlanta, GA: US Department

of Health and Human Services, CDC; 2020. https://www.cdc.gov/

tobacco/data_statistics/surveys/nyts/index.htm

5. Market Data Retrieval. National education database master extract.

Shelton, CT: Market Data Retrieval; 2019.

6. US Department of Education, National Center for Education Statistics.

Common core of data: America’s public schools. Washington, DC:

US Department of Education, National Center for Education Statistics.

http://nces.ed.gov/ccd

7. US Department of Education, National Center for Education Statistics.

Private School Universe Survey (PSS). Washington, DC: US Department

of Education, National Center for Education Statistics. http://nces.

ed.gov/surveys/pss

8. Wang TW, Gentzke AS, Creamer MR, et al. Tobacco product use and

associated factors among middle and high school students—United

States, 2019. MMWR Surveill Summ 2019;68(No. SS-12):1–22.

PMID:31805035 https://doi.org/10.15585/mmwr.ss6812a1

9. Anic GM, Sawdey MD, Jamal A, Trivers KF. Frequency of use among

middle and high school student tobacco product users—United States,

2015–2017. MMWR Morb Mortal Wkly Rep 2018;67:1353–7.

PMID:30543601 https://doi.org/10.15585/mmwr.mm6749a1

10. Creamer MR, Everett Jones S, Gentzke AS, Jamal A, King BA. Tobacco

product use among high school students—Youth Risk Behavior Survey,

United States, 2019. MMWR Suppl 2020;69:56–63. PMID:32817607

https://doi.org/10.15585/mmwr.su6901a7

11. Apelberg BJ, Corey CG, Hoffman AC, et al. Symptoms of tobacco

dependence among middle and high school tobacco users: results

from the 2012 National Youth Tobacco Survey. Am J Prev Med

2014;47(Suppl 1):S4–14. PMID:25044195 https://doi.org/10.1016/j.

amepre.2014.04.013

12. Marynak KL, Wang X, Borowiecki M, et al. Nicotine pouch unit sales

in the US, 2016–2020. JAMA 2021;326:566–8. PMID:34374729

https://doi.org/10.1001/jama.2021.10366

13. Truth Initiative. Colliding crises: youth mental health and

nicotine use. Washington, DC: Truth Initiative; 2021. https://

truthinitiative.org/research-resources/emerging-tobacco-products/

colliding-crises-youth-mental-health-and-nicotine-use

14. 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://e-cigarettes.surgeongeneral.gov/documents/

surgeon-generals-advisory-on-e-cigarette-use-among-youth-2018.pdf

15. Arrazola RA, Dube SR, King BA. Tobacco product use among middle

and high school students—United States, 2011 and 2012. MMWR

Morb Mortal Wkly Rep 2013;62:893–7. PMID:24226625 https://www.

cdc.gov/mmwr/preview/mmwrhtml/mm6245a2.htm

16. Gentzke AS, Creamer M, Cullen KA, et al. Vital signs: tobacco product

use among middle and high school students—United States, 2011–2018.

MMWR Morb Mortal Wkly Rep 2019;68:157–64. PMID:30763302

https://doi.org/10.15585/mmwr.mm6806e1

17. Gentzke AS, Wang TW, Jamal A, et al. Tobacco product use among

middle and high school students—United States, 2020. MMWR Morb

Mortal Wkly Rep 2020;69:1881–8. PMID:33332300 https://doi.

org/10.15585/mmwr.mm6950a1

18. Park-Lee E, Ren C, Sawdey MD, et al. Notes from the field: e-cigarette

use among middle and high school students—National Youth Tobacco

Survey, United States, 2021. MMWR Morb Mortal Wkly Rep

2021;70:1387–9 10. PMID:34591834 https://doi.org/10.15585/

mmwr.mm7039a4

19. Kreslake JM, Simard BJ, O’Connor KM, Patel M, Vallone DM, Hair EC.

E-cigarette use among youths and young adults during the COVID-19

pandemic: United States, 2020. Am J Public Health 2021;111:1132–40.

PMID:33856888 https://doi.org/10.2105/AJPH.2021.306210

20. Gaiha SM, Lempert LK, Halpern-Felsher B. Underage youth and young

adult e-cigarette use and access before and during the coronavirus disease

2019 pandemic. JAMA Netw Open 2020;3:e2027572. PMID:33270127

https://doi.org/10.1001/jamanetworkopen.2020.27572

Surveillance Summaries

MMWR / March 11, 2022 / Vol. 71 / No. 5 15

US Department of Health and Human Services/Centers for Disease Control and Prevention

21. Singh T, Agaku IT, Arrazola RA, et al. Exposure to advertisements and

electronic cigarette use among US middle and high school students.

Pediatrics 2016;137:e20154155. PMID:27244815 https://doi.

org/10.1542/peds.2015-4155

22. Hébert ET, Case KR, Kelder SH, Delk J, Perry CL, Harrell MB. Exposure

and engagement with tobacco- and e-cigarette-related social media.

J Adolesc Health 2017;61:371–7. PMID:28669801 https://doi.

org/10.1016/j.jadohealth.2017.04.003

23. Noar SM, Rohde JA, Prentice-Dunn H, Kresovich A, Hall MG,

Brewer NT. Evaluating the actual and perceived effectiveness of

e-cigarette prevention advertisements among adolescents. Addict Behav

2020;109:106473. PMID:32521287 https://doi.org/10.1016/j.

addbeh.2020.106473

24. Allen JA, Duke JC, Davis KC, Kim AE, Nonnemaker JM, Farrelly MC.

Using mass media campaigns to reduce youth tobacco use: a review.

Am J Health Promot 2015;30:e71–82. PMID:25372236 https://doi.

org/10.4278/ajhp.130510-LIT-237

25. CDC. Best practices for comprehensive tobacco control programs—2014.

Atlanta, GA: US Department of Health and Human Services, CDC;

2014. https://www.cdc.gov/tobacco/stateandcommunity/best_practices/

index.htm

26. US Preventive Services Task Force. Prevention and cessation of tobacco

use in children and adolescents: primary care interventions. Rockville,

MD: US Preventive Services Task Force; 2020. https://www.

uspreventiveservicestaskforce.org/uspstf/recommendation/

tobacco-and-nicotine-use-prevention-in-children-and-adolescents-

primary-care-interventions

27. Brener ND, Billy JO, Grady WR. Assessment of factors affecting the

validity of self-reported health-risk behavior among adolescents: evidence

from the scientific literature. J Adolesc Health 2003;33:436–57.

PMID:14642706 https://doi.org/10.1016/S1054-139X(03)00052-1

28. Boykan R, Messina CR, Chateau G, Eliscu A, Tolentino J, Goniewicz ML.

Self-reported use of tobacco, e-cigarettes, and marijuana versus urinary

biomarkers. Pediatrics 2019;143:e20183531. PMID:31010908 https://

doi.org/10.1542/peds.2018-3531

29. US Census Bureau. School enrollment in the United States: October

2020—detailed tables. Washington, DC: US Department of Commerce,

Census Bureau; 2021. https://www.census.gov/data/tables/2020/demo/

school-enrollment/2020-cps.html

Surveillance Summaries

16 MMWR / March 11, 2022 / Vol. 71 / No. 5

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE 1. Percentage of middle and high school students who reported ever using tobacco products, by product,* overall and by school level,

sex, and race and ethnicity — National Youth Tobacco Survey, United States, 2021

Characteristic

Sex Race and ethnicity

TotalFemale Male

White,

non-Hispanic

Black,

non-Hispanic

Hispanic

†

Other,

non-Hispanic

% (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI)

Estimated no.

of users

Overall

Any tobacco product

24.5 (22.2–27.1) 23.8 (21.7–26.1) 26.7 (23.7–29.9) 21.9 (19.2–24.9) 22.4 (20.7–24.2) 16.1 (11.6–21.8) 24.1 (22.1–26.3) 6,600,000

E-cigarettes 20.1 (17.9–22.5) 18.8 (16.8–21.0) 23.1 (20.3–26.2) 12.6 (10.4–15.2) 17.6 (15.8–19.5) 12.7 (8.9–17.7) 19.4 (17.5–21.5) 5,300,000

Cigarettes 8.0 (6.9–9.1) 8.3 (7.3–9.4) 9.3 (8.1–10.8) 6.2 (4.8–8.0) 7.1 (6.0–8.4) 5.9 (3.5–10.0) 8.1 (7.2–9.1) 2,180,000

Cigars 3.7 (3.2–4.3) 6.6 (5.6–7.9) 5.9 (4.7–7.3) 6.8 (5.5–8.4) 4.1 (3.4–4.9) 1.9 (1.1–3.4) 5.2 (4.5–6.0) 1,400,000

Smokeless tobacco 2.2 (1.6–2.8) 5.0 (4.1–6.2) 4.8 (3.9–5.8) 1.8 (1.2–2.7) 2.3 (1.7–3.0) —** 3.6 (2.9–4.5) 960,000

Hookahs 3.1 (2.5–3.8) 2.5 (2.0–3.0) 2.1 (1.6–2.7) 5.0 (4.0–6.3) 3.2 (2.3–4.3) — 2.8 (2.3–3.3) 740,000

Nicotine pouches 1.2 (0.9–1.7) 2.6 (2.0–3.2) 2.6 (2.1–3.3) 0.7 (0.4–1.3) 1.3 (0.9–1.9) — 1.9 (1.5–2.4) 490,000

Heated tobacco products 1.8 (1.5–2.2) 1.7 (1.5–2.0) 1.7 (1.4–2.1) 1.7 (1.1–2.5) 2.1 (1.5–2.9) — 1.8 (1.5–2.0) 440,000

Pipe tobacco 0.9 (0.6–1.2) 1.2 (0.9–1.6) 1.3 (1.0–1.6) — 0.9 (0.7–1.3) — 1.0 (0.8–1.3) 270,000

Any combustible tobacco

product

††

11.3 (10.1–12.5) 12.4 (11.1–13.8) 12.6 (10.9–14.4) 14.0 (11.8–16.4) 10.4 (9.3–11.6) 8.3 (5.5–12.4) 11.9 (10.8–13.0) 3,200,000

Two or more tobacco

products

§§

9.1 (8.0–10.3) 10.9 (9.5–12.4) 11.8 (10.1–13.7) 8.5 (6.8–10.5) 8.5 (7.3–9.9) 6.3 (4.2–9.4) 10.0 (8.9–11.3) 2,740,000

High school (grades 9–12)

Any tobacco product 35.2 (32.4–38.1) 33.0 (30.3–35.8) 37.8 (34.7–41.1) 27.7 (25.1–30.6) 29.7 (27.2–32.4) 27.9 (22.5–34.0) 34.0 (31.6–36.5) 5,220,000

E-cigarettes 30.2 (27.4–33.1) 27.7 (25.0–30.6) 33.8 (30.7–37.1) 16.9 (14.5–19.7) 25.0 (22.4–27.9) 23.0 (17.6–29.5)

28.9 (26.4–31.4) 4,430,000

Cigarettes 10.8 (9.3–12.5) 11.5 (9.9–13.3) 13.0 (11.3–14.9) 6.4 (4.7–8.5) 9.5 (7.6–11.9) 9.6 (5.6–15.8) 11.2 (9.9–12.6) 1,680,000

Cigars 4.9 (4.2–5.8) 10.0 (8.6–11.7) 8.7 (7.3–10.4) 8.7 (7.0–10.6) 5.4 (4.3–6.8) — 7.6 (6.6–8.8) 1,140,000

Smokeless tobacco 2.4 (1.8–3.3) 6.8 (5.5–8.4) 6.6 (5.4–7.9) 1.7 (1.0–2.9) 2.2 (1.5–3.2) — 4.7 (3.8–5.9) 700,000

Hookahs 4.2 (3.4–5.3) 3.5 (2.8–4.3) 2.9 (2.3–3.8) 6.8 (5.3–8.7) 4.0 (3.0–5.3) 5.1 (2.9–8.9) 3.8 (3.2–4.6) 570,000

Nicotine pouches 1.7 (1.3–2.4) 4.1 (3.3–5.1) 4.1 (3.3–5.1) — 1.5 (1.0–2.2) — 3.0 (2.4–3.6) 420,000

Heated tobacco products 2.5 (1.9–3.1) 2.1 (1.8–2.5) 2.3 (1.9–2.8) 2.1 (1.2–3.7) 2.4 (1.6–3.4) — 2.3 (2.0–2.6) 310,000

Pipe tobacco 1.1 (0.7–1.8) 1.7 (1.2–2.4) 1.8 (1.3–2.4) — 1.1 (0.7–1.8) — 1.4 (1.1–1.9) 210,000

Any combustible tobacco

product

15.4 (13.6–17.2) 17.6 (15.9–19.5) 17.8 (15.9–19.8) 17.4 (15.0–20.1) 13.5 (11.3–16.2) 14.1 (9.8–19.9) 16.6 (15.1–18.1) 2,500,000

Two or more tobacco

products

12.8 (11.4–14.4) 16.2 (14.3–18.4) 17.2 (15.2–19.4) 10.8 (8.8–13.4) 11.6 (9.5–14.1) 10.9 (7.6–15.5) 14.6 (13.1–16.3) 2,240,000

Middle school (grades 6–8)

Any tobacco product 11.1 (9.3–13.2) 11.5 (9.9–13.4) 10.3 (8.7–12.1) 14.0 (10.9–17.8) 13.2 (10.5–16.5) 6.0 (3.7–9.6) 11.3 (9.8–13.0) 1,340,000

E-cigarettes 7.5 (6.2–9.1) 7.0 (5.8–8.5) 7.5 (6.3–9.0) 7.0 (4.9–9.8) 8.4 (6.5–10.8) 3.8 (2.2–6.6) 7.3 (6.2–8.6) 860,000

Cigarettes 4.2 (3.2–5.6) 3.9 (3.1–5.0) 3.8 (2.9–5.1) 5.7 (3.8–8.4) 4.1 (2.8–5.8) — 4.1 (3.2–5.1) 480,000

Cigars 2.0 (1.5–2.7) 2.2 (1.7–2.7) 1.7 (1.2–2.3) 4.3 (3.2–5.8) 2.5 (1.6–3.8) — 2.1 (1.7–2.6) 240,000

Smokeless tobacco 1.8 (1.2–2.6) 2.5 (1.8–3.6) 2.1 (1.5–2.8) 1.9 (1.1–3.3) 2.3 (1.5–3.5) — 2.2 (1.6–3.0) 250,000

Hookahs 1.5 (1.0–2.3) 1.1 (0.7–1.5)

0.6 (0.4–1.0) 2.7 (1.8–3.9) 2.1 (1.2–3.7) — 1.3 (0.9–1.8) 150,000

Nicotine pouches 0.6 (0.3–1.1) 0.5 (0.3–0.8) 0.4 (0.3–0.7) — — — 0.6 (0.4–0.8) 60,000

Heated tobacco products 1.0 (0.7–1.4) 1.2 (0.9–1.8) 0.8 (0.5–1.3) — 1.7 (1.0–3.0) — 1.1 (0.9–1.5) 120,000

Pipe tobacco — 0.5 (0.3–0.8) 0.4 (0.2–0.6) — 0.7 (0.4–1.2) — 0.5 (0.3–0.7) 50,000

Any combustible tobacco

product

6.0 (4.9–7.4) 5.4 (4.5–6.5) 4.7 (3.8–5.9) 9.2 (6.7–12.5) 6.5 (5.0–8.6) — 5.7 (4.8–6.8) 670,000

Two or more tobacco

products

4.3 (3.3–5.7) 3.7 (2.8–4.9) 3.6 (2.7–4.9) 5.4 (3.6–8.1) 4.7 (3.4–6.5) — 4.0 (3.2–5.1) 480,000

Abbreviation: e-cigarettes = electronic cigarettes.

* Ever use of e-cigarettes was determined by asking, “Have you ever used an e-cigarette, even once or twice?” Ever use of cigarettes was determined by asking, “Have you ever smoked a

cigarette, even one or two puffs?” Ever use of cigars was determined by asking, “Have you ever smoked a cigar, cigarillo, or little cigar, even one or two puffs?” Smokeless tobacco was

defined as use of chewing tobacco, snuff, or dip, snus, or dissolvable tobacco products. Ever use of smokeless tobacco was determined by asking the following questions: for chewing

tobacco, snuff, and dip: “Have you ever used chewing tobacco, snuff, or dip, even just a small amount?”; for snus: “Have you ever used snus, even just one time?”; and for dissolvable tobacco

products: “Have you ever used dissolvable tobacco products, even just one time?” Responses from these questions were combined to derive overall smokeless tobacco use. Ever use of

hookahs was determined by asking, “Have you ever smoked tobacco in a hookah or water pipe, even one or two puffs?” Ever use of nicotine pouches was determined by asking, “Have

you ever used a “nicotine pouch,” even just one time?” Ever use of heated tobacco products was determined by asking, “Have you ever used a heated tobacco product, even just one time?”

Ever use of pipe tobacco (not hookahs) was determined by asking, “Have you ever smoked pipes filled with tobacco (not hookah or water pipe), even just one time?” Because of missing

data on the ever use questions, denominators for each tobacco product might be different. For each question, response options were “yes” or “no.”

†

Hispanic persons could be of any race.

Estimated weighted total number of ever tobacco product users was rounded down to the nearest 10,000 persons. Overall estimates were reported among 20,413 U.S. middle and high

school students. School level was determined by self-reported grade level: high school (grades 9–12; n = 10,515) and middle school (grades 6–8; n = 9,763). Overall estimates might not

directly total to sums of corresponding subgroup estimates because of rounding or inclusion of students who did not self-report sex, race and ethnicity, or grade level.

Any tobacco product use was defined as ever use of any tobacco product (e-cigarettes, cigarettes, cigars [cigars, cigarillos, or little cigars], smokeless tobacco [chewing tobacco, snuff, or

dip, snus, or dissolvable tobacco products], hookahs, pipe tobacco, heated tobacco products, nicotine pouches, or bidis [small brown cigarettes wrapped in a leaf ]), even just one time.

** Data were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%.

††

Any combustible tobacco product use was defined as ever use of cigarettes, cigars (cigars, cigarillos, or little cigars), hookahs, pipe tobacco, or bidis, even just one time.

§§

Defined as ever use of two or more tobacco products (e-cigarettes, cigarettes, cigars [cigars, cigarillos, or little cigars], smokeless tobacco [chewing tobacco, snuff, or dip, snus, or dissolvable

tobacco products], hookahs, pipe tobacco, heated tobacco products, nicotine pouches, or bidis), even just one time.

Surveillance Summaries

MMWR / March 11, 2022 / Vol. 71 / No. 5 17

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE 2. Percentage of middle and high school students who reported current (past 30-day) tobacco product use, by product,* overall and by

school level, sex, and race and ethnicity — National Youth Tobacco Survey, United States, 2021

Characteristic

Sex Race and ethnicity

TotalFemale Male

White,

non-Hispanic

Black,

non-Hispanic

Hispanic

†

Other,

non-Hispanic

% (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI)

Estimated no.

of users

Overall

Any tobacco product

9.6 (8.4–11.0) 9.0 (7.9–10.3) 11.0 (9.5–12.8) 8.2 (6.5–10.2) 7.4 (6.4–8.7) 5.4 (3.6–8.1) 9.3 (8.3–10.5) 2,550,000

E-cigarettes 8.0 (6.8–9.4) 7.1 (6.1–8.3) 9.6 (8.2–11.4) 4.3 (3.1–6.0) 6.0 (4.9–7.2) 4.1 (2.7–6.2) 7.6 (6.6–8.7) 2,060,000

Cigarettes 1.5 (1.2–1.9) 1.5 (1.2–2.0) 1.8 (1.4–2.2) 1.0 (0.6–1.6) 1.5 (1.1–2.0) —** 1.5 (1.3–1.8) 410,000

Cigars 1.1 (0.8–1.4) 1.8 (1.5–2.1) 1.4 (1.1–1.8) 3.1 (2.4–4.1) 0.9 (0.7–1.2) — 1.4 (1.2–1.7) 380,000

Smokeless tobacco 0.5 (0.3–0.7) 1.3 (1.0–1.8) 1.1 (0.8–1.5) — 0.7 (0.5–1.0) — 0.9 (0.7–1.2) 240,000

Hookahs 0.9 (0.6–1.4) 0.8 (0.6–1.0) 0.5 (0.4–0.7) 2.2 (1.4–3.4) 1.0 (0.6–1.5) — 0.8 (0.7–1.1) 220,000

Nicotine pouches 0.5 (0.3–0.7) 1.0 (0.7–1.4) 0.9 (0.6–1.3) — 0.7 (0.4–1.0) — 0.8 (0.6–1.0) 200,000

Heated tobacco products 0.6 (0.4–0.8) 0.7 (0.5–1.0) 0.6 (0.5–0.9) 0.7 (0.4–1.3) 0.7 (0.4–1.1) — 0.7 (0.5–0.8) 170,000

Pipe tobacco 0.3 (0.2–0.5) 0.3 (0.2–0.6) 0.4 (0.2–0.6) — 0.3 (0.2–0.6) — 0.3 (0.2–0.5) 80,000

Any combustible tobacco

product

††

3.1 (2.6–3.8) 3.2 (2.8–3.7) 3.1 (2.6–3.7) 5.2 (4.1–6.6) 2.8 (2.3–3.4) — 3.2 (2.8–3.6) 860,000

Two or more tobacco

products

§§

2.4 (1.9–2.9) 3.0 (2.5–3.7) 3.1 (2.6–3.8) 3.0 (2.2–4.0) 2.2 (1.7–2.9) — 2.7 (2.3–3.2) 740,000

High school (grades 9–12)

Any tobacco product 13.8 (11.9–16.0) 13.0 (11.2–15.1) 16.2 (14.1–18.6) 11.0 (8.7–13.9) 9.1 (7.4–11.1) 9.3 (6.3–13.6) 13.4 (11.8–15.2) 2,060,000

E-cigarettes 11.9 (10.0–14.0) 10.7 (9.1–12.6) 14.5 (12.4–16.8) 5.9 (4.2–8.2) 7.6 (6.0–9.6) 7.4 (4.9–10.9)

11.3 (9.7–13.0) 1,720,000

Cigarettes 1.8 (1.3–2.3) 2.0 (1.5–2.7) 2.2 (1.8–2.8) — 1.6 (1.2–2.3) — 1.9 (1.5–2.4) 280,000

Cigars 1.5 (1.1–2.1) 2.6 (2.1–3.3) 2.1 (1.6–2.6) 4.4 (3.3–5.9) 1.2 (0.8–1.6) — 2.1 (1.7–2.6) 310,000

Smokeless tobacco

—

1.7 (1.2–2.4) 1.5 (1.0–2.1) — — — 1.2 (0.8–1.6) 170,000

Hookahs 1.3 (0.8–2.0) 1.2 (0.9–1.5) 0.8 (0.5–1.1) 3.2 (1.9–5.2) 1.3 (0.8–2.3) — 1.2 (0.9–1.6) 180,000

Nicotine pouches 0.6 (0.3–1.0) 1.6 (1.1–2.3) 1.4 (0.9–2.2) — — — 1.1 (0.8–1.6) 160,000

Heated tobacco products 0.7 (0.5–1.2) 0.9 (0.6–1.4) 0.9 (0.6–1.3) — — — 0.8 (0.6–1.1) 120,000

Pipe tobacco — — 0.5 (0.3–0.9) — — — 0.4 (0.3–0.7) 60,000

Any combustible tobacco

product

4.2 (3.3–5.2) 4.6 (3.8–5.4) 4.3 (3.5–5.1) 7.3 (5.5–9.6) 3.5 (2.7–4.5) — 4.4 (3.8–5.1) 660,000

Two or more tobacco

products

3.1 (2.4–4.0) 4.5 (3.6–5.6) 4.4 (3.7–5.4) 4.0 (2.8–5.7) 2.6 (2.0–3.5) — 3.8 (3.2–4.6) 580,000

Middle school (grades 6–8)

Any tobacco product 4.4 (3.5–5.5) 3.6 (2.9–4.5) 3.4 (2.7–4.4) 4.5 (3.4–5.9) 5.3 (3.9–7.1) 2.2 (1.2–3.8) 4.0 (3.3–4.8) 470,000

E-cigarettes 3.2 (2.4–4.2) 2.3 (1.9–3.0) 2.6 (1.9–3.5) 2.3 (1.4–4.0) 3.9 (2.9–5.3) — 2.8 (2.2–3.4) 320,000

Cigarettes 1.2 (0.8–1.8) 0.9 (0.6–1.4) 1.0 (0.7–1.5) 1.1 (0.6–1.9) 1.2 (0.7–1.9) — 1.0 (0.8–1.4) 120,000

Cigars 0.5 (0.3–0.9) 0.6 (0.4–0.9) 0.5 (0.3–0.7) 1.4 (0.8–2.3) 0.6 (0.4–1.1) — 0.6 (0.4–0.8) 60,000

Smokeless tobacco — 0.8 (0.5–1.2) 0.5 (0.3–0.9) — — — 0.6 (0.4–0.9) 60,000

Hookahs —

— — — — — 0.4 (0.2–0.6) 40,000

icotine pouches — 0.2 (0.1–0.3) — — — — 0.3 (0.2–0.5) 30,000

Heated tobacco products 0.4 (0.2–0.7) 0.4 (0.3–0.7) — — — — 0.4 (0.3–0.6) 40,000

Pipe tobacco — — — — — — 0.2 (0.1–0.3) 20,000

Any combustible tobacco

product

1.9 (1.3–2.7) 1.4 (1.0–1.9) 1.4 (1.0–1.9) 2.4 (1.7–3.3) 1.9 (1.3–2.8) — 1.6 (1.3–2.1) 190,000

Two or more tobacco

products

1.5 (0.9–2.3) 1.1 (0.8–1.5) 1.2 (0.8–1.8) 1.6 (1.0–2.5) 1.6 (1.0–2.7) — 1.3 (0.9–1.7) 150,000

Abbreviation: e-cigarettes = electronic cigarettes.

* Past 30-day use of e-cigarettes was determined by asking, “During the past 30 days, on how many days did you use e-cigarettes?” Past 30-day use of cigarettes was determined by asking,

“During the past 30 days, on how many days did you smoke cigarettes?” Past 30-day use of cigars was determined by asking, “During the past 30 days, on how many days did you smoke

cigars, cigarillos, or little cigars?” Smokeless tobacco was defined as use of chewing tobacco, snuff, or dip, snus, or dissolvable tobacco products. Past 30-day use of smokeless tobacco was

determined by asking, “During the past 30 days, on how many days did you use [chewing tobacco, snuff, or dip, snus, or dissolvable tobacco products]?” Responses from these questions

were combined to derive overall smokeless tobacco use. Past 30-day use of hookahs was determined by asking, “During the past 30 days, on how many days did you smoke tobacco in a

hookah or water pipe?” Past 30-day use of nicotine pouches was determined by asking, “During the past 30 days, on how many days did you use nicotine pouches?” Past 30-day use of

heated tobacco products was determined by asking, “During the past 30 days, on how many days did you use heated tobacco products?” Past 30-day use of pipe tobacco (not hookahs)

was determined by asking, “In the past 30 days, on how many days did you smoke pipes filled with tobacco?” Because of missing data on the past 30-day use questions, denominators for

each tobacco product might be different. For each product, current use was defined as self-reported use on ≥1 day during the past 30 days.

†

Hispanic persons could be of any race.

Estimated weighted total number of current tobacco product users was rounded down to the nearest 10,000 persons. Overall estimates were reported among 20,413 U.S. middle and

high school students. School level was determined by self-reported grade level: high school (grades 9–12; n = 10,515) and middle school (grades 6–8; n = 9,763). Overall estimates might

not directly total to sums of corresponding subgroup estimates because of rounding or inclusion of students who did not self-report sex, race and ethnicity, or grade level.

Any tobacco product use was defined as use of any tobacco product (e-cigarettes, cigarettes, cigars [cigars, cigarillos, or little cigars], smokeless tobacco [chewing tobacco, snuff, or dip,

snus, or dissolvable tobacco products], hookahs, pipe tobacco, heated tobacco products, nicotine pouches, or bidis [small brown cigarettes wrapped in a leaf ]) on ≥1 day during the past

30 days.

** Data were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%.

††

Any combustible tobacco product use was defined as use of cigarettes, cigars (cigars, cigarillos, or little cigars), hookahs, pipe tobacco, or bidis on ≥1 day during the past 30 days.

§§

Defined as use of two or more tobacco products (e-cigarettes, cigarettes, cigars [cigars, cigarillos, or little cigars], smokeless tobacco [chewing tobacco, snuff, or dip, snus, or dissolvable

tobacco products], hookahs, pipe tobacco, heated tobacco products, nicotine pouches, or bidis) on ≥1 day during the past 30 days.

Surveillance Summaries

18 MMWR / March 11, 2022 / Vol. 71 / No. 5

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE 3. Percentage of middle and high school students who reported ever use or current (past 30-day) use of any tobacco product,* overall

and by selected demographic characteristics and social determinant indicators — National Youth Tobacco Survey, United States, 2021

Characteristic

Ever use, any tobacco product Current use, any tobacco product

% (95% CI) Estimated no. of users

†

% (95% CI) Estimated no. of users

†

Overall

Sexual identity

Heterosexual 22.8 (20.7–25.0) 4,210,000 7.9 (7.0–9.0) 1,460,000

Gay, lesbian, or bisexual 35.4 (32.4–38.4) 1,220,000 14.2 (11.9–17.0) 490,000

Not sure 14.4 (11.8–17.5) 340,000 5.5 (4.2–7.3) 130,000

Transgender

No, not transgender 23.4 (21.3–25.7) 5,210,000 8.2 (7.3–9.3) 1,830,000

Yes, transgender 37.9 (31.3–45.0) 160,000 18.9 (13.8–25.4) 80,000

Not sure 26.4 (20.7–33.1) 180,000 9.1 (6.1–13.5) 60,000

I don’t know what this question is asking 18.4 (14.7–22.8) 180,000 9.7 (6.9–13.4) 90,000

Psychological distress (PHQ-4 scale)

None 16.6 (14.7–18.8) 2,070,000 5.5 (4.7–6.3) 680,000

Mild 27.3 (25.0–29.7) 1,340,000 9.6 (8.3–11.1) 470,000

Moderate 29.3 (25.7–33.2) 910,000 11.2 (8.8–14.1) 340,000

Severe 37.8 (33.9–41.8) 1,110,000 14.2 (11.9–16.8) 410,000

Family affluence scale**

Low 24.4 (22.4–26.6) 1,490,000 9.2 (7.8–10.8) 560,000

Medium 22.3 (20.2–24.6) 2,400,000 7.7 (6.7–8.8) 820,000

High 24.0 (20.9–27.5) 1,760,000 8.8 (7.5–10.3) 640,000

Grades in school

Mostly As 18.3 (15.9–21.0) 1,980,000 5.5 (4.6–6.7) 590,000

Mostly Bs 25.7 (23.3–28.3) 1,770,000 9.6 (8.2–11.1) 650,000

Mostly Cs 31.3 (28.3–34.4) 910,000 13.2 (11.0–15.8) 380,000

Mostly Ds 36.7 (32.1–41.6) 360,000 15.6 (12.6–19.2) 150,000

Mostly Fs 41.7 (36.8–46.8) 350,000 17.3 (13.4–22.0) 140,000

Speak language other than English (home)

Yes 20.5 (18.4–22.8) 1,440,000 6.4 (5.5–7.3) 440,000

No 24.5 (22.1–27.1) 4,310,000 9.2 (8.1–10.5) 1,620,000

High school (grades 9–12)

Sexual identity

Heterosexual 31.6 (29.2–34.1) 3,420,000 11.4 (10.1–12.9) 1,230,000

Gay, lesbian, or bisexual 43.8 (40.1–47.6) 910,000 17.4 (14.2–21.1) 360,000

Not sure 26.8 (22.5–31.7) 240,000 10.2 (7.3–13.9) 90,000

Transgender

No, not transgender 32.7 (30.3–35.2) 4,190,000 11.7 (10.3–13.2) 1,490,000

Yes, transgender 45.6 (36.7–54.8) 110,000 24.5 (17.2–33.6) 60,000

Not sure 38.4 (29.3–48.3) 120,000 12.3 (6.8–21.4) 30,000

I don’t know what this question is asking 30.9 (24.0–38.9) 140,000 17.9 (12.1–25.5) 80,000

Psychological distress (PHQ-4 scale)

None 25.4 (22.9–28.0) 1,680,000 8.3 (7.2–9.6) 550,000

Mild 37.1 (33.9–40.3) 1,100,000 13.6 (11.5–16.0) 400,000

Moderate 37.5 (32.6–42.6) 710,000 15.2 (11.7–19.5) 290,000

Severe 46.5 (42.5–50.5) 840,000 17.6 (14.5–21.2) 310,000

Family affluence scale

Low 33.2 (30.5–36.0) 1,170,000 12.7 (10.4–15.4) 440,000

Medium 31.4 (28.5–34.5) 1,930,000 11.2 (9.6–13.0) 680,000

High 34.9 (31.7–38.3) 1,400,000 12.8 (11.0–14.9) 510,000

Grades in school

Mostly As 27.8 (24.6–31.2) 1,680,000 8.5 (7.1–10.2) 510,000

Mostly Bs 35.4 (32.6–38.2) 1,420,000 13.7 (11.8–15.8) 550,000

Mostly Cs 40.7 (36.8–44.7) 710,000 17.9 (14.8–21.5) 310,000

Mostly Ds 42.6 (35.2–50.4) 250,000 18.4 (13.1–25.2) 100,000

Mostly Fs 48.3 (41.8–54.9) 260,000 19.6 (14.4–26.0) 100,000

Speak language other than English (home)

Yes 28.5 (25.7–31.4) 1,070,000 8.4 (6.7–10.4) 310,000

No 34.5 (32.0–37.1) 3,480,000 13.5 (11.9–15.2) 1,350,000

See table footnotes on the next page.

Surveillance Summaries

MMWR / March 11, 2022 / Vol. 71 / No. 5 19

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE 3. (Continued) Percentage of middle and high school students who reported ever use or current (past 30-day) use of any tobacco product,*

overall and by selected demographic characteristics and social determinant indicators — National Youth Tobacco Survey, United States, 2021

Characteristic

Ever use, any tobacco product Current use, any tobacco product

% (95% CI) Estimated no. of users

†

% (95% CI) Estimated no. of users

†

Middle school (grades 6–8)

Sexual identity

Heterosexual 10.0 (8.7–11.6) 760,000 3.0 (2.4–3.6) 220,000

Gay, lesbian, or bisexual 22.5 (18.8–26.6) 300,000 9.5 (7.1–12.5) 120,000

Not sure 6.8 (4.6–9.9) 100,000 2.6 (1.6–4.0) 30,000

Transgender

No, not transgender 10.6 (9.2–12.2) 990,000 3.5 (2.9–4.3) 330,000

Yes, transgender 27.8 (19.0–38.7) 50,000 —

††

—

Not sure 16.7 (11.6–23.4) 60,000 6.5 (3.7–11.0) 20,000

I don’t know what this question is asking 7.4 (5.0–10.9) 40,000 2.3 (1.4–3.9) 10,000

Psychological distress (PHQ-4 scale)

None 6.3 (5.3–7.5) 360,000 2.1 (1.6–2.7) 120,000

Mild 12.2 (10.0–14.8) 230,000 3.4 (2.5–4.5) 60,000

Moderate 16.4 (13.1–20.2) 190,000 4.9 (3.3–7.1) 50,000

Severe 24.1 (19.6–29.3) 270,000 8.8 (6.3–12.1) 90,000

Family affluence scale

Low 12.3 (10.4–14.5) 310,000 4.4 (3.6–5.4) 110,000

Medium 10.0 (8.3–11.9) 450,000 3.0 (2.2–4.0) 130,000

High 10.8 (8.8–13.1) 350,000 3.8 (2.9–4.9) 120,000

Grades in school

Mostly As 6.0 (4.8–7.3) 280,000 1.7 (1.2–2.4) 70,000

Mostly Bs 12.2 (10.0–14.9) 340,000 3.7 (2.7–5.0) 100,000

Mostly Cs 17.0 (13.9–20.7) 190,000 6.1 (4.5–8.3) 70,000

Mostly Ds 27.9 (21.4–35.5) 110,000 11.2 (7.6–16.1) 40,000

Mostly Fs 30.4 (22.0–40.4) 90,000 13.3 (9.1–19.1) 40,000

Speak language other than English (home)

Yes 11.1 (8.8–13.9) 350,000 3.8 (2.8–5.2) 120,000

No 10.9 (9.2–12.9) 810,000 3.6 (2.8–4.5) 260,000

Abbreviations: e-cigarettes = electronic cigarettes; PHQ-4 = four-item Patient Health Questionnaire.

* Any tobacco product includes e-cigarettes, cigarettes, cigars (cigars, cigarillos, or little cigars), smokeless tobacco (chewing tobacco, snuff, or dip; snus; dissolvable

tobacco products), hookahs, pipe tobacco, bidis (small brown cigarettes wrapped in a leaf), heated tobacco products and nicotine pouches. Ever use of any tobacco

product was defined as self-reported ever use of any tobacco product, even just one time. Current use of any tobacco product was defined as self-reported use of

any tobacco product on ≥1 day during the past 30 days.

†

Estimated weighted total numbers of ever and current tobacco product users were rounded down to the nearest 10,000 persons. Overall estimates might not

directly total to sums of corresponding subgroup estimates by school level because of rounding or inclusion of students who did not self-report grade level.

Overall estimates were reported among 20,413 U.S. middle and high school students. School level was determined by self-reported grade level: high school

(grades 9–12; n = 10,515) and middle school (grades 6–8; n = 9,763).

A composite scale made up of four questions to assess psychological distress: “During the past two weeks, how often have you been bothered by any of the

following problems?”: 1) little interest or pleasure in doing things; 2) feeling down, depressed, or hopeless; 3) feeling nervous, anxious, or on edge; 4) not being

able or stop or control worrying. Response options were provided with a numeric value [not at all = 0; several days = 1; more than half of the days = 2; and nearly

every day = 3]. Responses were summed (range: 0–12) and categorized as none (0–2), mild (3–5), moderate (6–8) and severe (9–12). The PHQ–4 scale was reported

among respondents who had complete data on all four questions (n = 17,355).

A composite scale made up of four questions. Numeric values were assigned to each response and summed across responses: 1) “Does your family own a vehicle

(such as a car, van, or truck)?” [no = 0; yes, one = 1; yes, two or more = 2]; 2) “Do you have your own bedroom?” [no = 0; yes = 1]; 3) “How many computers (including

laptops and tablets, not including game consoles and smartphones) does your family own?” [none = 0; one= 1; two = 2; more than two = 3]; and 4) “During the

past 12 months, how many times did you travel on vacation with your family?” [not at all = 0; once = 1; twice = 2; more than twice = 3]. Summed responses

(range: 0–9) were categorized into approximate tertiles based on the weighted distribution of scores in this sample: low (0–5), medium (6–7), and high (8–9). The

family affluence scale was reported among respondents who had complete data on all four questions (n = 17,878).

††

Data were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%.

Surveillance Summaries

20 MMWR / March 11, 2022 / Vol. 71 / No. 5

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE 4. Frequency of use* among middle and high school students currently (past 30-day) using each tobacco product,

†

overall and by school

level — National Youth Tobacco Survey, United States, 2021

Characteristic

1–5 days 6–19 days 20–30 days

% (95% CI)

Estimated no.

of users

% (95% CI)

Estimated no.

of users

% (95% CI)

Estimated no.

of users

Overall

E-cigarettes 44.5 (40.7–48.3) 910,000 16.2 (13.8–18.8) 330,000 39.4 (35.4–43.5) 810,000

Cigarettes 66.5 (57.8–74.3) 270,000 14.6 (10.4–20.1) 60,000 18.9 (13.6–25.7) 70,000

Cigars 67.1 (60.0–73.5) 250,000 12.2 (8.3–17.7) 40,000 20.7 (15.3–27.4) 80,000

Chewing tobacco, snuff, or dip 50.5 (40.1–60.9) 100,000 20.0 (13.8–28.0) 30,000 29.5 (22.4–37.9) 50,000

Snus 57.3 (41.7–71.6) 50,000 —

— 26.1 (15.5–40.6) 20,000

Hookahs 66.2 (57.1–74.3) 140,000 13.9 (9.0–20.9) 30,000 19.9 (14.0–27.5) 40,000

Pipe tobacco 65.3 (45.8–80.7) 50,000 — — — —

Heated tobacco products 54.3 (42.9–65.3) 90,000 23.6 (15.3–34.7) 40,000 22.1 (13.7–33.5) 30,000

Nicotine pouches 63.5 (53.5–72.5) 120,000 19.3 (11.7–30.1) 30,000 17.2 (11.3–25.3) 30,000

High school (grades 9–12)

E-cigarettes 40.2 (36.0–44.5) 690,000 16.3 (13.5–19.5) 280,000 43.6 (39.0–48.2) 750,000

Cigarettes 66.9 (56.5–75.9) 190,000 13.3 (8.7–19.7) 30,000 19.9 (13.8–27.6) 50,000

Cigars 67.3 (59.0–74.6) 210,000 12.0 (7.7–18.3) 30,000 20.7 (14.6–28.5) 60,000

Chewing tobacco, snuff, or dip 47.6 (34.8–60.6) 60,000 22.2 (14.2–33.0) 30,000 30.3 (21.8–40.2) 40,000

Snus — — — — — —

Hookahs 68.2 (57.5–77.3) 120,000 14.7 (9.3–22.6) 20,000 17.0 (11.0–25.5) 30,000

Pipe tobacco — — — — — —

Heated tobacco products 55.6 (41.7–68.7) 60,000 19.7 (12.2–30.3) 20,000 24.7 (13.6–40.6) 30,000

Nicotine pouches 64.1 (52.1–74.6) 100,000 21.0 (12.2–33.5) 30,000 15.0 (9.1–23.7) 20,000

Middle school (grades 6–8)

E-cigarettes 66.7 (60.0–72.8) 210,000 16.1 (11.3–22.6) 50,000 17.2 (12.8–22.6) 50,000

Cigarettes 68.0 (56.1–77.9) 80,000 14.8 (8.2–25.1) 10,000 17.2 (9.3–29.8) 20,000

Cigars 66.7 (51.3–79.1) 40,000 — — 20.1 (10.8–34.4) 10,000

Chewing tobacco, snuff, or dip 57.6 (43.2–70.7) 30,000 — — 28.0 (16.0–44.3) 10,000

Snus — — — — — —

Hookahs — — — — — —

Pipe tobacco — — — — — —

Heated tobacco products 51.0 (30.1–71.5) 20,000 — — — —

Nicotine pouches — — — — — —

Abbreviation: e-cigarettes = electronic cigarettes.

* Frequency of current use of e-cigarettes; cigarettes; cigars (cigars, cigarillos, or little cigars); chewing tobacco, snuff, or dip; snus; dissolvable tobacco products; pipe

tobacco; hookahs; heated tobacco products; and nicotine pouches was determined by asking respondents on how many days they smoked or used each respective

tobacco product during the past 30 days. Respondents could enter a valid response of 0–30 days. Responses were recoded as 1–5 days, 6–19 days, and 20–30 days.

†

Estimates of frequency of use of dissolvable tobacco products are statistically unreliable (overall and by school level) and are omitted from the table.

Estimated weighted total number of users was rounded down to the nearest 10,000 persons. Overall estimates might not directly total to sums of corresponding

subgroup estimates because of rounding or inclusion of students who did not self-report grade level.

Data were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%.

Surveillance Summaries

MMWR / March 11, 2022 / Vol. 71 / No. 5 21

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE 5. Flavored tobacco product* use among middle and high school students overall and among those who reported current (past 30-day)

use

†

of each tobacco product, by school level, sex, and race and ethnicity — National Youth Tobacco Survey, United States, 2021

Characteristic

Tobacco product

Any tobacco

% (95% CI)

E-cigarettes

% (95% CI)

Cigarettes

% (95% CI)

Cigars

% (95% CI)

Smokeless

tobacco**

% (95% CI)

Hookahs

% (95% CI)

Pipe tobacco

% (95% CI)

Heated tobacco

products

% (95% CI)

Nicotine pouches

% (95% CI)

Overall

Flavored tobacco

product use among

all students

††

7.2 (6.2–8.2) 6.2 (5.3–7.3) 0.6 (0.4–0.8) 0.6 (0.5–0.8) 0.6 (0.5–0.9) 0.4 (0.3–0.5) 0.1 (0.1–0.2) 0.3 (0.2–0.4) 0.5 (0.3–0.7)

Current use

Estimated weighted

no. of flavored

tobacco product

users

§§

1,950,000 1,680,000 150,000 160,000 170,000 100,000 30,000 70,000 120,000

Flavored tobacco

product use among

current tobacco

users

¶¶

79.1 (76.0–81.9) 84.7 (81.4–87.5) 38.8 (32.3–45.7) 44.4 (36.9–52.1) 70.1 (60.8–77.9) 46.6 (38.3–55.2) 34.4 (20.1–52.1) 44.0 (34.0–54.5) 61.6 (49.7–72.2)

School level

High school

(grades 9–12)

80.2 (76.8–83.3) 85.8 (82.3–88.7) 41.1 (33.2–49.5) 41.1 (32.9–49.7) 72.1 (60.3–81.5) 42.9 (33.1–53.3) —*** 41.0 (27.8–55.7) 63.9 (50.1–75.7)

Middle school

(grades 6–8)

74.6 (67.5–80.6) 79.2 (69.1–86.6) 34.8 (24.9–46.3) 59.9 (46.5–72.0) 65.5 (50.9–77.6) — — 51.5 (35.2–67.4) —

Sex

Female 84.3 (80.2–87.7) 88.8 (85.1–91.6) 41.8 (32.5–51.8) 55.8 (43.3–67.6) 61.9 (44.3–76.8) 52.2 (39.5–64.6) — 55.1 (37.6–71.4) —

Male 74.1 (70.0–77.8) 80.5 (75.7–84.6) 37.0 (28.5–46.4) 38.2 (29.9–47.3) 72.6 (61.0–81.8) 40.4 (29.5–52.4) — 35.5 (21.1–53.1) 60.3 (45.0–73.8)

Race and ethnicity

White, non-Hispanic 82.9 (79.4–85.9) 86.5 (82.5–89.7) 38.2 (29.4–47.7) 43.6 (34.8–52.8) 75.7 (62.9–85.2) 36.0 (21.6–53.4) — 37.7 (23.8–54.0) 65.2 (48.7–78.7)

Black, non-Hispanic 66.2 (58.8–72.8) 76.3 (61.8–86.6) — 46.3 (33.6–59.4) — 50.4 (36.0–64.8) — — —

Hispanic

†††

76.4 (71.2–80.9) 83.6 (78.0–88.0) 28.6 (19.4–40.1) 45.3 (29.0–62.7) — — — — —

Other, non-Hispanic 79.4 (67.1–87.9) 86.6 (72.3–94.2) — — — — — — —

Abbreviation: e-cigarettes = electronic cigarettes.

* For each respective tobacco product excluding cigarettes, current (past 30-day) users were asked, “Were any of the [tobacco product] that you used in the past 30 days flavored to taste

like menthol, mint, clove or spice, alcohol (wine, cognac), candy, fruit, chocolate, or any other flavor?” Response options were “yes,” “no,” or “don’t know.” Those who responded yes were

considered flavored tobacco product users.

†

Reported among respective current (past 30-day) users for each product. Past 30-day use of e-cigarettes was determined by asking, “During the past 30 days, on how many days did you

use e-cigarettes?” Past 30-day use of cigarettes was determined by asking, “During the past 30 days, on how many days did you smoke cigarettes?” Past 30-day use of cigars was determined

by asking, “During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?” Past 30-day use of smokeless tobacco was determined by asking the following

question for use of chewing tobacco, snuff, and dip: “During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip?” Past 30-day use of snus was determined

by asking the following question for use of snus: “During the past 30 days, on how many days did you use snus?” Past 30-day use of dissolvable tobacco products was determined by

asking the following question for use of dissolvable tobacco products: “During the past 30 days, on how many days did you use dissolvable tobacco products?” Past 30-day use of pipe

tobacco was determined by asking the following question for use of pipe tobacco: “During the past 30 days, on how many days did you smoke pipes filled with tobacco?” Past 30-day

use of hookahs was determined by asking, “During the past 30 days, on how many days did you smoke tobacco in a hookah or water pipe?” Past 30-day use of heated tobacco products

was determined by asking the following question for use of heated tobacco products: “During the past 30 days, on how many days did you use heated tobacco products?” Past 30-day

use of nicotine pouches was determined by asking the following question for use of heated tobacco products: “During the past 30 days, on how many days did you use nicotine pouches?”

Any tobacco use includes use of e-cigarettes, cigarettes, cigars (cigars, cigarillos, or little cigars), smokeless tobacco (chewing tobacco, snuff, or dip; snus; dissolvable tobacco products),

hookahs, pipe tobacco, bidis (small brown cigarettes wrapped in a leaf), heated tobacco products, and nicotine pouches on ≥1 day during the past 30 days.

Flavored cigarette use refers to menthol cigarette use. Current cigarette smokers were categorized as flavored (menthol) cigarette smokers: if they responded “yes” to the question,

“Menthol cigarettes are cigarettes that taste like mint. During the past 30 days, were the cigarettes that you usually smoked menthol?”; or if they indicated “Kool” or “Newport” as a brand

they usually smoked in the past 30 days. Usual brand was determined based on responses to two questions: 1) “During the past 30 days, what brands of cigarettes did you smoke? (Select

one or more)” and 2) “During the past 30 days, what brand of cigarettes did you usually smoke? (Choose only one answer).” If “Kool” or “Newport” was the only brand selected for the first

question, or if multiple brands were selected in the first question and “Kool” or “Newport” was selected for the second question, “Kool” or “Newport” was considered the respondent’s

usual brand. Those who selected “some other brand(s) not listed here” could provide a write-in response; write-in responses corresponding to an original response option were recoded.

Those who reported “no” or “not sure” to the menthol question or those who did not report “Newport” or “Kool” as their usual brand were categorized as nonmenthol smokers; all other

past 30-day cigarette smokers who did not provide any valid response were assigned as missing menthol smoking status.

** Flavored tobacco product use was assessed separately among current (past 30-day) users of chewing tobacco, snuff, or dip; snus; and dissolvable tobacco product users. Flavored use

was then recoded as a composite among users of any current smokeless tobacco product combined.

††

Calculated among all respondents regardless of tobacco product use status. Because of missing data, denominators for each tobacco product might be different: any tobacco (n = 20,167),

e-cigarettes (n = 20,084), cigarettes (n = 19,936), cigars (n = 19,860), smokeless tobacco [chewing tobacco, snuff, or dip; snus; dissolvable tobacco products] (n = 19,778), hookahs

(n = 19,697), pipe tobacco (n = 19,655), heated tobacco products (n = 19,501), and nicotine pouches (n = 19,500).

§§

Estimated weighted total number of flavored tobacco product users was rounded down to the nearest 10,000 persons.

¶¶

Calculated among current users of any tobacco (n =1,792), e-cigarettes (n = 1,383), cigarettes (n = 314), cigars (n = 299), smokeless tobacco (n = 210), hookahs (n = 168), pipe tobacco

(n = 64), heated tobacco products (n = 133), and nicotine pouches (n = 137).

*** Data were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%.

†††

Hispanic persons could be of any race.

Surveillance Summaries

22 MMWR / March 11, 2022 / Vol. 71 / No. 5

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE 6. Reasons for first e-cigarette use* among middle and high school students who reported ever using e-cigarettes, and reasons for

current (past 30-day) e-cigarette use

†

among middle and high school students who reported currently using e-cigarettes, overall and by school

level — National Youth Tobacco Survey, United States, 2021

Characteristic

Among ever e-cigarette users Among current e-cigarette users

% (95% CI) Estimated no. of users

Overall

A friend [used/uses] them 57.8 (55.0–60.4) 2,990,000 28.3 (25.4–31.5) 560,000

I [was/am] curious about them 47.6 (45.4–49.9) 2,460,000 10.3 (8.5–12.6) 200,000

I [was/am] feeling anxious, stressed, or depressed 25.1 (23.0–27.4) 1,300,000 43.4 (39.4–47.4) 860,000

To get a high or buzz from nicotine 23.3 (21.5–25.2) 1,200,000 42.8 (38.4–47.4) 850,000

A family member [used/uses] them 18.6 (16.5–20.9) 960,000 8.7 (7.0–10.8) 170,000

I [could/can] use them to do tricks 16.5 (14.5–18.7) 850,000 20.0 (17.5–22.7) 390,000

They [were/are] available in flavor, such as menthol, mint,

candy, fruit, or chocolate

13.5 (12.0–15.0) 690,000 13.2 (11.1–15.6) 260,000

I [could/can] use them unnoticed at home or at school 10.8 (9.5–12.4) 560,000 13.0 (10.9–15.3) 250,000

They are less harmful than other forms of tobacco,

such as cigarettes

8.3 (7.1–9.6) 420,000 10.3 (8.3–12.7) 200,000

They [were/are] easier to get that other tobacco products,

such as cigarettes

4.8 (3.8–6.0) 240,000 6.0 (4.7–7.7) 120,000

I’ve seen people on TV, online, or in movies use them 4.5 (3.7–5.6) 230,000 2.9 (2.1–4.0) 50,000

To try to quit using other tobacco products, such as cigarettes 2.5 (1.9–3.4) 130,000 4.6 (3.5–6.1) 90,000

They cost less than other tobacco products, such as cigarettes 2.2 (1.6–2.9) 110,000 4.7 (3.4–6.6) 90,000

Some other reason 10.6 (9.2–12.1) 540,000 19.5 (16.9–22.5) 380,000

High school (grades 9–12)

A friend [used/uses] them 60.6 (57.7–63.4) 2,630,000 27.6 (24.6–30.8) 460,000

I [was/am] curious about them 47.2 (44.7–49.7) 2,050,000 9.0 (7.0–11.5) 150,000

I [was/am] feeling anxious, stressed, or depressed 24.5 (22.0–27.2) 1,060,000 43.2 (38.5–48.1) 720,000

To get a high or buzz from nicotine 24.9 (22.9–26.9) 1,080,000 45.3 (40.4–50.3) 750,000

A family member [used/uses] them 16.0 (13.9–18.4) 690,000 6.3 (4.8–8.3) 100,000

I [could/can] use them to do tricks 16.4 (14.2–18.8) 710,000 19.5 (16.9–22.5) 320,000

They [were/are] available in flavor, such as menthol, mint,

candy, fruit, or chocolate

13.2 (11.7–14.8) 570,000 13.2 (11.1–15.7) 220,000

I [could/can] use them unnoticed at home or at school 11.2 (9.6–13.0) 480,000 13.9 (11.7–16.5) 230,000

They are less harmful than other forms of tobacco,

such as cigarettes

8.3 (7.2–9.6) 360,000 10.3 (8.2–13.0) 170,000

They [were/are] easier to get that other tobacco products,

such as cigarettes

4.5 (3.4–6.0) 190,000 5.5 (4.1–7.3)

90,000

I’ve seen people on TV, online, or in movies use them 4.4 (3.5–5.6) 190,000 2.5 (1.7–3.6) 40,000

To try to quit using other tobacco products, such as cigarettes 2.3 (1.6–3.3) 100,000 4.1 (2.9–5.9) 60,000

They cost less than other tobacco products, such as cigarettes 1.9 (1.3–2.7) 80,000 4.1 (2.8–6.1) 60,000

Some other reason 9.0 (7.6–10.7) 390,000 19.0 (16.1–22.4) 310,000

Middle school (grades 6–8)

A friend [used/uses] them 42.6 (37.8–47.7) 340,000 31.7 (24.1–40.4) 90,000

I [was/am] curious about them 49.4 (44.1–54.9) 400,000 17.8 (13.4–23.3) 50,000

I [was/am] feeling anxious, stressed, or depressed 28.1 (24.6–31.9) 230,000 45.0 (38.8–51.4) 140,000

To get a high or buzz from nicotine 14.5 (11.0–19.0) 110,000 29.2 (22.7–36.6) 90,000

A family member [used/uses] them 32.0 (28.2–36.1) 260,000 21.0 (15.9–27.2) 60,000

I [could/can] use them to do tricks 16.3 (12.9–20.4) 130,000 22.2 (15.3–31.1) 60,000

They [were/are] available in flavor, such as menthol, mint, candy,

fruit, or chocolate

14.2 (10.8–18.5) 110,000 12.1 (7.8–18.1) 30,000

I [could/can] use them unnoticed at home or at school 8.3 (6.0–11.4) 60,000 8.1 (4.7–13.7) 20,000

They are less harmful than other forms of tobacco, such as

cigarettes

7.7 (5.4–10.9) 60,000 10.0 (6.3–15.7) 30,000

They [were/are] easier to get that other tobacco products,

such as cigarettes

6.0 (3.9–9.0) 40,000 7.8 (4.7–12.6) 20,000

I’ve seen people on TV, online, or in movies use them 4.9 (3.5–6.7) 30,000 —

—

To try to quit using other tobacco products, such — — 6.0 (3.4–10.5) 10,000

They cost less than other tobacco products, such as cigarettes — — 7.5 (4.3–12.9) 20,000

Some other reason 18.4 (15.1–22.3) 150,000 22.0 (14.9–31.1) 60,000

Abbreviations: e-cigarettes = electronic cigarettes; TV = television.

* Responses to the question, “Why did you first use an e-cigarette? (Select one or more)” were assessed among students who reported “yes” to the question, “Have

you ever used an e-cigarette, even once or twice?” Respondents indicating “some other reason” could specify through write-in option; write-ins were not examined

in this report (n = 275).

†

Responses to the question, “Why did you currently use e-cigarettes? (Select one or more)” were assessed among students who reported using e-cigarettes on

1–30 days, from the question, “During the past 30 days, on how many days did you use e-cigarettes? Respondents indicating “some other reason” could specify

through write-in option; write-ins were not examined in this report (n = 195).

Estimated weighted total numbers of ever and current e-cigarette users were rounded down to the nearest 10,000 persons. Overall estimates might not directly

total to sums of corresponding subgroup estimates because of rounding or inclusion of students who did not self-report grade level.

Data were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%.

Surveillance Summaries

MMWR / March 11, 2022 / Vol. 71 / No. 5 23

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE 7. Access to tobacco products*

,†

among middle and high school students who reported current (past 30-day) use of each tobacco

product — National Youth Tobacco Survey, United States, 2021

Access to each

tobacco product

Tobacco product

Any tobacco

% (95% CI)

E-cigarettes

% (95% CI)

Cigarettes

% (95% CI)

Cigars

% (95% CI)

Smokeless

tobacco

% (95% CI)

Hookahs

% (95% CI)

Pipe tobacco

% (95% CI)

Heated tobacco

products

% (95% CI)

Nicotine pouch

% (95% CI)

How did you get your [tobacco product]?

I got them from a

friend

32.8 (29.7–36.0) 32.3 (28.7–36.2) 18.4 (13.5–24.7) 22.1 (16.2–29.2) 26.3 (18.5–35.9) 23.9 (16.8–33.0) —** 23.4 (12.8–39.0) 22.7 (14.9–33.0)

I bought them myself 31.3 (28.5–34.2) 31.1 (27.4–35.0) 22.0 (16.3–29.0) 29.8 (23.4–37.0) 24.1 (17.6–32.1) 18.3 (12.8–25.5) — 14.6 (8.8–23.2) —

I had someone else

buy them for me

28.8 (26.0–31.8) 28.7 (25.7–31.8) 13.6 (9.4–19.1) 23.7 (17.7–31.1) 26.8 (19.8–35.3) 15.7 (9.9–24.2) — 24.5 (14.8–37.7) 17.7 (11.2–27.0)

Someone offered

them to me

26.3 (23.1–29.7) 21.7 (19.2–24.4) 16.4 (10.7–24.2) 22.8 (17.3–29.4) 27.8 (19.5–37.9) 26.5 (18.8–35.8) 32.0 (19.5–47.8) 23.7 (15.6–34.2) 24.6 (17.2–33.9)

I asked someone to

give me some

19.4 (16.6–22.6) 16.3 (13.8–19.2) 20.2 (14.6–27.3) 14.3 (8.9–22.2) 23.6 (15.4–34.4) 22.1 (13.0–35.0) 22.8 (12.2–38.6) — 13.3 (7.1–23.3)

I got them from a

family member

14.5 (12.3–17.1) 10.2 (8.2–12.6) 17.5 (12.7–23.6) 16.7 (12.1–22.6) 20.5 (13.7–29.5) 19.5 (11.9–30.3) — 15.8 (8.5–27.7) —

I took them from a

store or another

person

6.0 (4.6–7.7) 3.3 (2.4–4.6) 12.2 (8.0–18.2) 6.5 (3.8–10.7) 9.2 (5.2–15.7) — — — —

I got them in some

other way

21.3 (19.0–23.8) 15.7 (13.1–18.6) 21.8 (16.3–28.5) 22.7 (16.6–30.3) 23.5 (16.7–31.9) 24.6 (17.5–33.3) 23.4 (15.3–34.1) 27.5 (20.1–36.5) 20.6 (11.7–33.8)

Where did you buy your [tobacco product]?

I did not buy them 48.6 (45.9–51.4) 37.2 (34.2–40.3) 48.0 (40.9–55.2) 33.2 (26.1–41.1) 33.4 (24.2–44.0) 54.2 (45.7–62.5) 37.0 (25.0–50.8) 33.2 (24.2–43.5) 34.3 (24.3–46.0)

Bought them from

another person

(friend, family

member, someone

else)

22.5 (19.4–26.1) 21.5 (18.2–25.2) 14.7 (10.3–20.5) 13.4 (9.2–19.0)

21.0 (14.4–29.4) — 23.6 (13.2–38.6) 24.2 (15.5–35.8) 13.9 (7.9–23.3)

A vape shop or

tobacco shop

20.2 (16.8–24.0) 22.2 (18.3–26.6) 7.0 (4.1–11.7) 12.2 (8.2–17.8) — — — — —

A gas station,

convenience store

19.6 (16.9–22.7) 17.7 (14.4–21.5) 17.1 (12.1–23.6) 34.1 (26.2–42.9) 17.9 (11.2–27.3) 8.5 (4.7–15.0) — — —

A drugstore

4.8 (3.5–6.5) 3.7 (2.6–5.4)

— —

5.0 (2.8–8.8)

— — — —

A grocery store

4.8 (3.6–6.4) 2.6 (1.6–4.0) 5.3 (3.0–9.1)

—

10.3 (5.8–17.7)

— — — —

Through the mail 3.6 (2.4–5.4) 2.2 (1.3–3.8) — — 6.7 (3.7–11.9) — — — —

On the Internet

3.5 (2.5–4.8) 2.9 (1.9–4.5)

— — — — — — —

A mall or shopping

center kiosk or

stand

3.2 (2.1–4.9) 1.7 (1.0–2.8) — — — — — — —

A vending machine 2.9 (2.1–4.2) 1.8 (1.2–2.8) — — — 6.9 (3.7–12.2) — — —

Through a delivery

service

2.4 (1.6–3.5) 1.6 (0.9–2.5) — — — — — — —

Some other place 15.8 (13.8–18.1) 12.3 (10.5–14.4) 17.9 (12.6–24.8) 14.5 (9.6–21.3) 22.2 (16.3–29.3) 18.9 (11.0–30.4) — 19.8 (13.2–28.7) 21.5 (13.0–33.4)

Abbreviation: e-cigarettes = electronic cigarettes.

* “During the past 30 days, how did you get your [e-cigarette devices, pods, cartridges, or e-liquid refills; cigarettes; cigars, cigarillos, or little cigars; chewing tobacco, snuff, or dip; hookahs;

pipe tobacco; snus; dissolvable tobacco products; heated tobacco products; nicotine pouches]? (Select one or more).”

†

“During the past 30 days, where did you buy your [e-cigarette devices, pods, cartridges, or e-liquid refills; cigarettes; cigars, cigarillos, or little cigars; chewing tobacco, snuff, or dip; hookahs;

pipe tobacco; snus; dissolvable tobacco products; heated tobacco products; nicotine pouches]

Any tobacco use includes use of e-cigarettes, cigarettes, cigars (cigars, cigarillos, or little cigars), smokeless tobacco (chewing tobacco, snuff, or dip; snus; or dissolvable tobacco products),

hookahs, pipe tobacco, bidis (small brown cigarettes wrapped in a leaf), heated tobacco products and nicotine pouches on ≥1 day during the past 30 days.

Access (“how did you get …” and “where did you buy …”) during the past 30 days was assessed separately for smokeless tobacco products (chewing tobacco, snuff, or dip; snus; or dissolvable

tobacco products). Access was then recoded as a smokeless composite among students who reported past 30-day use of one or more smokeless tobacco product.

** Data were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%.

Surveillance Summaries

24 MMWR / March 11, 2022 / Vol. 71 / No. 5

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE 8. Recognition of public education campaign advertisements against tobacco product use in the past 12 months* among middle and

high school students, overall and by school level — National Youth Tobacco Survey, United States, 2021

Characteristic

Sex Race and ethnicity

Total

Male

% (95% CI)

Female

% (95% CI)

White, non-

Hispanic

% (95% CI)

Black, non-

Hispanic

% (95% CI)

Hispanic

†

% (95% CI)

Other, non-

Hispanic

% (95% CI) % (95% CI) Estimated no.

Overall

One or more 78.3 (76.5–79.9) 71.9 (70.3–73.5) 79.2 (77.6–80.8) 75.8 (73.2–78.3) 69.8 (67.7–71.7) 67.6 (62.4–72.3) 75.2 (73.7–76.6) 19,560,000

The Real Cost 65.0 (62.7–67.3) 56.5 (54.4–58.5) 66.5 (64.5–68.6) 54.9 (51.3–58.4) 55.0 (52.9–57.1) 54.8 (49.0–60.5) 60.9 (58.9–62.8) 15,830,000

Truth 41.7 (39.4–43.9) 37.7 (35.8–39.6) 43.9 (41.5–46.3) 38.2 (34.7–41.8) 35.9 (34.2–37.6) 29.9 (26.6–33.5) 39.7 (37.9–41.6) 10,200,000

Tips, Tips from

Former Smokers

19.9 (18.6–21.2) 19.7 (18.5–21.1) 21.8 (20.4–23.2) 20.8 (18.3–23.5) 16.9 (15.7–18.2) 16.5 (12.9–20.9) 19.8 (18.7–20.9) 5,080,000

Fresh Empire 7.5 (5.5–10.1) 6.3 (5.5–7.3) 5.4 (4.1–7.0) 17.6 (13.9–21.9) 5.9 (5.1–6.9) 4.7 (3.1–7.0) 6.9 (5.7–8.4) 1,780,000

This Free Life 5.0 (4.4–5.6) 4.5 (3.9–5.3) 4.7 (3.9–5.5) 5.8 (4.6–7.2) 4.7 (3.9–5.6) 4.7 (3.2–6.8) 4.8 (4.3–5.3) 1,220,000

Some other advertisement 12.0 (11.0–13.0) 11.3 (10.4–12.3) 11.0 (10.0–12.0) 13.7 (11.9–15.6) 12.2 (11.2–13.3) 10.6 (8.5–13.1) 11.7 (11.0–12.4) 2,990,000

High school (grades 9–12)

One or more 82.4 (80.4–84.3) 76.1 (73.9–78.2) 84.1 (82.5–85.5) 78.0 (74.6–81.1) 71.3 (68.4–74.1) 74.0 (68.2–79.0) 79.4 (77.7–81.1) 11,570,000

The Real Cost 69.4 (66.6–72.1) 61.7 (59.2–64.2) 71.9 (69.5–74.2) 56.6 (52.4–60.6) 57.9 (55.4–60.3) 61.3 (52.6–69.3) 65.8 (63.4–68.0) 9,560,000

Truth 48.4 (45.7–51.0) 44.2 (41.8–46.7) 51.4 (49.1–53.7) 40.8 (36.3–45.5) 40.3 (37.5–43.1) 37.0 (30.7–43.8) 46.4 (44.1–48.7) 6,680,000

Tips, Tips from

Former Smokers

21.7 (20.0–23.5) 20.2 (18.3–22.2) 23.2 (21.5–25.0) 21.6 (18.1–25.5) 17.5 (15.7–19.4) 14.3 (10.2–19.7) 21.0 (19.6–22.5) 3,020,000

Fresh Empire 10.1 (7.0–14.3) 7.5 (6.2–8.9) 6.7 (4.9–9.2)

22.8 (17.3–29.4) 7.1 (5.7–8.8) 6.2 (3.9–9.6) 8.8 (6.9–11.2) 1,270,000

This Free Life 5.2 (4.4–6.0) 4.7 (3.9–5.7) 4.6 (3.8–5.6) 5.0 (3.8–6.6) 5.4 (4.4–6.6) 6.1 (4.1–9.0) 4.9 (4.4–5.6) 710,000

Some other advertisement 10.7 (9.6–12.0) 8.6 (7.6–9.8) 9.0 (7.9–10.3) 12.3 (9.9–15.2) 10.0 (8.7–11.6) 10.1 (6.9–14.5) 9.7 (8.9–10.6) 1,400,000

Middle school (grades 6–8)

One or more 72.9 (70.6–75.0) 66.8 (64.7–68.8) 72.4 (70.1–74.6) 73.1 (69.2–76.7) 68.0 (65.1–70.6) 62.2 (55.8–68.2) 69.8 (68.0–71.6) 7,940,000

The Real Cost 59.5 (56.5–62.4) 50.1 (47.4–52.8) 59.0 (56.5–61.5) 52.8 (46.4–59.1) 51.8 (47.7–55.8) 49.4 (43.5–55.3) 54.8 (52.4–57.3) 6,250,000

Truth 32.9 (30.9–34.9) 29.6 (27.8–31.5) 33.0 (30.8–35.2) 34.6 (30.5–38.8) 30.8 (28.3–33.3) 23.8 (20.2–27.8) 31.2 (29.7–32.8) 3,490,000

Tips, Tips from

Former Smokers

17.5 (16.0–19.1) 19.2 (17.9–20.6) 19.7 (18.0–21.5) 19.8 (16.8–23.1) 16.3 (14.6–18.0) 18.5 (14.7–23.0) 18.3 (17.1–19.5) 2,040,000

Fresh Empire 4.1 (3.4–5.0) 5.0 (4.0–6.1) 3.4 (2.6–4.6) 10.5 (7.8–14.1) 4.6 (3.4–6.0) —

4.5 (3.8–5.3) 500,000

This Free Life 4.7 (3.8–5.8) 4.4 (3.4–5.5) 4.7 (3.5–6.3) 6.8 (4.9–9.5) 3.9 (3.0–4.9) — 4.5 (3.8–5.4) 500,000

Some other advertisement 13.6 (12.1–15.1) 14.6 (13.4–16.0) 13.7 (12.3–15.2) 15.6 (13.4–18.1) 14.6 (13.0–16.4) 11.0 (9.1–13.3) 14.1 (13.2–15.0) 1,580,000

Abbreviation: e-cigarettes = electronic cigarettes.

* All respondents were asked, “In the past 12 months, have you seen or heard “The Real Cost,” on television, the internet, social media, or radio as part of ads about tobacco?” Response options

included “yes,” “no,” and “not sure.” Those who selected “yes” were considered to have recognized the advertisement. Additionally, all respondents were asked, “In the past 12 months, have

you seen or heard any other ads against tobacco with the following names or slogans on television, the internet, social media, or on the radio? (Select one or more).” Response options

included : “Truth,” “Tips or Tips from Former Smokers,” “Fresh Empire,” “This Free Life,” “some other ad”; or exclusively select “I haven’t seen or heard any of these ads.” A composite of having

recognized at least one ad was also assessed. Those who indicated “some other ad” could specify with a write-in response; analysis of these write-in responses (n = 892) was not included

in this report.

†

Hispanic persons could be of any race.

Estimated weighted total number of flavored tobacco product users was rounded down to the nearest 10,000 persons. Overall estimates might not directly total to sums of corresponding

subgroup estimates because of rounding or inclusion of students who did not self-report grade level.

Data were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%.

Surveillance Summaries

MMWR / March 11, 2022 / Vol. 71 / No. 5 25

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE 9. Exposure* to sources of tobacco product marketing (advertisements or promotions) among middle and high school students who

reported contact with each source, overall and by school level, sex, and race and ethnicity — National Youth Tobacco Survey, United States, 2021

Characteristic

Retail

stores

†

% (95% CI)

Internet

% (95% CI)

Television, streaming

services, or

movies

% (95% CI)

Newspapers

magazines**

% (95% CI)

Any

source

††

% (95% CI)

Prevalence of exposure to any tobacco product marketing (e-cigarettes, cigarettes, and other tobacco products)

Overall 65.4 (63.6–67.1) 43.9 (42.3–45.4) 30.3 (28.9–31.8) 34.0 (32.6–35.4) 75.7 (74.3–77.0)

Estimated no.

§§

16,240,000 11,050,000 7,460,000 4,830,000 19,210,000

Sex

Male 64.2 (62.3–66.1) 40.9 (39.2–42.6) 27.4 (25.9–29.0) 33.4 (31.5–35.3) 73.2 (71.7–74.8)

Female 66.6 (64.6–68.6) 46.9 (45.3–48.6) 33.3 (31.6–34.9) 34.6 (32.8–36.4) 78.3 (76.8–79.8)

Race and ethnicity

White, non-Hispanic 69.9 (67.7–71.9) 42.8 (40.6–45.0) 27.8 (26.0–29.8) 33.1 (31.1–35.0) 78.1 (76.5–79.6)

Black, non-Hispanic 61.7 (59.2–64.1) 49.2 (47.0–51.3) 39.7 (36.5–43.1) 36.2 (33.4–39.2) 76.0 (73.7–78.3)

Hispanic

¶¶

61.3 (59.6–63.0) 45.0 (42.9–47.0) 31.9 (30.0–33.8) 35.0 (32.7–37.3) 73.9 (72.3–75.3)

Other, non-Hispanic 53.9 (50.4–57.5) 40.6 (36.0–45.3) 27.7 (24.5–31.1) 34.1 (28.9–39.7) 66.0 (62.3–69.5)

School level

High school (grades 9–12) 69.7 (67.4–71.9) 45.8 (43.8–47.8) 32.6 (30.4–34.9) 35.6 (33.7–37.5) 79.6 (78.0–81.1)

Middle school (grades 6–8) 59.8 (57.7–61.9) 41.2 (39.3–43.2) 27.3 (25.5–29.2) 31.6 (29.5–33.8) 70.7 (69.1–72.3)

Exposure to e-cigarette marketing***

Overall 58.7 (56.9–60.5) 36.0 (34.8–37.2) 21.7 (20.5–23.0) 28.7 (27.2–30.1) 70.3 (68.8–71.7)

Estimated no. 14,370,000 8,970,000 5,240,000 3,500,000 17,770,000

Sex

Male 57.5 (55.6–59.4) 33.7 (32.3–35.1) 19.8 (18.5–21.2) 28.3 (26.3–30.4) 67.7 (66.1–69.3)

Female 60.0 (57.9–62.0) 38.4 (37.0–39.8) 23.6 (22.2–25.0) 29.1 (27.2–31.0) 73.0 (71.3–74.6)

Race and ethnicity

White, non-Hispanic 63.6 (61.5–65.7) 35.9 (34.2–37.6) 19.3 (17.7–21.1) 27.7 (25.8–29.7) 73.1 (71.4–74.7)

Black, non-Hispanic 52.4 (49.8–55.0) 38.6 (36.7–40.5) 30.4 (27.7–33.2) 30.6 (27.2–34.3) 70.4 (68.0–72.7)

Hispanic 54.7 (52.9–56.6) 36.2 (34.7–37.8) 23.1 (21.6–24.7) 30.4 (28.0–32.9) 67.7 (65.8–69.4)

Other, non-Hispanic 47.3 (43.5–51.1) 33.1 (29.0–37.5) 20.2 (17.2–23.5) 26.6 (21.4–32.5) 60.0 (56.1–63.8)

School level

High school (grades 9–12) 63.2 (60.8–65.6) 38.1 (36.4–39.8) 23.3 (21.5–25.3) 29.4 (27.4–31.6) 74.3 (72.6–75.9)

Middle school (grades 6–8) 52.8 (50.9–54.8) 33.2 (31.6–34.8) 19.5 (18.1–21.0) 27.4 (25.4–29.6) 65.1 (63.4–66.7)

See table footnotes on the next page.

Surveillance Summaries

26 MMWR / March 11, 2022 / Vol. 71 / No. 5

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE 9. (Continued) Exposure* to sources of tobacco product marketing (advertisements or promotions) among middle and high school

students who reported contact with each source, overall and by school level, sex, and race and ethnicity — National Youth Tobacco Survey,

United States, 2021

Characteristic

Retail

stores

†

% (95% CI)

Internet

% (95% CI)

Television, streaming

services, or

movies

% (95% CI)

Newspapers

magazines**

% (95% CI)

Any

source

††

% (95% CI)

Exposure to cigarette and other tobacco product marketing

†††

Overall 50.9 (49.1–52.7) 27.0 (25.5–28.5) 21.4 (20.1–22.7) 25.5 (24.3–26.8) 59.1 (57.2–60.9)

Estimated no. 12,100,000 6,500,000 5,040,000 2,920,000 14,550,000

Sex

Male 49.6 (47.8–51.4) 25.1 (23.4–26.8) 19.4 (18.0–20.8) 24.7 (23.2–26.1) 56.8 (54.9–58.7)

Female 52.4 (50.2–54.6) 28.9 (27.0–30.8) 23.4 (21.9–25.0) 26.3 (24.6–28.2) 61.5 (59.1–63.9)

Race and ethnicity

White, non-Hispanic 54.9 (52.5–57.2) 25.6 (23.6–27.6) 19.3 (17.8–20.9) 25.2 (23.5–26.9) 61.8 (59.3–64.2)

Black, non-Hispanic 47.4 (44.6–50.1) 32.5 (30.3–34.7) 28.0 (25.4–30.8) 28.4 (26.1–30.9) 58.9 (56.3–61.4)

Hispanic 48.0 (46.2–49.8) 28.0 (26.1–29.9) 23.3 (21.6–25.0) 24.9 (22.7–27.4) 56.9 (55.1–58.7)

Other, non-Hispanic 40.2 (36.7–43.7) 25.4 (21.5–29.7) 18.8 (15.7–22.4) 24.9 (20.8–29.5) 49.3 (44.9–53.6)

School level

High school (grades 9–12) 53.9 (51.6–56.2) 27.3 (25.3–29.3) 23.3 (21.4–25.2) 27.0 (25.3–28.9) 61.7 (59.4–63.9)

Middle school (grades 6–8) 47.1 (44.8–49.4) 26.4 (24.7–28.2) 19.0 (17.5–20.5) 23.2 (21.1–25.4) 55.7 (53.4–57.9)

Abbreviations: e-cigarettes = electronic cigarettes; TV = television.

* Exposure to tobacco product marketing was assessed for each of four marketing sources (retail stores; Internet; television, streaming sources, or movies; and

newspapers or magazines) and any source combined. For each source, exposure was assessed separately for 1) e-cigarettes and 2) cigarettes or other tobacco

products. A composite measure of exposure to any tobacco product marketing was also assessed. Prevalence of exposure to tobacco product marketing was

restricted to students who reported using each source.

†

Assessed by the questions, “When you go to a convenience store, supermarket, or gas station, how often do you see ads or promotions for (e-cigarettes; cigarettes

or other tobacco products)?” Response options for both questions included, “I never go to a convenience store, supermarket, or gas station,” “never,” “rarely,”

“sometimes,” “most of the time,” and “always.” Respondents were categorized as exposed if they reported “sometimes,” “most of the time,” or “always”; respondents

were categorized as unexposed if they reported “never” or “rarely.” Persons who reported “I never go to a convenience store, supermarket, or gas station” were set

to missing and excluded from product-specific analyses. Total unweighted denominators included n = 18,065 (e-cigarettes) and n = 17,571 (cigarettes or other

tobacco products). A composite measure of exposure to any tobacco product marketing when going to retail stores (e-cigarettes and cigarettes or other tobacco

products) was assessed among respondents who had visited a retail outlet and had nonmissing data for at least one measure (n = 18,361).

Assessed by the questions, “When you are using the Internet, how often do you see ads or promotions for (e-cigarettes; cigarettes or other tobacco products)?”

Response options for both questions included, “I do not use the Internet,” “never,” “rarely,” “sometimes,” “most of the time,” and “always.” Respondents were categorized

as exposed if they reported “sometimes,” “most of the time,” or “always”; respondents were categorized as unexposed if they reported “never” or “rarely.” Persons

who reported “I do not use the Internet” were set to missing and excluded from product-specific analyses. Total unweighted denominators included n = 18,408

(e-cigarettes) and n = 17,858 (cigarettes or other tobacco products). A composite measure of exposure to any tobacco product marketing when using the Internet

(e-cigarettes and cigarettes or other tobacco products) was assessed among respondents who had used the Internet and had nonmissing data for at least one

measure (n = 18,627).

Assessed by the questions, “When you watch TV or streaming services (such as Netflix, Hulu, or Amazon Prime), or go to the movies, how often do you see ads or

promotions for (e-cigarettes; cigarettes or other tobacco products)?” Response options for both questions included, “I do not watch TV or streaming services, or

go to the movies,” “never,” “rarely,” “sometimes,” “most of the time,” and “always.” Respondents were categorized as exposed if they reported “sometimes,” “most of

the time,” or “always”; respondents were categorized as unexposed if they reported “never” or “rarely.” Persons who reported “I do not watch TV or streaming services

or go to the movies” were set to missing and excluded from product-specific analyses. Total unweighted denominators for exposure to tobacco product marketing

included n = 17,883 (e-cigarettes) and n = 17,428 (cigarettes or other tobacco products). A composite measure of exposure to any tobacco product marketing

when watching television or streaming services or going to the movies (e-cigarettes and cigarettes or other tobacco products) was assessed among respondents

who had watched TV or streaming services or who went to the movies and had nonmissing data for at least one measure (n = 18,215).

** Assessed by the questions, “When you read newspapers or magazines, how often do you see ads or promotions for (e-cigarettes; cigarettes or other tobacco

products)?” Response options for both questions included, “I do not read newspapers or magazines,” “never,” “rarely,” “sometimes,” “most of the time,” and “always.”

Respondents were categorized as exposed if they reported “sometimes,” “most of the time,” or “always”; respondents were categorized as unexposed if they reported

“never” or “rarely.” Persons who reported “I do not read newspapers or magazines” were set to missing and excluded from the analyses. Total unweighted denominators

for exposure to tobacco product marketing included n = 9,082 (e-cigarettes) and n = 8,583 (cigarettes or other tobacco products). A composite measure of exposure

to any tobacco product marketing when reading newspapers or magazines (e-cigarettes and cigarettes or other tobacco products) was assessed among respondents

who had read newspapers or magazines and had nonmissing data for at least one measure (n = 10,627).

††

A composite measure of any advertising or promotion exposure (any source) was assessed based on exposure to retail stores; the Internet, television, streaming

services, movies; and newspapers or magazines. Total unweighted denominators included n = 18,696 (e-cigarettes), n = 18,220 (cigarettes or other tobacco

products), and n = 18,763 (e-cigarettes and cigarettes or other tobacco products). For each category (e-cigarettes, cigarettes or other tobacco products, and

overall), persons with missing data across each potential source or those who reported “I never go to a convenience stores, supermarket, or gas station,” “I do not

use the Internet,” “I do not watch TV or streaming services or go to the movies,” and “I do not read newspapers or magazines” were excluded from the analysis.

§§

Estimated weighted total number of students was rounded down to the nearest 10,000 persons.

¶¶

Hispanic persons could be of any race.

*** Respondents were instructed as follows: “The next five questions ask about issues related to e-cigarette advertisement. Do not think about cigarettes or other

tobacco products when answering these questions.”

†††

Respondents were instructed as follows: “The next five questions ask about issues related to advertisements for tobacco products such as cigarettes, cigars,

smokeless tobacco, hookahs, roll-your-own cigarettes, pipe tobacco, snus, dissolvable tobacco products, bidis, heated tobacco products, and nicotine pouches.

Do not think of e-cigarettes when answering these questions.”

Surveillance Summaries

MMWR / March 11, 2022 / Vol. 71 / No. 5 27

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE 10. Observance of, and engagement with, e-cigarette content on social media among middle and high school students who reported

using social media,* overall and by school level, sex, and race and ethnicity — National Youth Tobacco Survey, United States, 2021

Characteristic

Sex Race and ethnicity

Total

Female

% (95% CI)

Male

% (95% CI)

White,

non-Hispanic

% (95% CI)

Black,

non-Hispanic

% (95% CI)

Hispanic

†

% (95% CI)

Other,

non-Hispanic

% (95% CI) % (95% CI) Estimated no.

Overall

Seeing e-cigarette–related post or content

Never 23.9 (22.2–25.8) 29.1 (27.5–30.7) 23.3 (21.8–24.8) 32.3 (30.0–34.6) 28.3 (26.4–30.2) 31.1 (25.9–36.7) 26.5 (25.2–27.9) 6,060,000

Less than monthly 25.6 (24.3–26.8) 27.2 (25.7–28.7) 26.6 (25.2–28.0) 24.7 (22.6–26.8) 25.6 (24.0–27.3) 31.8 (29.0–34.6) 26.4 (25.3–27.5) 6,030,000

Monthly 14.1 (13.1–15.3) 13.2 (12.3–14.1) 14.7 (13.7–15.7) 10.5 (9.1–12.0) 13.7 (12.8–14.7) 12.1 (9.6–15.1) 13.7 (13.0–14.3) 3,120,000

Weekly 20.4 (18.8–22.2) 19.1 (17.7–20.5) 21.8 (20.1–23.5) 17.4 (15.5–19.4) 17.8 (16.2–19.5) 16.3 (13.5–19.7) 19.7 (18.5–21.0) 4,510,000

Daily 15.9 (14.5–17.4) 11.5 (10.7–12.5) 13.6 (12.3–15.1) 15.2 (13.4–17.2) 14.6 (13.4–15.9) 8.8 (6.7–11.4) 13.7 (12.8–14.7) 3,130,000

Posting pictures or videos of e-cigarette use (by self or others)**

Never 85.8 (84.5–87.0) 85.5 (84.2–86.8) 87.4 (86.0–88.6) 80.0 (77.1–82.5) 84.0 (82.6–85.3) 87.4 (84.3–89.9) 85.6 (84.6–86.6) 19,490,000

Less than monthly 6.8 (6.0–7.6) 6.3 (5.6–7.1) 6.1 (5.4–6.8) 8.0 (6.7–9.5) 7.4 (6.3–8.7) 5.8 (3.9–8.8) 6.6 (6.1–7.1) 1,490,000

Monthly 2.4 (1.9–3.0) 3.3 (2.8–3.9) 2.5 (2.1–3.0) 4.0 (3.3–5.0) 3.1 (2.6–3.7) 3.0 (2.1–4.2) 2.9 (2.5–3.2) 640,000

Weekly 3.3 (2.8–3.9) 2.6 (2.2–3.2) 2.7 (2.1–3.4) 3.6 (2.8–4.7) 3.1 (2.6–3.7) 2.7 (1.6–4.6) 2.9 (2.6–3.3) 670,000

Daily 1.8 (1.5–2.1) 2.2 (1.8–2.8) 1.3 (1.0–1.7) 4.4 (3.3–5.9) 2.4 (2.0–3.0) —

††

2.0 (1.7–2.3) 450,000

Liking, commenting, sharing e-cigarette–related posts or content

§§

Never 70.4 (69.0–71.8) 77.5 (76.2–78.7) 73.6 (72.2–74.9) 72.1 (69.8–74.3) 73.6 (72.1–75.0) 79.9 (76.1–83.3) 73.9 (72.9–74.9) 16,750,000

Less than monthly 16.9 (15.8–18.1) 13.0 (11.8–14.3) 15.8 (14.8–17.0) 15.2 (13.2–17.4) 14.1 (12.7–15.6) 12.6 (10.2–15.6) 15.0 (14.2–15.8)

3,390,000

Monthly 5.2 (4.6–5.8) 4.0 (3.4–4.6) 4.7 (4.1–5.3) 3.8 (2.9–4.9) 5.2 (4.4–6.1) 3.2 (2.1–4.8) 4.6 (4.1–5.0) 1,030,000

Weekly 5.0 (4.4–5.8) 3.5 (3.1–4.0) 4.1 (3.7–4.6) 4.6 (3.9–5.6) 4.6 (4.1–5.2) 2.9 (1.9–4.3) 4.3 (4.0–4.6) 960,000

Daily 2.5 (2.0–3.1) 2.0 (1.6–2.4) 1.7 (1.4–2.2) 4.3 (3.3–5.5) 2.6 (1.9–3.4) 1.3 (0.8–2.1) 2.3 (1.9–2.7) 510,000

High school (grades 9–12)

Seeing e-cigarette–related post or content

Never 17.7 (15.8–19.7) 22.3 (20.8–23.9) 17.2 (15.7–18.8) 29.1 (26.1–32.3) 21.5 (19.9–23.1) 23.0 (15.8–32.1) 20.0 (18.7–21.4) 2,650,000

Less than monthly 24.3 (22.8–25.8) 27.7 (25.8–29.7) 25.9 (24.1–27.7) 22.6 (20.2–25.2) 26.9 (24.9–29.0) 32.2 (28.4–36.3) 26.1 (24.7–27.5) 3,450,000

Monthly 15.3 (13.7–17.0) 15.0 (13.6–16.5) 16.2 (14.8–17.7) 12.3 (10.4–14.6) 14.3 (12.8–15.9) 14.5 (10.7–19.4) 15.1 (14.2–16.2) 2,000,000

Weekly 23.6 (21.6–25.7) 21.3 (19.6–23.1) 24.6 (22.5–26.8) 18.3 (15.6–21.3) 19.8 (17.4–22.3) 20.7 (15.9–26.5) 22.4 (20.9–24.0) 2,970,000

Daily 19.1 (17.2–21.3) 13.7 (12.4–15.1) 16.1 (14.2–18.3) 17.7 (15.4–20.2) 17.6 (15.6–19.8) 9.5 (6.7–13.4) 16.3 (15.0–17.7) 2,160,000

Posting pictures or videos of e-cigarette use (by self or others)

Never 83.9 (82.6–85.2) 84.2 (82.4–85.8) 85.9 (84.0–87.6) 79.3 (76.5–81.8) 82.0 (80.2–83.6) 85.1 (80.9–88.5) 84.0 (82.8–85.2) 11,080,000

Less than monthly 7.1 (6.2–8.1) 6.8 (5.9–7.8) 6.6 (5.6–7.7) 7.4 (5.9–9.3) 7.8 (5.7–10.6) 6.6 (4.3–10.0) 6.9 (6.3–7.7) 910,000

Monthly 2.9 (2.3–3.6) 3.8 (3.0–4.8) 2.9 (2.4–3.7) 4.5 (3.4–5.9) 3.8 (2.9–4.8) 3.3 (1.9–5.7) 3.4 (2.9–4.0) 440,000

Weekly 3.9 (3.3–4.7) 3.0 (2.5–3.6) 3.1 (2.5–3.7) 4.1 (3.0–5.5) 3.8 (3.1–4.6) — 3.4 (3.0–3.9) 450,000

Daily 2.1 (1.7–2.7) 2.3 (1.7–3.1) 1.5 (1.1–2.1) 4.7 (3.2–6.7) 2.7 (2.1–3.5) — 2.2 (1.8–2.6) 290,000

Liking, commenting, sharing e-cigarette–related posts or content

Never 66.7 (65.0–68.4) 73.7 (72.0–75.3) 69.9 (68.0–71.8) 70.9 (67.8–73.9) 69.8 (68.0–71.4) 74.6 (68.8–79.8) 70.3 (69.1–71.4) 9,230,000

Less than monthly 19.6 (18.0–21.3) 15.6 (14.1–17.3)

18.2 (16.7–19.8) 16.7 (13.9–19.8) 17.2 (15.3–19.3) 16.3 (12.7–20.6) 17.6 (16.5–18.7) 2,310,000

Monthly 5.7 (5.0–6.6) 4.9 (4.0–5.9) 5.6 (4.9–6.6) 3.5 (2.3–5.2) 5.7 (4.9–6.7) 4.0 (2.2–7.1) 5.3 (4.7–5.9) 690,000

Weekly 5.7 (4.8–6.7) 3.9 (3.3–4.6) 4.7 (4.0–5.5) 5.3 (4.2–6.7) 4.9 (4.0–6.0) 3.7 (2.4–5.7) 4.8 (4.2–5.4) 620,000

Daily 2.2 (1.7–2.9) 1.9 (1.4–2.6) 1.6 (1.2–2.0) 3.6 (2.6–5.0) 2.4 (1.7–3.5) — 2.1 (1.7–2.5) 270,000

See table footnotes on the next page.

Surveillance Summaries

28 MMWR / March 11, 2022 / Vol. 71 / No. 5

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE 10. (Continued) Observance of, and engagement with, e-cigarette content on social media among middle and high school students

who reported using social media,* overall and by school level, sex, and race and ethnicity — National Youth Tobacco Survey, United States, 2021

Characteristic

Sex Race and ethnicity

Total

Female

% (95% CI)

Male

% (95% CI)

White,

non-Hispanic

% (95% CI)

Black,

non-Hispanic

% (95% CI)

Hispanic

†

% (95% CI)

Other,

non-Hispanic

% (95% CI) % (95% CI) Estimated no.

Middle school (grades 6–8)

Seeing e-cigarette–related post or content

Never 32.2 (30.2–34.3) 39.1 (36.5–41.7) 32.8 (30.6–35.2) 37.1 (33.7–40.7) 36.9 (33.9–39.9) 38.8 (33.4–44.5) 35.5 (33.7–37.3) 3,390,000

Less than monthly 27.2 (25.4–29.0) 26.3 (24.1–28.5) 27.7 (25.7–29.8) 27.4 (24.2–30.9) 24.0 (21.6–26.5) 31.3 (27.3–35.7) 26.7 (25.3–28.2) 2,550,000

Monthly 12.6 (11.1–14.3) 10.5 (9.3–11.8) 12.3 (10.8–13.9) 7.8 (5.9–10.3) 13.0 (10.9–15.5) 9.7 (7.2–12.9) 11.6 (10.6–12.7) 1,100,000

Weekly 16.4 (14.8–18.1) 15.8 (14.0–17.7) 17.5 (15.7–19.4) 16.1 (13.9–18.6) 15.2 (13.1–17.7) 12.1 (9.5–15.2) 16.1 (14.8–17.5) 1,530,000

Daily 11.6 (10.1–13.3) 8.4 (7.1–9.8) 9.7 (8.2–11.5) 11.6 (9.2–14.4) 10.9 (9.3–12.8) 8.1 (5.5–11.8) 10.1 (9.0–11.3) 960,000

Posting pictures or videos of e-cigarette use (by self or others)

Never 88.4 (86.3–90.3) 87.6 (85.8–89.2) 89.7 (88.0–91.2) 81.3 (75.8–85.7) 86.7 (84.3–88.8) 89.6 (86.2–92.2) 88.0 (86.3–89.4) 8,370,000

Less than monthly 6.2 (5.1–7.6) 5.6 (4.8–6.6) 5.3 (4.3–6.5) 8.4 (6.5–10.8) 6.9 (5.5–8.5) — 6.0 (5.2–6.9) 570,000

Monthly 1.7 (1.2–2.4) 2.6 (2.1–3.2) 1.8 (1.4–2.4) 3.4 (2.2–5.2) 2.2 (1.5–3.3) 2.7 (1.9–3.8) 2.1 (1.8–2.6) 200,000

Weekly 2.4 (1.6–3.4) 2.1 (1.5–3.1) 2.1 (1.3–3.4) 2.9 (1.8–4.7) 2.2 (1.4–3.7) — 2.2 (1.6–3.0) 210,000

Daily 1.3 (0.9–1.9) 2.0 (1.4–2.9) 1.0 (0.6–1.7) 4.0 (2.3–6.9) 1.9 (1.3–2.9) — 1.7 (1.2–2.2) 150,000

Liking, commenting, sharing e-cigarette–related posts or content

Never 75.2 (72.9–77.4) 83.0 (81.1–84.7) 79.3 (77.4–81.1) 73.7 (70.1–77.0) 78.4 (75.6–80.9) 85.0 (81.0–88.2) 79.0 (77.3–80.5) 7,480,000

Less than monthly 13.3 (11.9–15.0) 9.3 (8.0–10.7) 12.2 (11.0–13.6) 13.0 (11.2–15.0) 10.1 (8.3–12.4) 9.2 (6.8–12.4) 11.4 (10.4–12.4) 1,070,000

Monthly 4.4 (3.6–5.3)

2.7 (2.2–3.4) 3.2 (2.6–3.9) 4.3 (3.2–5.7) 4.5 (3.4–6.0) 2.5 (1.5–4.1) 3.6 (3.0–4.2) 330,000

Weekly 4.2 (3.4–5.1) 3.0 (2.3–3.8) 3.3 (2.7–4.1) 3.7 (2.6–5.2) 4.2 (3.4–5.3) — 3.6 (3.1–4.1) 330,000

Daily 2.9 (2.1–3.8) 2.0 (1.4–2.9) 2.0 (1.4–2.8) 5.3 (3.3–8.5) 2.7 (1.9–4.0) — 2.5 (2.0–3.2) 230,000

Abbreviation: e-cigarettes = electronic cigarettes.

* All respondents were asked, “How often do you use social media?” Response options included “never/I don’t use social media”; “less than one time per week”; “about one time per week”;

“a few times per week”; “less than 1 hour, daily”; “about 1–2 hours, daily”; “about 3–4 hours, daily”; “4 hours or more, daily.” Subsequent questions on observance and engagement with

e-cigarette content were assessed among those with non-missing data who reported a response other than “never/I don’t use social media” (n = 16,960).

†

Hispanic persons could be of any race.

Estimated weighted total number of students was rounded down to the nearest 10,000 persons. Overall estimates might not directly total to sums of corresponding subgroup estimates

because of rounding or inclusion of students who did not self-report grade level.

Assessed by the question, “When you use social media, how often do you see posts or content (pictures, videos, or text) related to e-cigarettes?”

Assessed by the question, “When you use social media, how often do you post pictures or videos of yourself or someone else using e-cigarettes?”

††

Data were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%.

§§

Assessed by the question, “When you use social media, how often have you liked, comments, or shared posts or content (pictures, videos, or text) related to e-cigarettes?”

Surveillance Summaries

MMWR / March 11, 2022 / Vol. 71 / No. 5 29

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE 11. Urges to use tobacco products and quitting behaviors among middle and high school students who reported current (past 30-day)

tobacco product use,* overall and by school level, sex, and race and ethnicity — National Youth Tobacco Survey, United States, 2021

Characteristic

Past–30-day craving

†

Within 30 minutes of waking

Thinking about quitting

Past-year quit attempt**

% (95% CI)

Estimated no.

of users

††

% (95% CI)

Estimated

no. of users % (95% CI)

Estimated

no. of users % (95% CI)

Estimated

no. of users

Overall 27.2 (24.1–30.5) 620,000 19.5 (16.9–22.4) 440,000 65.3 (61.7–68.9) 1,320,000 60.2 (57.0–63.3) 1,200,000

Sex

Male 22.1 (18.3–26.5) 240,000 19.8 (16.2–24.0) 220,000 61.8 (56.5–66.8) 630,000 57.6 (53.4–61.7) 590,000

Female 32.1 (27.6–37.0) 370,000 19.4 (15.6–23.8) 220,000 69.4 (64.8–73.6) 680,000 63.0 (58.7–67.1) 600,000

Race and ethnicity

White, non-Hispanic 30.7 (26.7–34.9) 440,000 21.5 (18.6–24.7) 310,000 66.6 (62.0–70.9) 870,000 59.8 (55.9–63.5) 770,000

Black, non-Hispanic 19.4 (13.5–27.1) 40,000 11.3 (6.4–19.2) 20,000 62.0 (52.3–70.8) 130,000 63.0 (53.4–71.6) 140,000

Hispanic

§§

22.0 (17.1–27.9) 90,000 17.1 (11.7–24.4) 70,000 65.6 (58.1–72.4) 240,000 61.3 (52.0–69.8) 210,000

Other, non-Hispanic 21.1 (13.0–32.3) 10,000 —

¶¶

— 54.8 (34.4–73.8) 40,000 56.7 (35.9–75.4) 40,000

High school

(Grades 9–12)

27.1 (23.5–31.0) 500,000 21.8 (18.8–25.1) 400,000 64.9 (60.3–69.1) 1,070,000 58.2 (54.5–61.8) 950,000

Sex

Male 23.1 (18.6–28.2) 210,000 21.7 (17.7–26.4) 200,000 61.8 (55.2–68.0) 530,000 55.9 (51.4–60.3) 480,000

Female 31.4 (26.4–36.9) 280,000 22.1 (17.6–27.3) 200,000 68.7 (63.7–73.3) 540,000 60.7 (55.4–65.7) 460,000

Race and ethnicity

White, non-Hispanic 30.6 (26.2–35.5) 380,000 22.9 (19.7–26.3) 280,000 66.0 (60.8–70.8) 750,000 59.2 (55.0–63.2) 670,000

Black, non-Hispanic 20.0 (13.0–29.5) 30,000 14.1 (8.0–23.6) 20,000 59.6 (48.5–69.8) 100,000 57.4 (46.4–67.8) 90,000

Hispanic 17.7 (11.8–25.7) 50,000 20.4 (12.9–30.7) 50,000

65.4 (55.0–74.5) 160,000 57.6 (45.1–69.1) 130,000

Other, non-Hispanic

— — — — — — — —

Middle school

(grades 6–8)

28.1 (22.6–34.3) 120,000 9.4 (6.5–13.4) 30,000 67.6 (60.2–74.3) 240,000 68.4 (63.1–73.2) 240,000

Sex

Male 17.7 (12.2–25.0) 30,000 10.3 (6.2–16.7) 10,000 62.5 (52.6–71.4) 100,000 65.8 (57.3–73.4) 100,000

Female 35.6 (26.9–45.3) 80,000 8.8 (5.1–14.5) 20,000 71.6 (61.7–79.8) 130,000 71.6 (63.5–78.5) 130,000

Race and ethnicity

White, non-Hispanic 31.4 (23.2–40.9) 50,000 12.9 (8.3–19.7) 20,000 70.2 (62.2–77.1) 110,000 63.3 (55.3–70.6) 100,000

Black, non-Hispanic

— — — —

71.1 (50.4–85.6) 30,000 81.9 (69.8–89.8) 40,000

Hispanic 32.1 (22.7–43.3) 40,000

— —

67.1 (52.6–78.9) 70,000 67.7 (53.5–79.3) 70,000

Other, non-Hispanic — — — — — — — —

Abbreviation: e-cigarettes = electronic cigarettes.

* Any current tobacco product use was defined as use of any tobacco product (e-cigarettes, cigarettes, cigars [cigars, cigarillos, or little cigars], smokeless tobacco

[chewing tobacco, snuff or dip; snus; or dissolvable tobacco products], hookahs, pipe tobacco, heated tobacco products, nicotine pouches, or bidis [small brown

cigarettes wrapped in a leaf]) on ≥1 day during the past 30 days.

†

Assessed by the question, “During the past 30 days, have you had a strong craving or felt like you really needed to use a tobacco product of any kind?” The response

options were “yes” or “no.”

Assessed by the question, “How soon after you wake up do you want to use a tobacco product?” Response options were dichotomized as within 30 minutes (“within

5 minutes” or “from 6 to 30 minutes”) or not within 30 minutes (“from more than 30 minutes to 1 hour”; “after >1 hour but <24 hours”; “I rarely want to use tobacco

products”; or “I do not want to use tobacco products”).

Assessed by the question, “Are you seriously thinking about quitting the use of all tobacco products?” Response options were dichotomized as yes (“yes, during the

next 30 days”; “yes, during the next 6 months”; “yes, during the next 12 months”; or “yes, but not during the next 12 months”) or no (“no, I am not thinking about

quitting the use of all tobacco products”).

** Assessed by the question, “During the past 12 months, how many times have you stopped using all tobacco products for one day or longer because you were trying

to quit all tobacco products for good?” Response options were dichotomized as yes (“1 time,” “2 times,” “3 to 5 times,” “6 to 9 times,” or “10 or more times”) or no (“no,

I did not try to quit all tobacco products during the past 12 months”).

††

Estimated weighted total numbers of users were rounded down to the nearest 10,000 persons. Overall estimates might not directly total to sums of corresponding

subgroup estimates because of rounding or inclusion of students who did not self-report sex, race and ethnicity, or grade level.

§§

Hispanic persons could be of any race.

¶¶

Data were statistically unreliable because of unweighted denominator <50 or a relative standard error >30%.

The Morbidity and Mortality Weekly Report (MMWR) Series is prepared by the Centers for Disease Control and Prevention (CDC) and is available free

of charge in electronic format. To receive an electronic copy each week, visit MMWR at https://www.cdc.gov/mmwr/index.html.

Readers who have difficulty accessing this PDF file may access the HTML file at https://www.cdc.gov/mmwr/volumes/71/ss/ss7105a1.htm?s_

cid=ss7105a1_w. Address all inquiries about the MMWR Series to Editor-in-Chief, MMWR Series, Mailstop V25-5, CDC, 1600 Clifton Rd., N.E.,

Atlanta, GA 30329-4027 or to [email protected]v.

All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated.

MMWR and Morbidity and Mortality Weekly Report are service marks of the U.S. Department of Health and Human Services.

Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations

or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of these sites. URL addresses

listed in MMWR were current as of the date of publication.

ISSN: 1546-0738 (Print)