The Tobacco Epidemic in Youth and Adolescents in the United States
Updated: Aug 12, 2021
Rohit Saralaya, Amarillo High School, Amarillo, Texas, USA
There are 1.1 billion smokers in the world. An estimated 37 million tobacco users are youth aged 13-15 years, of which 13 million use smokeless tobacco. Tobacco use in youth is hence labeled as a “pediatric epidemic”. 90% of smokers start smoking and get addicted before the age of 25. Tobacco kills more than 8 million people globally each year, which accounts for 1 in 10 deaths worldwide. By 2030, 80% of these deaths will be in low and middle income countries (WHO Report on the Global Tobacco Epidemic, 2011).
Smoking is estimated to cost an astounding 1.4 trillion USD globally in economic damage each year. Over 80% of the world’s tobacco users live in developing nations adding to the economic and health burdens these populations already face. In some countries like Malawi (called the most tobacco-dependent country in the world), Kazakhstan and even the United States, children from poor families are employed in tobacco farming to increase family income (Ramos, Health and Human Rights Journal, 2018). The Global Youth Tobacco Survey (2012-2015) data from 61 countries showed that median youth smoking prevalence was 10.7% with the lowest rate in Sri Lanka (1.7%) and the highest in Timor-Leste (35%) (MMWR CDC, 2017).
In the United States, the tobacco epidemic is a physical, economic, and major public health threat. Approximately 1,600 youth smoke their first cigarette every day and 200 of these become new regular smokers. Half of them will ultimately die from this addiction (SAMHSA, 2018). As reported by the U.S. Surgeon General, if current tobacco usage patterns persist, an estimated 5.6 million of today’s youth — about 1 of every 13 Americans aged 17 years or younger — will die prematurely from a smoking-related illness (US Dept. of Health and Human Services, 2014).
There are various forms of tobacco use, and all forms are harmful. No level of nicotine exposure is safe. Cigarette smoking is the most common form, but other tobacco products include smokeless tobacco, cigars, pipe tobacco, waterpipe tobacco, bidis, kretek and, more recently, e-cigarettes. The serious health consequences of tobacco usage such as heart disease, strokes, COPD (Chronic Obstructive Pulmonary Disease like chronic bronchitis and emphysema), lung, oral, and other cancers are all well-known (cancer.org, 2017). What is less known is a new and dangerous lung disease called EVALI (E-cigarette or vaping product use-associated lung injury), as named by the CDC. It was first discovered in August 2019 in healthy patients who developed severe lung disease, which sometimes resulted in sudden death. Adding flavors to e-cigarettes such as chocolate, mint and bubble-gum made them more attractive to younger consumers. Misinformative statements claiming that vaping was safe and would help smokers quit further exacerbated the problem. Although a clear cause has yet to be found, EVALI appears to be associated with vitamin E acetate, which is added as a diluent to e-cigarettes. Most cases appear to be connected to e-cigarettes containing THC (tetrahydrocannabinol), a chemical derived from marijuana (Editorial, The Lancet 2020). Unfortunately, no treatment besides the empiric use of corticosteroids, antibiotics, antivirals, and supportive care is currently available for EVALI (Siegel, MMWR 2019).
Social mass media has not only normalized tobacco use but also glorified it. Tobacco commercials have traditionally targeted young men as a masculine pastime for cowboys and racecar drivers (American Lung Association, 2020). Remember the Marlboro man?
Figure 1. Malboro Man in Berlin (O-CANADA, n.d.).
Higher placement of tobacco retailers and advertisements in minority and low-income youth communities are consistent with data showing that youth from these demographics are more likely to start smoking earlier (Yu, 2010). Young people may be more likely to use tobacco products if a parent is using them in the house with easier accessibility and availability. Peer pressure to fit in and emulate friends is a big contributing factor. Biologically, young brains are more sensitive to nicotine and teenagers become dependent more quickly than adults. Mental health issues like depression, stress and low self-esteem may make youngsters more likely to use tobacco as there is expectation of a positive outcome associated with smoking such as coping with stress, appetite suppression and weight loss.
Yet amidst all these negative data lies a silver lining. The CDC and FDA analyzed national data in 2019 and 2020 from the National Youth Tobacco Survey (NYTS). This was a school-based, self-administered survey of middle and high school students to determine changes in the current (past 30-day) use of seven tobacco products. Use of all tobacco products dropped by 1.73 million users from 6.2 million in 2019 to 4.47 million students in 2020.
Figure 2. Percentage of all tobacco use in high-school students-National Youth Tobacco Survey 2019-2020 (Gentzke AS et al., 2020).
Figure 3. Percentage of all tobacco use in middle-school students-National Youth Tobacco Survey 2019-2020 (Gentzke AS et al., 2020).
What caused this positive trend and how can we capitalize on it?
Various national, state, and local programs contributed to this drop in the rate of tobacco use from 2019 to 2020. No significant change in use of these products had been seen between 2010 and 2019. In December 2019, the federal minimum age for sale of tobacco products was increased by the FDA from 18 to 21 years making these products less accessible. Increasing tobacco taxes has been the most cost-effective way to reduce usage, health-care costs and generate revenue. An increase in tobacco tax of 10% decreases consumption by 4%. The FDA issued guidelines in January 2020 to enforce steps against flavored e-cigarettes. Several states restricted the sale of flavored e-cigarettes (Cullen, 2019). States like California have enforced smoke-free laws in workplaces, restaurants, bars, and sporting events (Huang, 2015). This should become a mandate across all states to truly see a change.
Strategies to restrict advertising, limit retail outlets in poorer neighborhoods, and prohibit online price discounting have helped but more has to be done (Center for Public Health Systems Science, 2014). Insurance companies need to incentivize families with non-smokers via reduced premiums to encourage quitting. Routine screenings, education and counseling in schools will definitely have an impact. Parents also need to quit smoking and have conversations with their children about the dangers of tobacco use. Aggressive screening and treatment protocols for tobacco use at pediatricians’ offices will help. Mass media campaigns with large pictorial and graphic warnings will also motivate youths to quit tobacco use or not start in the first place. Since 9 out of 10 smokers become addicted by age 25, protecting young people in the critical window of ages 15-24 years is vital to eradicate tobacco use in the next generation (Reitsma, 2021).
For more information visit http://www.cdc.gov/tobacco/ or call the Office on Smoking and Health at 1-800-784-8669 (1-800-QUIT-NOW).
American Lung Association (2020) Tobacco Industry Marketing,https://www.lung.org/policy-advocacy/tobacco/tobacco-industry-marketing
Arrazola, R. A., Ahluwalia, I. B., Pun, E., Quevodo, I. G. de, Babb, S., & Armour, B. S. (2017, May 26). Current Tobacco Smoking and Desire to Quit Smoking Among Students Aged 13–15 Years — Global Youth Tobacco Survey, 61 Countries, 2012–2015. Morbidity and Mortality Weekly Report, Volume 66, Issue Number XX. https://www.cdc.gov/mmwr/volumes/66/wr/pdfs/mm6620.pdf
Bacon, C. (2014, July). 2014. Tobacco Prevention and Cessation Initiative: 2013 Evaluation Report. https://cphss.wustl.edu/items/type/reports-and-tools/2014-2/
Center for Disease Control (2014)Smoking and Youth, 2014 Surgeon General's Report: The Health Consequences of Smoking—50 Years of Progress. https://www.cdc.gov/tobacco/data_statistics/sgr/50th-anniversary/pdfs/fs_smoking_youth_508.pdf
Cullen, K. A., Gentzke, A. S., Sawdey, M. D., Chang, J. T., Anic, G. M., Wang, T. W., Creamer, M. L. R., Jamal, A., Ambrose, B. K., & King, B. A. (2019). E-Cigarette Use Among Youth in the United States, 2019,JAMA, 322(21), 2095. https://doi.org/10.1001/jama.2019.18387
Huang, J. (2015, August 7). The American Journal of Public Health (AJPH) from the American Public Health Association (APHA) publications. Sociodemographic Disparities in Local Smoke-Free Law Coverage in 10 States https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.302655
Ramos, A. K. (2018, December). Child Labor in Global Tobacco Production: A Human Rights Approach to an Enduring Dilemma.Child Labor in Global Tobacco Production. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6293346/
Reitsma, M. B., Flor, L. S., Mullany, E. C., Gupta, V., Hay, S. I., & Gakidou, E. (2021). Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and initiation among young people in 204 countries and territories, 1990–2019. The Lancet Public Health, 6(7). https://doi.org/10.1016/s2468-2667(21)00102-x
Siegel, D. A. (2019, October 17). Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury - United States, October 2019. Centers for Disease Control and Preventionhttps://www.cdc.gov/mmwr/volumes/68/wr/mm6841e3.htm
Smith, D. M., & Goniewicz, M. L. (2020) The role of policy in the EVALI outbreak: solution or contributor? The Lancet Respiratory Medicine, 8(4), 343–344. https://doi.org/10.1016/s2213-2600(20)30065-5
The American Cancer Society Medical and editorial content team. (2017). Health Risks of Smoking Tobacco, American Cancer Societyhttps://www.cancer.org/healthy/stay-away-from-tobacco/health-risks-of-tobacco/health-risks-of-smoking-tobacco.html.
World Health Organization (2011, August 31). WHO Report on the Global Tobacco Epidemic 2011: Warning about the dangers of tobacco.https://escholarship.org/uc/item/5np8p434.
Yu, D., Peterson, N. A., Sheffer, M. A., Reid, R. J., & Schnieder, J. E. (2010) Tobacco outlet density and demographics: Analysing the relationships with a spatial regression approach. Public Health, 124(7), 412–416. https://doi.org/10.1016/j.puhe.2010.03.024
2018 NSDUH Annual National Report: CBHSQ Data. SAMHSA.gov. (2019, August 20). https://www.samhsa.gov/data/report/2018-nsduh-annual-national-report