Trends in Smoking Behaviors AmongUS Adolescent Cigarette SmokersSunday Azagba, PhD,a Lauren Manzione, MPH,a Lingpeng Shan, MS,a Jessica King, PhDb

abstractINTRODUCTION: Identifying trends in smoking behaviors among youth cigarette smokers couldinform youth policy and interventions.

METHODS: Using 2011–2018 National Youth Tobacco Survey data, logistic/linear regressionswere used to analyze trends in smoking frequency, intensity, age of first cigarette use, andelectronic cigarette (e-cigarette) use frequency among current smokers. Stratified analyseswere conducted among male, female, middle school, and high school students and race andethnicity subgroups separately.

RESULTS: From 2011 to 2018, there was a decrease in smoking $10 days (50.0% to 38.3%),$20 days (37.2% to 26.3%), and 30 days (26.6% to 18.2%) among current smokers. Smokingprevalence decreased among male, female, high school, non-Hispanic white, and non-Hispanicother students. Overall, light smoking (#5 cigarettes per day [CPDs]) increased (76.6% to82.7%), and moderate smoking (6–10 CPDs) decreased (10.7% to 8.3%). Trends in light,moderate, and heavy smoking varied by demographic groups. Age at first cigarette useincreased among female (12.28 to 13.29), high school (12.91 to 13.18), and non-Hispanicother students (11.64 to 12.83) and decreased among male students (12.90 to 12.57). From2014 to 2018, there was an increase in e-cigarette use frequency for $10 days (20.8% to40.9%), $20 days (13.5% to 31.7%), and all 30 days (9.3% to 22%).

CONCLUSIONS: From 2011 to 2018, current youth cigarette smokers smoked fewer days and fewerCPDs, and age of first cigarette use increased. However, over time, male youth smoked moreheavily and started smoking earlier. E-cigarette use increased from 2014 to 2018. Differencesby demographic characteristics can inform future research and interventions.

WHAT’S KNOWN ON THIS SUBJECT: Cigarette use hasdeclined among youth, but it is unclear whethersmoking behaviors such as smoking frequency,smoking intensity, and age of first use have changedamong continuing smokers.

WHAT THIS STUDY ADDS: Between 2011 and 2018,current cigarette-smoking youth smoked fewer daysper month and fewer cigarettes per day, and the ageof first cigarette use increased. However, over time,male youth smoked more heavily and started smokingearlier.

To cite: Azagba S, Manzione L, Shan L, et al. Trends inSmoking Behaviors Among US Adolescent CigaretteSmokers. Pediatrics. 2020;145(3):e20193047

aDepartment of Family and Preventive Medicine, School of Medicine and bDepartment of Health and Kinesiology,College of Health, University of Utah, Salt Lake City, Utah

Dr Azagba conceptualized and designed the study and supervised all aspects of the study; Mr Shanconducted the data analysis; and all authors contributed to the drafting of the manuscript, criticallyreviewed the manuscript, and approved the final manuscript as submitted.

DOI: https://doi.org/10.1542/peds.2019-3047

Accepted for publication Dec 16, 2019

Address correspondence to Sunday Azagba, PhD, Division of Public Health, Department of Familyand Preventive Medicine, University of Utah, 375 Chipeta Way, Salt Lake City, UT 84108. E-mail:sunday.azagba@utah.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2020 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant tothis article to disclose.

FUNDING: No external funding.

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Despite years of progress, tobacco useis still the leading cause ofpreventable death in the UnitedStates.1 Since the first SurgeonGeneral Report in 1964, whichconcluded cigarette smokingsubstantially contributes to morbidityand mortality, the prevalence of adultcigarette smokers has declined from42% to 14% in 2017.1,2 However,34.3 million adults still smoke, and.480000 Americans die each yearbecause of smoking-relateddisease.1,2 Smoking is responsible for.87% of lung cancer deaths, 61% ofall pulmonary disease deaths, and32% of all deaths from coronaryheart disease.2 It has also been linkedto health conditions in all majororgans, including stroke, diabetes,tuberculosis, cancers, and many otherchronic diseases.2 In 2018, 1.18million high school students and200000 middle school studentsreported smoking cigarettes in thepast 30 days.3 Consequently, 5.6million US youth are projected to dieprematurely from smoking-relatedcauses.2

Reducing smoking among youth wasone of the goals of the 2009 FamilySmoking Prevention and TobaccoControl Act (FSPTCA).4 The actgranted the US Food and DrugAdministration (FDA) the authority toregulate the content, marketing, andsale of tobacco products.4 The use ofthis authority was specifically focusedon restricting tobacco marketing andsales to youth.4 From 2011 to 2018,the prevalence of cigarette smokingamong all US middle school and highschool students declined significantlyfrom 15.8% to 8.1%. However, little isknown about the trend of smokingbehaviors among US youth cigarettesmokers during that time.

Many studies on youth smoking haveexamined smoking prevalence,comparing results between smokersand nonsmokers.3,5–7 However, fewstudies have analyzed behaviors, suchas frequency and intensity,specifically among youth cigarette

smokers.8–12 These studies tend toinclude users and nonusers and focuson multiple products, which maymask important findings amongcigarette smokers. Despite increasesin other product use, such aselectronic cigarettes (e-cigarettes),cigarettes remain the most harmfultobacco product, and efforts shouldbe made to continue targeting youthwho smoke cigarettes. However,e-cigarettes are also of major concernbecause they are now the mostcommonly used tobacco productamong US youth. In 2018, 21% ofyouth reported past 30-daye-cigarette use compared with 8.1%of youth who reported cigaretteuse.13

Vapor products are not without riskand have been linked to .2000 casesof lung injury (e-cigarette or vapingproduct use–associated lung injury),including 47 deaths.14 In addition,most youth e-cigarette users reportpolytobacco use.15–17 Those who usecombustible cigarettes ande-cigarettes concurrently could be atrisk for increased substance abuseand other risky behavior.11,18–20

Analyzing youth smoking behaviorover time provides additional insightsto inform policy and preventionefforts. Jones et al10 found thatsmoking intensity decreased amongcurrent cigarette-smoking youth, withheavy smokers decreasing from18.0% to 7.8% and light smokersincreasing from 67.2% in 1991 to79.4% in 2009. If youth aretransitioning from heavy to lightsmoking, efforts might be focused oneducating youth that light smokingremains harmful. In addition, there isfurther understanding to be gainedfrom examining trends in youthsmoking by demographiccharacteristics given the disparities insmoking among subpopulations.7,21

Identifying differences in smokingbehaviors between demographicgroups (eg, male or female sex) couldhelp target populations who are atgreatest risk. However, to our

knowledge, no studies have examinednational trends in youth smokingbehaviors since the implementationof the FSPTCA in 2009. The currentstudy used the National YouthTobacco Survey (NYTS) to examinethe trends of smoking behaviorsamong middle and high schoolstudents in the United States from2011 to 2018.

METHODS

Data

The NYTS was designed to providecomprehensive national data ontobacco-related indicators for middleschool (grades 6–8) and high school(grades 9–12) students to supportthe design, implementation, andevaluation of comprehensive tobaccoprevention and control programs.22

The NYTS uses a stratified 3-stagecluster sample design anda weighting factor for each student,which results in nationallyrepresentative data for public,Catholic, and other private schoolstudents enrolled in grades 6 through12 in the United States. For each year,students in randomly selected USstates and the District of Columbiawere invited to participate;participation was confidential,voluntary, and approved by parents.During a regular class period,participants completed self-administered, paper-and-pencil,scannable questionnaires thatincluded questions regardingtobacco-related beliefs, attitudes,behaviors, and exposure to pro- andantitobacco influences. For each year,the overall response rates rangedfrom 63% to 89%, and the number ofparticipants ranged from 17711 to24 658. In our study, we restrictedour analysis to students who werecurrent smokers and were notmissing grade information. Currentsmokers were defined as studentswho smoked cigarettes at least oncein the 30 days before the survey onthe basis of the response to the

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survey question, “During the past 30days, on how many days did yousmoke cigarettes?” On the basis of thestudy criteria, 11 123 middle and highschool students were included in theanalyses.

Measures

The main outcome variables ofinterest were 3 smoking behaviors:smoking frequency (in days),cigarettes smoked per day, and theage of first cigarette use. Smokingfrequency items were derived fromthe question, “During the past 30days, on how many days did yousmoke cigarettes?” Possible answersincluded “0 days,” “1 or 2 days,” “3 to5 days,” “6 to 9 days,” “10 to 19 days,”“20 to 29 days,” and “all 30 days.”Consistent with a study conducted byJones et al,10 3 dichotomous variableswere created to measure trends forsmoking frequency: smokedcigarettes $10 days, smokedcigarettes $20 days, and smokedcigarettes every day (all 30 days).

Cigarettes smoked per day (smokingintensity) was derived from thequestion “During the past 30 days, onthe days you smoked, about howmany cigarettes did you smoke perday?” We categorized currentsmokers by cigarettes smoked perday into 3 categories: light smokers(#1–5 cigarettes per day [CPDs]),moderate smokers (6–10 CPDs), andheavy smokers ($11 CPDs).

Age at first cigarette use wasmeasured by using the surveyquestion, “How old were you whenyou first tried cigarette smoking, even1 or 2 puffs?” and was analyzed asa continuous variable.

E-cigarette use frequency wasderived from the question “During thepast 30 days, on how many days didyou use e-cigarettes?” for all availableyears (2014–2018). Threedichotomous variables that weresimilar to measures of smokingfrequency were created to measuretrends for e-cigarette frequency: use

e-cigarettes $10 days, usee-cigarettes $20 days, and usee-cigarettes every day (all 30 days).Demographic variables included inthe analyses were sex (male orfemale), race and ethnicity (non-Hispanic white, non-Hispanic AfricanAmerican, Hispanic, or non-Hispanicothers), and grade (6th–12th grade).Because of small sample sizes, non-Hispanic Asian American, non-Hispanic American Indian or Alaskannative, non-Hispanic Native Hawaiianor Pacific Islander, and multiple raceswere recoded into the “non-Hispanicothers” group.

Statistical Analyses

We generated national estimates ofsmoking behaviors (smokingfrequency, smoking intensity, age offirst cigarette use, and e-cigarette usefrequency) among current smokers inmiddle school and high schoolstudents for each year of dataindependently. Additionally, estimateswere calculated for the full sampleand in male, female, middle school,and high school subgroups separately.Logistic regression models were usedto test the statistical significance ofthe linear trend for measurements ofsmoking frequency, smokingintensity, and e-cigarette usefrequency. Linear regression modelswere used to test the statisticalsignificance of the linear trend of themean age of first cigarette use. Theage variable was treated asa continuous variable. Sex, race andethnicity, and grade were included ascovariates. Subgroup trend analyseswere conducted among male, female,middle school, and high schoolstudents and race and ethnicityseparately by using the samecovariates except for the stratifiedcriteria. Sampling weights and surveystratum were included in all analysesto account for the complex surveydesign. All tests were 2 sided andused a 5% significance level. All of thestatistical analyses were performedby using SAS 9.4 (SAS Institute, Inc,Cary, NC).

RESULTS

Of the 11 123 students included inour study, 8966 (83.4%) were highschool students, and 51.3% weremale. More than half of participatingstudents were non-Hispanic white(59.8%), followed by Hispanic(22.8%), non-Hispanic others (9.1%),and non-Hispanic African American(8.3%). Among the included currentsmokers, 35.2% smoked 1 to 2 daysduring the 30 days before the survey,23.5% smoked 3 to 9 days, 11.8%smoked 10 to 19 days, 8.8% smoked20 to 29 days, and 20.8% smoked all30 days. In terms of smokingintensity, 80.7% were light smokers(#5 CPDs), 9.3% were moderatesmokers (6–10), and 9.9% wereheavy smokers ($11 CPDs). Fore-cigarette use among currentsmokers, 40.3% did not usee-cigarettes during the past 30 daysbefore the survey, 15.7% used 1 to 2days, 16.9% used 3 to 9 days, 7.4%used 10 to 19 days, 5.2% used 20 to29 days, and 12.5% used all 30 days(Supplemental Table 2).

Trends in Smoking Frequency andSmoking Intensity

The trends in smoking frequency andsmoking intensity for currentcigarette users from 2011 to 2018 arepresented in Fig 1. A significantdecrease was found in all 3 measuresof smoking frequency. The percentageof current smokers smoking $10days, $20 days, and all 30 daysdecreased 11.7 percentage points(from 50.0% to 38.3%), 10.9percentage points (from 37.2% to26.3%), and 8.4 percentage points(from 26.6% to 18.2%), respectively,over the 8-year period. Light smokingamong current cigarette usersincreased significantly from 76.6% in2011 to 82.7% in 2018. Moderatesmoking decreased significantly from10.7% in 2011 to 8.3% in 2018.Heavy smoking decreased from 9.7%in 2011 to 9.0% in 2018, although thetrend was not statistically significantfor heavy smoking.

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The trends in smoking frequency andsmoking intensity for current cigaretteusers and by demographiccharacteristics from 2011 to 2018 arepresented in Figs 2 and 3 andSupplemental Fig 6. The percentage ofcurrent smokers smoking $10 days,$20 days, and all 30 days decreasedamong male, female (Fig 2), highschool (Fig 3), non-Hispanic white,and non-Hispanic other students.Similar to all current cigarette users,light smoking increased significantlyamong female (from 75.9% to 88.4%;Fig 2), high school (from 78.1% to82.1%; Fig 3), non-Hispanic white(from 78.9% to 84.1%; SupplementalFig 6), and non-Hispanic otherstudents (from 77.9% to 88.4%;Supplemental Fig 6), whereasmoderate smoking decreasedsignificantly among female (from11.0% to 7.4%; Fig 2), high school(from 12.0% to 9.2%; Fig 3), and non-Hispanic white students (from 12.5%to 9.4%; Supplemental Fig 6). Inaddition, heavy smoking decreasedsignificantly among female students(from 13.1% to 4.2%) but increasedsignificantly among male students(from 5.5% to 12.8%) from 2011 to2018 (Fig 2). No other significant

trends were observed for smokingfrequency or smoking intensity.

Trends in Age of First Cigarette Use

The trends in the age of first cigaretteuse overall and by demographiccharacteristics from 2011 to 2018 arepresented in Table 1 and SupplementalTable 3. Over the 8 years, the mean ageof first use of cigarettes increasedsignificantly from 12.56 years in 2011to 12.86 years in 2018. Similarly, in thedemographic subgroups, we founda significant increasing trend amongfemale students from 12.28 to13.29 years and among high schoolstudents from 12.91 to 13.18 yearsduring 2011–2018; however, the meanage of first use decreased significantlyamong male students during the sameperiod from 12.90 to 12.57 years. Inaddition, the mean age of first useincreased significantly from 11.64 to12.83 years among non-Hispanic otherstudents (Supplemental Table 3). Nosignificant trend in the mean age offirst use was found among otherdemographic subgroups.

Trends in E-cigarette Use Frequency

The trends in e-cigarette usefrequency among current cigarette

smokers from 2014 to 2018, stratifiedby demographic characteristics, arepresented in Figs 4 and 5. Thepercentage of current smokers usinge-cigarettes $10 days, $20 days, andall 30 days increased 20.1 percentagepoints (from 20.8% to 40.9%), 18.2percentage points (from 13.5% to31.7%), and 12.7 percentage points(from 9.3% to 22.0%), respectively,over the 4-year period (Fig 4). Asimilar increase was found amongmale, female, middle school, and highschool students as well as race andethnicity subgroups. However, thetrends were not significant for thepercentage of current female smokersusing e-cigarettes $10 days (from18.6% to 30.1%; Fig 4) andpercentage of current Hispanicsmokers using e-cigarettes $20 days(from 18.7% to 26.5%; Fig 5) or usinge-cigarettes every day (from 15.1% to20.1%; Fig 5).

DISCUSSION

We examined 2011–2018 NYTS datato determine trends in smokingfrequency, smoking intensity, and ageof first cigarette use among currentcigarette smokers. Over the period,current youth smokers smoked fewerdays and fewer CPDs, and the age offirst cigarette use increased. However,in subgroup analyses by grade and sex,we identified important differences.

The percentage of current smokerssmoking $10 days, $20 days, and all30 days decreased significantly overthe 8 years. We found that thepercentage of current smokerssmoking at least 10, 20, and all30 days decreased among male,female, high school, non-Hispanicwhite, and non-Hispanic othersubgroups. These trends highlightdecreasing cigarette use frequencyamong current cigarette smokers. Incontrast, Bold et al23 found anincrease in frequency of cigarette usefrom 2013 to 2015 among highschool students. However, Boldet al’s23 study was among

FIGURE 1Smoking frequency and smoking intensity among current cigarette smokers from 2011 to 2018. A,Smoking frequency. B, Smoking intensity. Smoking frequency was measured by the number of dayssmoked in the past 30 days: smoked cigarettes $10 days, smoked cigarettes $20 days, and smokedcigarettes every day (all 30 days). Smoking intensity was measured by the number of cigarettes smokedper day: light smokers (#1–5 CPDs), moderate smokers (6–10 CPDs), and heavy smokers ($11 CPDs).

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Connecticut students, which is nota nationally representative sample,and their analyses did not appear tocontrol for age or grade.

We found that from 2011 to 2018,most youth smokers smoked lessintensely. Notably, light smoking (#5CPDs) among current cigarette usersincreased significantly. Similarly,Jones et al10 found that light smokersincreased from 67.2% in 1991 to79.4% in 2009. We also found thatlight smoking increased significantlyamong female, high school, non-Hispanic white, and non-Hispanicother subgroups. In the current study,moderate smoking decreasedsignificantly overall and amongfemale and high school students. Thenumber of previous comparablestudies is limited, but authors ofa national study of US adults found

that from 2005 to 2014, the meannumber of cigarettes smoked foradult daily smokers decreased from16.7 to 13.8.21 Our results alsoindicate that heavy smokingdecreased significantly among femalestudents but increased significantlyamong male students from 2011 to2018, thus highlighting theimportance of stratifying by sex.

In the current study, the frequency ofe-cigarette use among currentsmokers increased significantly overthe period. This trend was alsosignificant in almost everydemographic subgroup. These resultsare in line with evidence that currentyouth e-cigarette use increased 78%from 2017 to 2018.24 This findingsuggests that some youth might bereducing cigarette use in favor ofe-cigarettes while still continuing to

smoke. Although there is someevidence that e-cigarettes containfewer toxicants than combustiblecigarettes, they still contain nicotine,ultrafine particles, chemicals, organiccompounds, and heavy metals thatcan lead to serious healthconsequences, such as e-cigarette orvaping product use–associated lunginjury and cancer.14,25 Evidence alsoshows that dual use of cigarettes ande-cigarettes is positively associatedwith illicit substance use, alcohol use,truancy, and poor academicperformance and is negatively relatedto quit intention.11,18–20 The increasewe observed in e-cigarette use amongcigarette smokers is concerning andwarrants further investigation.

Over the 8 years analyzed, the meanage of first cigarette use increasedsignificantly. In the demographic

FIGURE 2Smoking frequency and smoking intensity among current cigarette smokers from 2011 to 2018, stratified by sex. A, Smoking intensity. B, Smokingfrequency. Current cigarette smokers were defined as students who smoked cigarettes on $1 of the 30 days before the survey. Smoking frequency wasmeasured by the number of days smoked in the past 30 days: smoked cigarettes $10 days, smoked cigarettes $20 days, and smoked cigarettes everyday (all 30 days). Smoking intensity was measured by the number of cigarettes smoked per day: light smokers (#1–5 CPDs), moderate smokers (6–10CPDs), and heavy smokers ($11 CPDs). Prevalence and the 95% confidence interval (error bar) were presented for each year.

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subgroup analyses, we founda significant increasing trend amongfemale, high school, and non-Hispanicother students. However, the meanage of first use decreased significantlyamong male students during thesame period. It appears male youthsmokers are starting earlier andsmoking more intensely.

The contrast found in trends amongyoung men and women could stemfrom differences in social behaviorand roles.26 Authors of 1 study ofhigh school students concluded thatthe number of cigarettes smoked ina day is a good measure for currentsmoking among young women butnot young men.26 In a 2006 study of

high school students, smoking waspositively associated with buzz,pleasure, taste and/or smell, andstimulation and was negativelyassociated with exercise and/or sportimpairment among boys. Among girls,weight control was positivelyassociated with smoking, whereasnegative aesthetics, addiction, and

FIGURE 3Smoking frequency and smoking intensity among current cigarette smokers from 2011 to 2018, stratified by age (middle school or high school). A,Smoking frequency. B, Smoking intensity. Current cigarette smokers were defined as students who smoked cigarettes on $1 of the 30 days before thesurvey. Smoking frequency was measured by the number of days smoked in the past 30 days: smoked cigarettes$10 days, smoked cigarettes$20 days,and smoked cigarettes every day (all 30 days). Smoking intensity was measured by the number of cigarettes smoked per day: light smokers (#1–5CPDs), moderate smokers (6–10 CPDs), and heavy smokers ($11 CPDs). Prevalence and the 95% confidence interval (error bar) were presented foreach year.

TABLE 1 Age of First Cigarette Use Among Current Cigarette Smokers From 2011 to 2018, Overall and by Subgroups

Year All Studentsa Maleb Femalea Middle School High Schoola

2011 12.56 (12.40–12.71) 12.90 (12.69–13.11) 12.28 (12.07–12.49) 10.83 (10.63–11.04) 12.91 (12.74–13.09)2012 12.75 (12.57–12.93) 12.92 (12.63–13.21) 12.62 (12.45––12.80) 10.82 (10.55–11.10) 13.12 (12.94–13.29)2013 12.70 (12.49–12.90) 12.50 (12.23–12.76) 12.94 (12.68–13.19) 10.75 (10.33–11.17) 13.04 (12.83–13.24)2014 12.64 (12.42–12.86) 12.45 (12.15–12.76) 12.92 (12.66–13.19) 10.85 (10.49–11.21) 13.01 (12.80–13.21)2015 12.85 (12.60–13.11) 12.58 (12.25–12.91) 13.22 (12.93–13.51) 11.24 (10.91–11.56) 13.17 (12.88–13.45)2016 12.66 (12.42–12.90) 12.55 (12.23–12.88) 12.83 (12.50–13.16) 10.73 (10.44–11.03) 13.05 (12.80–13.30)2017 13.00 (12.74–13.27) 12.88 (12.49–13.28) 13.20 (12.90––13.51) 11.18 (10.67–11.68) 13.40 (13.10–13.69)2018 12.86 (12.63––13.10) 12.57 (12.24–12.89) 13.29 (13.01–13.57) 10.96 (10.60–11.31) 13.18 (12.94–13.43)

Data are presented as mean (95% confidence interval).a Significant increase in the mean age of first cigarette use was found from 2011 to 2018 (P , .05).b Significant decrease in the mean age of first cigarette use was found from 2011 to 2018 (P , .05).

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FIGURE 4E-cigarette use frequency among current cigarette smokers from 2014 to 2018, stratified by demographic characteristics. Current cigarette smokerswere defined as students who smoked cigarettes on$1 of the 30 days before the survey. E-cigarette use frequency was measured by the number of dayse-cigarette was used in the past 30 days: used e-cigarettes $10 days, used e-cigarettes $20 days, and used e-cigarettes every day (all 30 days). Thesmoking frequency was measured by the number of days smoked in the past 30 days: smoked cigarettes $10 days, smoked cigarettes $20 days, andsmoked cigarettes everyday (all 30 days). Prevalence and the 95% confidence interval (error bar) were presented for each year.

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negative mood were negativelyassociated with smoking.27 Thedifferences in smoking behaviors bysex are notable because they couldimpact responses to tobacco controlefforts targeted to youth.27

In our analyses of NYTS data post-FDA’s regulation of cigarettes, therewere important improvements inyouth cigarette-smoking frequency,intensity, and age of first use. As partof the FSPTCA, the FDA targets youthand young adults through educationalcampaigns such as The Real Cost.Some estimates suggest these effortshave reduced youth cigarette use,28

which is in line with our trendanalyses. However, our subgroupanalyses highlight that male youthsmokers remain a priority population.Additionally, increases in light

smoking and e-cigarette use maysuggest youth are smoking lessbut not necessarily quitting. Thus,efforts to educate youth about theharms of any tobacco use might bewarranted.

There are several limitations to thisstudy. Because analyses relied onsurvey responses, the results may besubject to recall bias. In addition, thesurvey was administered in a schoolsetting, which resulted in theexclusion of youth who are notenrolled or were not in attendance.Survey participation was alsooptional and required parentpermission, which may haveintroduced nonresponse bias. Despitelimitations, this study is unique in itsanalysis of US youth smoking trends,stratified by sex and age group.

CONCLUSIONS

In this study, we used the NYTS toexamine the trends of smokingbehaviors among middle and highschool students in the United Statesfrom 2011 to 2018. The percentage ofcurrent smokers smoking at least 10,20, and all 30 days decreasedsignificantly overall and among male,female, and high school subgroups.Past-month e-cigarette use frequencyrose significantly, surpassing cigaretteuse in 2018, highlighting the need forimproved e-cigarette prevention andcessation strategies. Light smokingamong current cigarette usersincreased significantly overall andamong female and high schoolsubgroups. Moderate smokingdecreased significantly overall andamong female and high schoolstudents. Heavy smoking decreasedsignificantly among female studentsbut increased significantly amongmale students. The mean age of firstuse of cigarettes increasedsignificantly overall and amongfemale and high school students butdecreased significantly among malestudents. Differences in resultsbetween young men and women areof particular note and can help informfuture research and interventions.

ABBREVIATIONS

CPD: cigarette per daye-cigarette: electronic cigaretteFDA: Food and Drug

AdministrationFSPTCA: Family Smoking Prevention

and Tobacco ControlAct

NYTS: National Youth TobaccoSurvey

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FIGURE 5E-cigarette use frequency among current cigarette smokers from 2014 to 2018, stratified by race andethnicity. Current cigarette smokers were defined as students who smoked cigarettes on $1 of the30 days before the survey. E-cigarette use frequency was measured by the number of dayse-cigarette was used in the past 30 days: used e-cigarettes $10 days, used e-cigarettes $20 days,and used e-cigarettes every day (all 30 days). NH, non-Hispanic.

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