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Awareness and Use of Non-conventional Tobacco Products Among U.S. Students, 2012

      Background

      Increasing diversity of the tobacco product landscape, including electronic cigarettes (e-cigarettes), hookah, snus, and dissolvable tobacco products (dissolvables), raises concerns about the public health impact of these non-conventional tobacco products among youth.

      Purpose

      This study assessed awareness, ever use, and current use of non-conventional tobacco products among U.S. students in 2012, overall and by demographic and tobacco use characteristics.

      Methods

      Data from the 2012 National Youth Tobacco Survey, a nationally representative survey of U.S. middle and high school students, were analyzed in 2013. Prevalence of awareness, ever use, and current use of e-cigarettes, hookah, snus, and dissolvables were calculated overall and by sex, school level, race/ethnicity, and conventional tobacco product use, including cigarettes, cigars, or smokeless tobacco (chewing tobacco, snuff, or dip).

      Results

      Overall, 50.3% of students were aware of e-cigarettes; prevalence of ever and current use of e-cigarettes was 6.8% and 2.1%, respectively. Awareness of hookah was 41.2% among all students, and that of ever and current use were 8.9% and 3.6%, respectively. Overall awareness; ever; and current use of snus (32%, 5.3%, 1.7%, respectively) and dissolvables (19.3%, 2.0%, 0.7%, respectively) were generally lower than those of e-cigarettes or hookah. Conventional tobacco product users were more likely to be aware of and to use non-conventional tobacco products.

      Conclusions

      Many U.S. students are aware of and use non-conventional tobacco products. Evidence-based interventions should be implemented to prevent and reduce all tobacco use among youth.

      Introduction

      Although the prevalence of cigarette smoking among U.S. high school students has declined over the past decade,
      • Arrazola R.A.
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      • Dube S.R.
      Patterns of current use of tobacco products among U.S. high school students for 2000–2012—findings from the National Youth Tobacco Survey.
      the tobacco product landscape has become more diverse during the same period. New products have been introduced to the U.S. market, including electronic cigarettes (e-cigarettes), snus, and dissolvable tobacco products (dissolvables). Additionally, hookah (also known as water pipe, shisha, or narghile smoking), used historically in other regions of the world, has become more popular in the U.S. According to the National Youth Tobacco Survey (NYTS), the prevalence of lifetime and past 30-day use of e-cigarettes doubled among U.S. middle and high school students during 2011–2012, to 6.8% and 2.1%, respectively.
      CDC
      Electronic cigarette use among middle and high school students—U.S., 2011–2012.
      Current use of hookah and dissolvables also increased among U.S. middle and high school students during this period.
      CDC
      Tobacco product use among middle and high school students—U.S., 2011–2012.
      These non-conventional tobacco products raise several concerns related to their impact on youth. Concerns include the risk of nicotine addiction, toxic effects of non-conventional products, and the potential negative impact of nicotine on adolescent brain development.
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      Further, the extent to which non-conventional product use may increase the likelihood of initiating cigarettes or other conventional tobacco products, or sustain use among those who might otherwise quit tobacco, is uncertain.
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      Although data on the health effects in U.S. populations are limited, non-conventional products have been found to contain toxicants, carcinogens, and other harmful constituents, albeit with the exception of hookah generally at much lower levels than combusted products such as cigarettes.
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      Nicotine levels in electronic cigarettes.
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      Comparison of nicotine and carcinogen exposure with water pipe and cigarette smoking.
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      Toxic and carcinogenic constituents in dissolvable tobacco products. Tobacco Products Scientific Advisory Committee. January 19, 2012.
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      New and traditional smokeless tobacco: comparison of toxicant and carcinogen levels.
      Some non-conventional tobacco products, including e-cigarettes and hookah, are not currently regulated by the U.S. Food and Drug Administration (FDA) under the 2009 Family Smoking Prevention and Tobacco Control Act and therefore are not subject to the same restrictions on manufacturing, marketing, and distribution that apply to conventional cigarettes and smokeless tobacco products. Moreover, unregulated tobacco products, such as e-cigarettes, can be purchased without age restriction in many states and on the Internet,
      The Heartland Institute
      Electronic cigarette legislation prohibiting sale to minors in other states, 2013.

      Lorillard Technologies Inc. Online sale of Blu electronic cigarettes. blucigs.com/store/.

      NJOY. Online sale of NJOY electronic cigarettes. njoy.com/.

      and they are being promoted through media channels that youth are commonly exposed to, such as TV.

      Internet Movie Database. Demo reel (Blu e-cig national TV commercial). imdb.com/video/demo_reel/vi2066392089/.

      Elliott S. E-cigarette makers’ ads echo tobacco’s heyday. The New York Times [Internet]. August 29, 2013. nytimes.com/2013/08/30/business/media/e-cigarette-makers-ads-echo-tobaccos-heyday.html?smid=pl-share.

      Little is known about use of non-conventional tobacco products among youth. Previous studies have focused on awareness or use of e-cigarettes, hookah, snus, or dissolvables among adults
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      Electronic nicotine delivery systems: adult use and awareness of the “e-cigarette” in the USA.
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      Current tobacco use among adults in the U.S.: findings from the National Adult Tobacco Survey.
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      Smokeless and flavored tobacco products in the U.S. 2009 Styles Survey results.
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      E-cigarette awareness, use, and harm perceptions in US adults.
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      • Arnetz B.B.
      Sociodemographic risk indicators of hookah smoking among white Americans: a pilot study.
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      Receptivity to Taboka and Camel Snus in a U.S. test market.
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      • Maziak W.
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      Waterpipe tobacco smoking: knowledge, attitudes, beliefs, and behavior in two U.S. samples.
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      Young adults’ perceptions about established and emerging tobacco products: results from eight focus groups.
      and college students.
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      • Wolfson M.
      Electronic cigarette use by college students.
      • Primack B.A.
      • Shensa A.
      • Kim K.H.
      • et al.
      Waterpipe smoking among U.S. university students.
      • Fielder R.L.
      • Carey K.B.
      • Carey M.P.
      Prevalence, frequency, and initiation of hookah tobacco smoking among first-year female college students: a one-year longitudinal study.
      • Cobb C.O.
      • Khader Y.
      • Nasim A.
      • Eissenberg T.
      A multiyear survey of waterpipe and cigarette smoking on a U.S. university campus.
      • Wolfson M.
      College students’ awareness and perceptions of dissolvable tobacco products. Tobacco Products Scientific Advisory Committee. January 20, 2012.
      • Sutfina E.L.
      • McCoyb T.P.
      • Reboussinb B.A.
      • Wagonera K.G.
      • Spanglerc J.
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      Prevalence and correlates of waterpipe tobacco smoking by college students in North Carolina.
      • Romito L.M.
      • Saxton M.K.
      • Coan L.L.
      • Christen A.G.
      Retail promotions and perceptions of R. J. Reynolds’ novel dissolvable tobacco in a U.S. test market.
      • Eissenberg T.
      • Ward K.D.
      • Smith-Simone S.
      • Maziak W.
      Waterpipe tobacco smoking on a U.S. College campus: prevalence and correlates.
      • Primack B.A.
      • Sidani J.
      • Agarwal A.A.
      • Shadel W.G.
      • Donny E.C.
      • Eissenberg T.E.
      Prevalence of and associations with waterpipe tobacco smoking among U.S. university students.
      • Rigotti N.A.
      • Lee J.E.
      Wechsler. U.S. college students’ use of tobacco products.
      However, comparable measures among national samples of youth have been limited until recently.
      CDC
      Electronic cigarette use among middle and high school students—U.S., 2011–2012.
      CDC
      Tobacco product use among middle and high school students—U.S., 2011–2012.
      • Amrock S.M.
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      Hookah use among adolescents in the U.S.: results of a national survey.
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      Monitoring the Future National Survey results on drug use, 1975–2012: Volume I, Secondary school students.
      No studies have assessed the prevalence and characteristics of youth awareness and ever use of non-conventional tobacco products at the national level.
      Given the concerns about the potential public health impact of non-conventional tobacco product use among youth, it is critical to monitor youth use of non-conventional tobacco products as part of broader tobacco monitoring activities in order to inform decisions on prevention of tobacco use among youth. To understand the spectrum of awareness and use of non-conventional tobacco products among youth in the U.S., data from the 2012 NYTS were analyzed to (1) estimate the prevalence of awareness, ever use, and current use of e-cigarettes, hookah, snus, and dissolvables among U.S. middle and high school students and (2) characterize patterns of awareness, ever use, and current use by selected demographic factors and other tobacco use.

      Methods

      Sample

      NYTS is an ongoing, nationally representative, school-based survey focusing on tobacco-related measures. It uses a stratified three-stage cluster sample design to produce cross-sectional, nationally representative estimates of U.S. middle (Grades 6–8) and high school (Grades 9–12) students. Details of NYTS methodology are described elsewhere.

      CDC. National Youth Tobacco Survey (NYTS). cdc.gov/tobacco/data_statistics/surveys/nyts/.

      The CDC’s IRB approved the NYTS data collection protocol. Of the 284 schools selected for participation in 2012 NYTS, 228 (80.3%) participated. A total of 24,658 (91.7%) surveys were completed by students in these schools, yielding an overall response rate of 73.6%.

      Measures

      Survey respondents were asked whether they had ever heard of, ever used, and currently use the following four non-conventional tobacco products: electronic cigarettes or e-cigarettes, such as Ruyan or NJOY, smoking tobacco from a hookah or a waterpipe, snus, such as Camel or Marlboro Snus, and dissolvable tobacco products such as Ariva, Stonewall, Camel orbs, Camel sticks, Marlboro sticks, or Camel strips.
      For each non-conventional tobacco product, awareness was defined by whether the product was selected in response to the question Which of the following tobacco products have you ever heard of? Ever use was defined by whether the product was selected in response to the question Which of the following products have you ever tried, even just one time? Current use was defined by whether each product was selected in response to the question During the past 30 days, which of the following products have you used on at least one day?
      Demographic characteristics included school level (middle or high); sex (male or female); and race/ethnicity (Hispanic, non-Hispanic white, non-Hispanic black, and other non-Hispanic, which included non-Hispanic Asian, American Indian or Alaska Native, Native Hawaiian or Pacific Islander, or those identifying as more than one race/ethnicity group). Respondents were asked about conventional tobacco product use, including (1) cigarettes; (2) cigars, cigarillos, or little cigars; and (3) smokeless tobacco (chewing tobacco, snuff, or dip). Ever use of conventional tobacco products was defined as yes to ever trying, even once or twice, any of the three products. Current use was defined as using any of the three products on at least 1 day in the past 30 days.
      Ever conventional cigarette-only smoking defined as a response of yes to ever trying cigarette smoking, even one or two puffs and never trying any other tobacco products (excluding each of the four assessed non-conventional products). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding each of the four assessed non-conventional products). Those who reported a combination of only no and missing product use responses were assigned as missing for conventional product use and cigarette-only smoking.

      Data Analysis

      Data were analyzed in 2013 using SAS-callable SUDAAN, version 11 (RTI International, Research Triangle Park NC) to provide weighted results that account for the complex sample design. Prevalence estimates and 95% CIs were calculated for awareness, ever use, and current use of e-cigarettes, hookah, snus, and dissolvables. Weighted population totals corresponding to estimates of overall use of each product were also calculated.
      Data were stratified by school level, and estimates were reported overall and by sex, race/ethnicity, and ever and current use of conventional tobacco products, cigarette-only smoking, and other non-conventional tobacco products (i.e., other than those for prevalence estimate). Differences between estimates were considered statistically significant if the 95% CIs did not overlap. Estimates with a relative SE of 40% or greater or a denominator less than 50 were not reported.

      Results

      Table 1 shows selected characteristics of the survey participants. Of students who completed the survey, 17.2% and 5.7% of middle school students reported ever and current use of conventional tobacco products, respectively. Among high school students, 44.7% and 21.7% reported ever and current use of conventional tobacco products, respectively.
      Table 1Selected characteristics of survey participants, 2012 National Youth Tobacco Survey
      n% (95% CI)
      OVERALL24,658
      MIDDLE SCHOOL11,66743.9 (39.4, 48.4)
      Sex
       Female5,79749.0 (47.9, 50.0)
       Male5,86551.0 (50.0, 52.1)
      Race/ethnicity
       White, non-Hispanic5,68752.6 (46.9, 58.3)
       Black, non-Hispanic1,36613.7 (9.2, 19.8)
       Hispanic2,61422.9 (19.5, 26.8)
       Other non-Hispanic
      Other non-Hispanic race/ethnicity includes non-Hispanic Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and multi-race.
      1,48810.8 (8.9, 13.0)
      Ever used conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes1,96717.2 (15.2, 19.4)
       No9,33982.8 (80.6, 84.8)
      Currently use conventional tobacco products
       Yes6785.7 (4.9, 6.6)
       No10,61594.3 (93.4, 95.1)
      HIGH SCHOOL12,89956.1 (51.6, 60.6)
      Sex
       Female6,43948.9 (47.7, 50.1)
       Male6,45851.1 (49.9, 52.3)
      Race/ethnicity
       White, non-Hispanic6,11454.9 (49.5, 60.1)
       Black, non-Hispanic1,74114.0 (11.0, 17.6)
       Hispanic3,09820.7 (17.4, 24.4)
       Other non-Hispanic
      Other non-Hispanic race/ethnicity includes non-Hispanic Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and multi-race.
      1,71110.5 (8.6, 12.7)
      Ever used conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes5,79844.7 (42.0, 47.5)
       No6,88655.3 (52.5, 58.0)
      Currently use conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes2,75521.7 (20.0, 23.6)
       No9,87978.3 (76.4, 80.0)
      a Other non-Hispanic race/ethnicity includes non-Hispanic Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and multi-race.
      b Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
      Overall, awareness of one or more non-conventional tobacco products was 64.6%, corresponding to a total of 16.8 million students; awareness was 55.5% and 71.6% among middle and high school students, respectively. Ever use of one or more non-conventional products was 14.9% overall, or 3.9 million students; ever use was 6.1% and 21.7% among middle and high school students, respectively. Current use of one or more non-conventional products was 6.2% overall, or 1.6 million students, and 2.7% and 8.8% among middle and high school students, respectively.
      Ever and current use were highest for hookah, followed by e-cigarettes, snus, and dissolvables. Among ever users of non-conventional tobacco products, 1% (ever snus users) to 7.5% (ever hookah users) had never used conventional tobacco products. Among current users of non-conventional tobacco products, the proportion of students who did not report current use of conventional products ranged from 3.6% among snus users to 22.8% among hookah users.
      Awareness of e-cigarettes was 50.3% overall, corresponding to a total of 13.1 million students; awareness was 40.8% and 57.6% among middle and high school students, respectively (Table 2). Ever use of e-cigarettes was 6.8% overall, or 1.8 million students; ever use was 2.7% and 10.0% among middle and high school students, respectively. Current use of e-cigarettes was 2.1% overall, or 550,000 students; current use was 1.1% and 2.8% among middle and high school students, respectively.
      Table 2Prevalence of awareness, ever use, and current use of e-cigarettes, U.S. students, 2012 National Youth Tobacco Survey, % (95% CI)
      CharacteristicsAwarenessEver useCurrent use
      OVERALL50.3 (48.5, 52.0)6.8 (5.9, 7.8)2.1 (1.8, 2.5)
      Sex
       Female48.6 (46.6, 50.6)5.5 (4.7, 6.4)1.4 (1.2, 1.7)
       Male51.9 (50.0, 53.8)8.1 (7.0, 9.3)2.8 (2.2, 3.5)
      Race/ethnicity
       White, non-Hispanic58.6 (56.5, 60.7)8.1 (7.0, 9.5)2.3 (1.9, 2.8)
       Black, non-Hispanic32.9 (30.0, 35.9)3.3 (2.6, 4.1)1.2 (0.7, 1.8)
       Hispanic41.1 (38.3, 44.0)6.2 (5.0, 7.6)2.4 (1.9, 3.2)
       Other non-Hispanic
      Other non-Hispanic race/ethnicity includes non-Hispanic Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and multi-race.
      51.6 (47.1, 56.0)6.1 (4.6, 8.0)1.9 (1.2, 2.9)
      Ever used conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes62.6 (59.9, 65.2)20.3 (18.3, 22.5)6.2 (5.3, 7.3)
       No44.7 (42.9, 46.4)0.5 (0.4, 0.7)0.2 (0.1, 0.3)
      Currently use conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes66.0 (62.7, 69.2)32.2 (29.0, 35.6)12.9 (11.0, 15.0)
       No47.7 (45.9, 49.5)2.5 (2.2, 2.9)0.3 (0.2, 0.5)
      Ever smoked only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding e-cigarettes). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding e-cigarettes).
       Yes56.4 (52.8, 60.0)8.9 (6.5, 12.1)1.7 (1.0, 3.0)
       No50.2(48.4, 52.0)6.6 (5.8, 7.6)2.1 (1.7, 2.5)
      Currently smoke only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding e-cigarettes). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding e-cigarettes).
       Yes70.9 (64.8, 76.3)32.2 (26.9, 38.0)9.7 (7.2, 12.9)
       No50.0 (48.2, 51.7)6.1 (5.3, 6.9)1.9 (1.6, 2.3)
      Ever used other non-conventional tobacco products
      Other non-conventional tobacco products include hookah, snus, or dissolvables. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes76.9 (74.3, 79.3)34.0 (31.0, 37.2)11.8 (10.0, 13.8)
       No46.3 (44.6, 48.1)3.0 (2.5, 3.5)0.8 (0.6, 1.0)
      Currently use other non-conventional tobacco products
      Other non-conventional tobacco products include hookah, snus, or dissolvables. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes74.2 (69.9, 78.0)38.1 (34.0, 42.4)19.0 (16.2, 22.2)
       No48.9 (47.1, 50.7)4.9 (4.3, 5.7)1.2 (1.0, 1.5)
      MIDDLE SCHOOL40.8 (38.9, 42.8)2.7 (2.2, 3.2)1.1 (0.9, 1.5)
      Sex
       Female39.4 (37.2, 41.6)2.4 (1.9, 3.0)0.8 (0.5, 1.1)
       Male42.2 (40.0, 44.5)3.0 (2.4, 3.6)1.5 (1.1, 2.1)
      Race/ethnicity
       White, non-Hispanic45.9 (43.6, 48.2)2.5 (2.0, 3.1)0.9 (0.6, 1.3)
       Black, non-Hispanic31.3 (25.4, 37.8)2.4 (1.3, 4.4)1.1 (0.6, 2.3)
       Hispanic34.0 (30.2, 37.9)3.3 (2.3, 4.6)2.0 (1.4, 2.9)
       Other non-Hispanic
      Other non-Hispanic race/ethnicity includes non-Hispanic Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and multi-race.
      44.4 (39.6, 49.4)2.4 (1.4, 4.3)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      Ever used conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes51.1 (47.8, 54.4)13.8 (12.0, 15.9)5.8 (4.7, 7.3)
       No38.9 (37.0, 40.8)0.4 (0.3, 0.6)0.2 (0.1, 0.3)
      Currently use conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes50.2 (45.6, 54.8)22.1 (18.7, 26.0)15.3 (11.6, 20.0)
       No40.1 (38.2, 42.1)1.5 (1.2, 1.8)0.3 (0.2, 0.5)
      Ever smoked only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding e-cigarettes). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding e-cigarettes).
       Yes49.3 (41.8, 56.8)9.5 (4.7, 18.3)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
       No40.5 (38.6, 42.5)2.3 (1.8, 2.8)1.0 (0.7, 1.3)
      Currently smoke only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding e-cigarettes). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding e-cigarettes).
       Yes51.7 (35.1, 68.1)19.2 (9.7, 34.5)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
       No40.7 (38.7, 42.7)2.3 (1.9, 2.8)1.0 (0.8, 1.3)
      Ever used other non-conventional tobacco products
      Other non-conventional tobacco products include hookah, snus, or dissolvables. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes66.2 (58.6, 73.0)26.6 (22.1, 31.7)13.6 (10.4, 17.6)
       No39.3 (37.4, 41.3)1.5 (1.2, 1.9)0.6 (0.4, 0.8)
      Currently use other non-conventional tobacco products
      Other non-conventional tobacco products include hookah, snus, or dissolvables. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes62.3 (52.1, 71.6)29.9 (23.3, 37.6)23.8 (17.0, 32.3)
       No40.3 (38.4, 42.3)2.1 (1.7, 2.6)0.7 (0.5, 1.0)
      HIGH SCHOOL57.6 (54.7, 60.4)10.0 (8.6, 11.6)2.8 (2.3, 3.5)
      Sex
       Female55.8 (52.8, 58.8)8.0 (6.7, 9.5)1.9 (1.5, 2.4)
       Male59.3 (56.0, 62.5)12.0 (10.2, 14.1)3.7 (2.9, 4.8)
      Race/ethnicity
       White, non-Hispanic67.9 (64.7, 70.9)12.3 (10.4, 14.4)3.3 (2.6, 4.2)
       Black, non-Hispanic34.0 (29.7, 38.5)3.9 (3.0, 5.0)1.2 (0.7, 2.0)
       Hispanic47.1 (43.7, 50.5)8.5 (6.6, 10.8)2.7 (1.9, 3.8)
       Other non-Hispanic
      Other non-Hispanic race/ethnicity includes non-Hispanic Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and multi-race.
      57.2 (51.4, 62.8)9.0 (6.8, 11.9)2.8 (1.8, 4.5)
      Ever used conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes65.9 (62.5, 69.2)22.2 (19.6, 25.0)6.3 (5.2, 7.6)
       No51.3 (48.4, 54.2)0.6 (0.4, 0.9)0.2 (0.1, 0.4)
      Currently use conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes69.2 (65.1, 73.0)34.2 (30.4, 38.2)12.3 (10.3, 14.6)
       No54.7 (51.8, 57.5)3.5 (2.9, 4.1)0.4 (0.2, 0.6)
      Ever smoked only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding e-cigarettes). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding e-cigarettes).
       Yes59.7 (55.2, 64.1)8.6 (6.4, 11.3)1.4 (0.6, 2.9)
       No57.8 (54.9, 60.7)10.1 (8.7, 11.7)2.9 (2.3, 3.6)
      Currently smoke only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding e-cigarettes). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding e-cigarettes).
       Yes74.8 (68.6, 80.1)34.7 (28.8, 41.2)9.5 (6.9, 13.0)
       No57.3 (54.5, 60.1)9.0 (7.7, 10.5)2.6 (2.0, 3.2)
      Ever used other non-conventional tobacco products
      Other non-conventional tobacco products include hookah, snus, or dissolvables. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes79.0 (76.4, 81.4)35.4 (32.0, 39.0)11.2 (9.4, 13.4)
       No52.8 (49.8, 55.7)4.3 (3.6, 5.2)1.0 (0.8, 1.4)
      Currently use other non-conventional tobacco products
      Other non-conventional tobacco products include hookah, snus, or dissolvables. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes76.9 (72.5, 80.7)39.7 (35.1, 44.6)17.7 (14.5, 21.4)
       No56.0 (53.1, 58.9)7.3 (6.2, 8.5)1.7 (1.3, 2.1)
      a Other non-Hispanic race/ethnicity includes non-Hispanic Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and multi-race.
      b Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
      c Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding e-cigarettes). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding e-cigarettes).
      d Other non-conventional tobacco products include hookah, snus, or dissolvables. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
      e Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      Overall, levels of awareness were similar among male and female students, but ever and current use were higher among male than female students. Awareness, ever use, and current use were highest among non-Hispanic white students and lowest among non-Hispanic black students. Ever or current users of conventional products, current cigarette-only smokers, and ever or current users of other non-conventional products were more likely than non-users to be aware of and use e-cigarettes.
      Awareness of hookah was 41.2% overall, corresponding to a total of 10.7 million students; 28.1% and 51.3% among middle and high school students were aware of hookah, respectively (Table 3). Ever use of hookah was 8.9% overall, or 2.3 million students; ever use was 2.7% and 13.6% among middle and high school students, respectively. Current use of hookah was 3.6% overall, or 950,000 students; current use was 1.3% and 5.4% among middle and high school students, respectively.
      Table 3Prevalence of awareness, ever use, and current use of hookah, U.S. students, 2012 National Youth Tobacco Survey, % (95% CI)
      CharacteristicsAwarenessEver useCurrent use
      OVERALL41.2 (39.4, 43.1)8.9 (7.9, 9.9)3.6 (3.1, 4.2)
      Sex
       Female42.1 (40.0, 44.1)8.0 (7.0, 9.1)3.0 (2.5, 3.5)
       Male40.4 (38.4, 42.4)9.7 (8.7, 10.9)4.2 (3.6, 4.9)
      Race/ethnicity
       White, non-Hispanic47.3 (44.9, 49.7)10.2 (8.8, 11.7)3.9 (3.3, 4.6)
       Black, non-Hispanic19.9 (17.1, 23.0)3.1 (2.4, 4.0)1.5 (1.1, 2.0)
       Hispanic40.7 (37.4, 44.0)10.6 (9.1, 12.3)5.0 (4.0, 6.3)
       Other non-Hispanic
      Other non-Hispanic race/ethnicity includes non-Hispanic Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and multi-race.
      41.6 (39.2, 43.9)7.2 (5.9, 8.9)2.4 (1.7, 3.3)
      Ever used conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes56.8 (53.6, 59.9)25.8 (23.4, 28.4)10.6 (9.3, 12.1)
       No34.0 (32.3, 35.8)1.0 (0.8, 1.3)0.4 (0.3, 0.5)
      Currently use conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes62.7 (59.3, 66.0)39.2 (35.6, 43.0)19.8 (17.3, 22.5)
       No37.9 (36.1, 39.7)3.8 (3.3, 4.4)1.0 (0.8, 1.2)
      Ever smoked only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding hookah). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding hookah).
       Yes43.3 (38.6, 48.2)7.4 (5.7, 9.6)2.2 (1.5, 3.3)
       No41.3 (39.5, 43.2)9.0 (8.0, 10.1)3.7 (3.2, 4.2)
      Currently smoke only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding hookah). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding hookah).
       Yes60.5 (54.4, 66.3)28.9 (24.0, 34.4)8.3 (5.6, 12.1)
       No40.9 (39.0, 42.7)8.3 (7.3, 9.3)3.4 (2.9, 3.9)
      Ever used other non-conventional tobacco products
      Other non-conventional tobacco products include e-cigarettes, snus, or dissolvables. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes72.9 (69.8, 75.9)42.6 (38.9, 46.4)18.0 (15.5, 20.7)
       No37.3 (35.5, 39.1)4.9 (4.3, 5.6)2.0 (1.7, 2.4)
      Currently use other non-conventional tobacco products
      Other non-conventional tobacco products include e-cigarettes, snus, or dissolvables. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes72.7 (68.2, 76.8)51.5 (46.6, 56.5)29.8 (26.1, 33.8)
       No39.9 (38.1, 41.7)7.0 (6.2, 7.8)2.6 (2.2, 3.1)
      MIDDLE SCHOOL28.1 (26.4, 29.9)2.7 (2.1, 3.3)1.3 (1.0, 1.7)
      Sex
       Female29.3 (27.4, 31.2)2.5 (1.8, 3.4)1.0 (0.7, 1.4)
       Male27.0 (24.9, 29.3)2.8 (2.3, 3.6)1.5 (1.1, 2.2)
      Race/ethnicity
       White, non-Hispanic29.9 (27.9, 32.0)2.2 (1.6, 2.9)0.9 (0.6, 1.3)
       Black, non-Hispanic15.7 (12.5, 19.4)1.5 (0.9, 2.5)0.9 (0.4, 1.9)
       Hispanic29.9 (26.6, 33.8)5.1 (3.8, 6.8)3.0 (2.2, 4.1)
       Other non-Hispanic
      Other non-Hispanic race/ethnicity includes non-Hispanic Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and multi-race.
      31.7 (28.5, 35.2)1.6 (0.9, 3.1)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      Ever used conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes43.1 (39.3, 47.0)14.3 (11.6, 17.4)6.7 (5.3, 8.5)
       No25.3 (23.5, 27.1)0.4 (0.3, 0.7)0.2 (0.1, 0.4)
      Currently use conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes46.7 (42.4, 51.1)25.1 (20.6, 30.1)16.3 (12.6, 20.8)
       No27.2 (25.4, 29.1)1.4 (1.0, 1.8)0.4 (0.3, 0.6)
      Ever smoked only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding hookah). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding hookah).
       Yes30.3 (22.8, 39.1)4.0 (2.2, 7.4)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
       No28.1 (26.3, 29.8)2.5 (2.0, 3.2)1.2 (0.9, 1.6)
      Currently smoke only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding hookah). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding hookah).
       Yes39.7 (29.8, 50.5)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
       No28.0 (26.3, 29.9)2.5 (1.9, 3.1)1.1 (0.8, 1.5)
      Ever used other non-conventional tobacco products
      Other non-conventional tobacco products include e-cigarettes, snus, or dissolvables. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes59.5 (53.1, 65.6)27.9 (23.1, 33.2)13.3 (9.9, 17.6)
       No26.4 (24.7, 28.2)1.4 (1.0, 1.9)0.7 (0.5, 1.0)
      Currently use other non-conventional tobacco products
      Other non-conventional tobacco products include e-cigarettes, snus, or dissolvables. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes59.7 (51.7, 67.2)37.3 (29.9, 45.3)26.3 (17.8, 36.9)
       No27.5 (25.7, 29.3)1.9 (1.5, 2.4)0.8 (0.6, 1.1)
      HIGH SCHOOL51.3 (48.5, 54.1)13.6 (12.1, 15.3)5.4 (4.6, 6.3)
      Sex
       Female52.0 (49.0, 55.0)12.2 (10.6, 13.9)4.5 (3.7, 5.4)
       Male50.7 (47.6, 53.7)15.0 (13.3, 16.9)6.2 (5.3, 7.3)
      Race/ethnicity
       White, non-Hispanic59.9 (56.5, 63.1)16.0 (13.9, 18.3)6.2 (5.2, 7.3)
       Black, non-Hispanic22.8 (18.0, 28.5)4.2 (3.0, 5.8)1.9 (1.4, 2.7)
       Hispanic49.7 (46.0, 53.4)15.1 (13.0, 17.5)6.6 (5.1, 8.5)
       Other non-Hispanic
      Other non-Hispanic race/ethnicity includes non-Hispanic Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and multi-race.
      49.2 (45.7, 52.8)11.7 (9.4, 14.4)4.0 (2.9, 5.4)
      Ever used conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes60.7 (56.9, 64.4)29.1 (26.2, 32.1)11.6 (10.0, 13.4)
       No44.0 (41.1, 46.9)1.6 (1.2, 2.2)0.6 (0.4, 0.9)
      Currently use conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes65.8 (61.9, 69.5)41.9 (37.8, 46.1)20.3 (17.5, 23.5)
       No47.7 (44.9, 50.5)6.0 (5.1, 7.0)1.5 (1.1, 1.9)
      Ever smoked only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding hookah). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding hookah).
       Yes49.0 (43.8, 54.1)8.8 (6.5, 12.0)2.5 (1.6, 4.0)
       No51.8 (49.1, 54.5)14.0 (12.4, 15.7)5.6 (4.8, 6.5)
      Currently smoke only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding hookah). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding hookah).
       Yes64.4 (57.7, 70.5)32.1 (26.3, 38.4)9.1 (6.1, 13.3)
       No51.0 (48.2, 53.9)12.9 (11.4, 14.5)5.2 (4.4, 6.0)
      Ever used other non-conventional tobacco products
      Other non-conventional tobacco products include e-cigarettes, snus, or dissolvables. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes76.2 (73.2, 78.9)46.1 (42.2, 50.0)18.9 (16.2, 22.1)
       No46.8 (43.9, 49.6)7.9 (6.9, 9.1)3.1 (2.6, 3.8)
      Currently use other non-conventional tobacco products
      Other non-conventional tobacco products include e-cigarettes, snus, or dissolvables. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes76.5 (71.2, 81.1)55.5 (49.5, 61.3)30.4 (26.1, 35.2)
       No49.8 (47.0, 52.6)11.1 (9.8, 12.4)4.1 (3.4, 4.9)
      a Other non-Hispanic race/ethnicity includes non-Hispanic Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and multi-race.
      b Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
      c Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding hookah). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding hookah).
      d Other non-conventional tobacco products include e-cigarettes, snus, or dissolvables. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
      e Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      Overall, levels of awareness were similar among male and female students. Ever use was comparable among male and female students, but current use was greater among males than female students. Non-Hispanic black students were less likely to be aware of or to be ever users of hookah than other races/ethnicities. Current use was lower among non-Hispanic black students than non-Hispanic white and Hispanic students. Ever or current users of conventional products, current cigarette-only smokers, and ever or current users of other non-conventional products had greater awareness, ever use, and current use of hookah compared to non-users.
      Awareness of snus was 32.0% overall, corresponding to a total of 8.3 million students; awareness was 26.3% and 36.5% among middle and high school students, respectively (Table 4). Ever use of snus was 5.3% overall, or 1.4 million students; ever use was 2.1% and 7.7% among middle and high school students, respectively. Current use of snus was 1.7% overall, or 450,000 students; current use was 0.8% and 2.5% among middle and high school students, respectively.
      Table 4Prevalence of awareness, ever use, and current use of snus, U.S. students, 2012 National Youth Tobacco Survey, % (95% CI)
      CharacteristicsAwarenessEver useCurrent use
      OVERALL32.0 (30.5, 33.6)5.3 (4.6, 6.0)1.7 (1.5, 2.1)
      Sex
       Female28.5 (27.1, 30.0)3.1 (2.6, 3.6)0.8 (0.6, 1.0)
       Male35.5 (33.6, 37.5)7.4 (6.4, 8.6)2.7 (2.2, 3.3)
      Race/ethnicity
       White, non-Hispanic38.2 (36.4, 40.1)6.6 (5.6, 7.7)2.2 (1.8, 2.8)
       Black, non-Hispanic15.6 (13.5, 18.0)2.1 (1.4, 3.1)0.5 (0.3, 0.9)
       Hispanic28.9 (26.8, 31.0)4.6 (3.9, 5.4)1.6 (1.3, 2.0)
       Other non-Hispanic
      Other non-Hispanic race/ethnicity includes non-Hispanic Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and multi-race.
      30.5 (27.7, 33.4)4.5 (3.5, 5.9)1.2 (0.8, 1.8)
      Ever used conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes43.3 (40.5, 46.2)16.5 (14.9, 18.3)5.4 (4.7, 6.2)
       No26.9 (25.7, 28.2)0.0 (0.0, 0.1)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      Currently use conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes51.7 (48.3, 55.1)26.2 (23.9, 28.7)11.9 (10.4, 13.6)
       No28.9 (27.5, 30.3)1.8 (1.5, 2.1)0.1 (0.0, 0.1)
      Ever smoked only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding snus). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding snus).
       Yes29.1 (25.6, 32.9)6.3 (4.9, 8.0)0.5 (0.3, 1.0)
       No32.4 (30.9, 33.9)5.2 (4.5, 6.0)1.8 (1.5, 2.1)
      Currently smoke only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding snus). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding snus).
       Yes43.2 (37.1, 49.6)14.0 (10.9, 17.9)3.7 (2.3, 6.0)
       No31.9 (30.4, 33.4)5.0 (4.3, 5.8)1.7 (1.4, 2.0)
      Ever used other non-conventional tobacco products
      Other non-conventional tobacco products include hookah, e-cigarettes, or dissolvables. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes57.1 (53.8, 60.3)26.4 (23.8, 29.3)10.0 (8.7, 11.5)
       No28.1 (26.8, 29.6)2.1 (1.7, 2.5)0.5 (0.4, 0.7)
      Currently use other non-conventional tobacco products
      Other non-conventional tobacco products include hookah, e-cigarettes, or dissolvables. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes58.6 (54.8, 62.4)28.8 (25.3, 32.7)16.6 (14.1, 19.5)
       No30.5 (28.9, 32.1)3.8 (3.2, 4.4)0.9 (0.7, 1.1)
      MIDDLE SCHOOL26.3 (24.7, 28.0)2.1 (1.7, 2.6)0.8 (0.6, 1.0)
      Sex
       Female23.6 (21.9, 25.4)1.7 (1.2, 2.4)0.6 (0.4, 0.9)
       Male29.0 (26.9, 31.2)2.5 (1.9, 3.1)1.0 (0.7, 1.4)
      Race/ethnicity
       White, non-Hispanic29.9 (28.1, 31.7)2.2 (1.7, 2.9)0.7 (0.5, 1.1)
       Black, non-Hispanic15.8 (13.4, 18.6)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
       Hispanic24.4 (21.4, 27.6)2.2 (1.7, 3.0)1.1 (0.7, 1.7)
       Other non-Hispanic
      Other non-Hispanic race/ethnicity includes non-Hispanic Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and multi-race.
      28.3 (24.4, 32.7)2.3 (1.4, 3.7)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      Ever used conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes38.1 (34.6, 41.8)12.4 (10.7, 14.3)4.5 (3.6, 5.6)
       No24.2 (22.6, 25.9)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      Currently use conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes43.2 (38.7, 47.7)21.7 (18.5, 25.4)12.9 (10.4, 16.0)
       No25.3 (23.6, 27.2)0.9 (0.7, 1.3)0.1 (0.0, 0.1)
      Ever smoked only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding snus). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding snus).
       Yes31.3 (23.8, 40.0)5.6 (3.4, 9.3)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
       No26.2 (24.6, 27.8)1.9 (1.5, 2.4)0.7 (0.5, 0.9)
      Currently smoke only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding snus). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding snus).
       Yes42.5 (30.1, 56.0)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
       No26.2 (24.5, 27.9)1.9 (1.5, 2.4)0.7 (0.5, 0.9)
      Ever used other non-conventional tobacco products
      Other non-conventional tobacco products include hookah, e-cigarettes, or dissolvables. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes52.4 (46.4, 58.2)22.3 (18.0, 27.3)9.4 (7.2, 12.2)
       No24.9 (23.3, 26.6)1.0 (0.7, 1.3)0.3 (0.2, 0.4)
      Currently use other non-conventional tobacco products
      Other non-conventional tobacco products include hookah, e-cigarettes, or dissolvables. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes51.5 (42.5, 60.4)21.5 (16.1, 28.2)14.2 (9.7, 20.2)
       No25.9 (24.2, 27.6)1.5 (1.2, 2.0)0.4 (0.3, 0.6)
      HIGH SCHOOL36.5 (34.2, 38.9)7.7 (6.7, 8.9)2.5 (2.0, 3.0)
      Sex
       Female32.3 (30.1, 34.7)4.2 (3.5, 5.0)0.9 (0.7, 1.3)
       Male40.6 (37.7, 43.4)11.2 (9.6, 13.0)3.9 (3.2, 4.9)
      Race/ethnicity
       White, non-Hispanic44.3 (41.8, 46.7)9.8 (8.3, 11.5)3.4 (2.7, 4.2)
       Black, non-Hispanic15.4 (12.3, 19.0)2.5 (1.6, 4.0)0.6 (0.3, 1.2)
       Hispanic32.5 (29.9, 35.2)6.4 (5.3, 7.8)1.8 (1.3, 2.5)
       Other non-Hispanic
      Other non-Hispanic race/ethnicity includes non-Hispanic Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and multi-race.
      32.1 (28.1, 36.4)6.3 (4.7, 8.4)1.6 (1.1, 2.5)
      Ever used conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes44.8 (41.3, 48.3)17.7 (15.6, 20.0)5.6 (4.7, 6.7)
       No30.1 (28.1, 32.1)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      Currently use conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes53.4 (49.5, 57.2)27.1 (24.2, 30.2)11.6 (9.8, 13.6)
       No32.1 (30.0, 34.3)2.6 (2.1, 3.1)0.1 (0.0, 0.1)
      Ever smoked only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding snus). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding snus).
       Yes28.2 (23.7, 33.1)6.6 (5.0, 8.6)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
       No37.3 (35.0, 39.6)7.8 (6.7, 9.1)2.6 (2.1, 3.2)
      Currently smoke only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding snus). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding snus).
       Yes43.4 (36.8, 50.1)14.9 (11.5, 19.2)3.4 (1.9, 6.1)
       No36.4 (34.0, 38.8)7.4 (6.4, 8.7)2.4 (1.9, 3.0)
      Ever used other non-conventional tobacco products
      Other non-conventional tobacco products include hookah, e-cigarettes, or dissolvables. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes58.0 (54.5, 61.4)27.2 (24.1, 30.6)9.9 (8.3, 11.8)
       No31.2 (28.9, 33.5)3.1 (2.6, 3.7)0.8 (0.6, 1.0)
      Currently use other non-conventional tobacco products
      Other non-conventional tobacco products include hookah, e-cigarettes, or dissolvables. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes60.2 (55.9, 64.4)30.3 (25.9, 35.1)16.8 (13.7, 20.4)
       No34.3 (31.9, 36.8)5.6 (4.8, 6.6)1.3 (1.0, 1.6)
      a Other non-Hispanic race/ethnicity includes non-Hispanic Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and multi-race.
      b Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
      c Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      d Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding snus). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding snus).
      e Other non-conventional tobacco products include hookah, e-cigarettes, or dissolvables. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
      Overall, awareness, ever use, and current use were greater among male than female students. Awareness and ever use were lower among non-Hispanic black students than other races/ethnicities. Current use was lower among non-Hispanic black students than Hispanic and non-Hispanic white students. Generally, ever or current users of conventional products, current cigarette-only smokers, and ever or current users of other non-conventional products had greater awareness, ever use, and current use of snus than non-users.
      Awareness of dissolvables was 19.3% overall, corresponding to a total of 5.0 million students; awareness was 18.2% and 20.0% among middle and high school students, respectively (Table 5). Ever use of dissolvables was 2.0% overall, or 530,000 students; ever use was 1.4% and 2.5% among middle and high school students, respectively. Current use of dissolvables was 0.7% overall, or 190,000 students; current use was 0.5% and 0.8% among middle and high school students, respectively.
      Table 5Prevalence of awareness, ever use, and current use of dissolvable tobacco products, U.S. students, 2012 National Youth Tobacco Survey, % (95% CI)
      AwarenessEver useCurrent use
      OVERALL19.3 (18.1, 20.5)2.0 (1.7, 2.4)0.7 (0.6, 0.9)
      Sex
       Female18.6 (17.4, 19.8)1.7 (1.4, 2.1)0.5 (0.4, 0.7)
       Male19.9 (18.5, 21.5)2.3 (1.9, 2.7)0.9 (0.7, 1.2)
      Race/ethnicity
       White, non-Hispanic20.5 (19.3, 21.9)1.9 (1.5, 2.3)0.5 (0.4, 0.7)
       Black, non-Hispanic11.2 (9.7, 12.8)1.2 (0.8, 2.0)0.6 (0.3, 1.0)
       Hispanic20.5 (18.7, 22.3)3.0 (2.3, 3.8)1.3 (1.0, 1.8)
       Other non-Hispanic
      Other non-Hispanic race/ethnicity includes non-Hispanic Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and multi-race.
      20.9 (18.9, 23.0)2.0 (1.4, 2.8)0.7 (0.4, 1.2)
      Ever used conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes22.8 (20.9, 24.7)6.3 (5.4, 7.2)2.2 (1.8, 2.6)
       No17.6 (16.4, 18.9)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      0.0 (0.0, 0.1)
      Currently use conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes24.0 (21.3, 26.8)8.7 (7.2, 10.4)4.3 (3.5, 5.3)
       No18.4 (17.3, 19.7)0.9 (0.7, 1.1)0.1 (0.1, 0.2)
      Ever smoked only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding dissolvables). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding dissolvables).
       Yes18.6 (14.9, 22.9)5.0 (3.6, 6.9)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
       No19.3 (18.1, 20.4)1.8 (1.6, 2.2)0.7 (0.6, 0.9)
      Currently smoke only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding dissolvables). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding dissolvables).
       Yes19.3 (14.5, 25.3)5.0 (3.1, 7.9)3.1 (1.7, 5.5)
       No19.3 (18.1, 20.5)1.9 (1.6, 2.2)0.6 (0.5, 0.8)
      Ever used other non-conventional tobacco products
      Other non-conventional tobacco products include hookah, snus, or e-cigarettes. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes29.5 (27.0, 32.1)9.8 (8.3, 11.5)3.9 (3.3, 4.7)
       No17.4 (16.2, 18.6)0.7 (0.6, 0.9)0.2 (0.1, 0.3)
      Currently use other non-conventional tobacco products
      Other non-conventional tobacco products include hookah, snus, or e-cigarettes. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes31.1 (27.2, 35.3)12.7 (10.0, 16.1)7.0 (5.5, 8.8)
       No18.4 (17.3, 19.6)1.3 (1.1, 1.5)0.3 (0.2, 0.5)
      MIDDLE SCHOOL18.2 (16.4, 20.2)1.4 (1.1, 1.8)0.5 (0.4, 0.8)
      Sex
       Female18.0 (16.5, 19.7)1.4 (1.0, 1.9)0.4 (0.2, 0.6)
       Male18.4 (16.0, 21.1)1.5 (1.1, 2.0)0.7 (0.4, 1.1)
      Race/ethnicity
       White, non-Hispanic19.4 (17.8, 21.1)1.0 (0.7, 1.4)0.4 (0.2, 0.7)
       Black, non-Hispanic11.7 (9.5, 14.4)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
       Hispanic18.6 (15.8, 21.7)2.3 (1.6, 3.3)1.0 (0.6, 1.6)
       Other non-Hispanic
      Other non-Hispanic race/ethnicity includes non-Hispanic Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and multi-race.
      19.6 (16.3, 23.5)1.5 (0.8, 2.8)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      Ever used conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes27.2 (23.5, 31.3)8.6 (7.0, 10.6)3.0 (2.1, 4.4)
       No16.5 (14.7, 18.5)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      Currently use conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes29.5 (23.7, 36.2)14.7 (10.9, 19.6)8.4 (5.5, 12.4)
       No17.4 (15.6, 19.4)0.7 (0.4, 1.0)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      Ever smoked only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding dissolvables). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding dissolvables).
       Yes22.3 (13.6, 34.3)6.6 (3.6, 11.6)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
       No18.0 (16.3, 19.8)1.2 (0.9, 1.6)0.5 (0.3, 0.7)
      Currently smoke only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding dissolvables). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding dissolvables).
       Yes27.1 (14.8, 44.3)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
       No18.1 (16.3, 20.1)1.3 (1.0, 1.6)0.4 (0.3, 0.6)
      Ever used other non-conventional tobacco products
      Other non-conventional tobacco products include hookah, snus, or e-cigarettes. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes39.8 (34.4, 45.6)15.0 (11.3, 19.7)6.3 (4.4, 9.0)
       No16.8 (15.0, 18.8)0.6 (0.5, 0.9)0.2 (0.1, 0.4)
      Currently use other non-conventional tobacco products
      Other non-conventional tobacco products include hookah, snus, or e-cigarettes. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes39.7 (29.7, 50.6)19.7 (13.4, 28.0)11.3 (7.3, 17.0)
       No17.6 (16.0, 19.4)0.9 (0.7, 1.2)0.3 (0.2, 0.4)
      HIGH SCHOOL20.0 (18.8, 21.4)2.5 (2.0, 3.0)0.8 (0.6, 1.0)
      Sex
       Female18.9 (17.5, 20.4)2.0 (1.5, 2.6)0.6 (0.4, 0.9)
       Male21.1 (19.4, 23.0)2.9 (2.4, 3.6)1.0 (0.8, 1.4)
      Race/ethnicity
       White, non-Hispanic21.4 (19.7, 23.1)2.5 (2.0, 3.2)0.6 (0.5, 0.9)
       Black, non-Hispanic10.7 (8.6, 13.2)1.0 (0.6, 1.6)0.7 (0.4, 1.3)
       Hispanic21.9 (20.2, 23.8)3.4 (2.5, 4.5)1.4 (1.0, 2.1)
       Other non-Hispanic
      Other non-Hispanic race/ethnicity includes non-Hispanic Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and multi-race.
      21.8 (19.4, 24.4)2.2 (1.5, 3.3)0.7 (0.4, 1.4)
      Ever used conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes21.5 (19.6, 23.4)5.5 (4.6, 6.6)1.8 (1.5, 2.3)
       No18.9 (17.7, 20.3)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      Currently use conventional tobacco products
      Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
       Yes22.7 (20.1, 25.6)7.3 (5.9, 9.0)3.3 (2.6, 4.2)
       No19.3 (18.1, 20.6)1.1 (0.9, 1.4)0.2 (0.1, 0.3)
      Ever smoked only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding dissolvables). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding dissolvables).
       Yes16.9 (13.5, 20.9)4.3 (2.9, 6.3)
      Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
       No20.2 (18.9, 21.6)2.3 (1.9, 2.9)0.8 (0.7, 1.1)
      Currently smoke only conventional cigarettes
      Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding dissolvables). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding dissolvables).
       Yes17.6 (12.8, 23.7)4.2 (2.4, 7.2)1.9 (0.9, 3.9)
       No20.1 (18.8, 21.5)2.4 (1.9, 2.9)0.7 (0.6, 1.0)
      Ever used other non-conventional tobacco products
      Other non-conventional tobacco products include hookah, snus, or e-cigarettes. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes27.3 (24.8, 29.9)8.5 (7.0, 10.4)3.2 (2.6, 4.0)
       No17.9 (16.6, 19.2)0.8 (0.7, 1.0)0.2 (0.1, 0.4)
      Currently use other non-conventional tobacco products
      Other non-conventional tobacco products include hookah, snus, or e-cigarettes. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
       Yes28.8 (25.3, 32.6)10.8 (8.4, 13.8)5.6 (4.1, 7.4)
       No19.1 (17.8, 20.4)1.6 (1.3, 2.0)0.4 (0.2, 0.6)
      a Other non-Hispanic race/ethnicity includes non-Hispanic Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and multi-race.
      b Conventional tobacco products include cigarettes, cigars/cigarillos/little cigars, or smokeless tobacco. Ever use was defined as tried at least one conventional tobacco product one or more times. Current use was defined as used at least one conventional tobacco product on at least 1 of the past 30 days.
      c Estimate not shown because the relative SE was 40% or greater or denominator less than 50.
      d Ever smoked only conventional cigarettes was defined as a response of yes to ever trying cigarette smoking, even one or two puffs, and never trying any other tobacco product (excluding dissolvables). Current cigarette-only smoking was defined as having smoked cigarettes on at least 1 of the past 30 days and not using any other tobacco product (excluding dissolvables).
      e Other non-conventional tobacco products include hookah, snus, or e-cigarettes. Ever use was defined as tried at least one non-conventional product one or more times. Current use was defined as used at least one non-conventional tobacco product on 1 or more of the past 30 days.
      Overall, awareness, ever use, and current use were similar among male and female students. Non-Hispanic black students had lower awareness of dissolvables than all other races/ethnicities. Ever or current users of conventional products, current cigarette-only smokers, and ever or current users of other non-conventional products had greater ever and current use of dissolvables than non-users.

      Discussion

      The findings of this study indicate that awareness of e-cigarettes, hookah, snus, and dissolvables is high among U.S. middle and high school students. Nearly two thirds of all students were aware of one or more of these non-conventional tobacco products, and 3.9 million were ever users of one or more of these products. Half of all students reported being aware of e-cigarettes, and 6.8%, or 1.8 million students, had ever used them. Although awareness of hookah was lower compared to that for e-cigarettes, more students reported ever use of hookah. Relative to e-cigarettes and hookah, fewer students are aware of and use snus and dissolvables.
      Consistent across all four products, students who were ever or current users of conventional products, current cigarette-only smokers, and ever or current users of other non-conventional products were more likely than non-users to be aware of and use these non-conventional products. This study also found that many ever users of non-conventional products had never used conventional products.
      Awareness and ever use of e-cigarettes among middle and high school students are higher than those found in most nationally representative surveys among U.S. adults in 2010.
      • King B.A.
      • Alam S.
      • Promoff G.
      • Arrazola R.
      • Dube S.R.
      Awareness and ever-use of electronic cigarettes among U.S. adults, 2010–2011.
      • Regan A.K.
      • Promoff G.
      • Dube S.R.
      • Arrazola R.
      Electronic nicotine delivery systems: adult use and awareness of the “e-cigarette” in the USA.
      • Pearson J.L.
      • Richardson A.
      • Niaura R.S.
      • Vallone D.M.
      • Abrams D.B.
      E-cigarette awareness, use, and harm perceptions in US adults.
      • McMillen R.
      • Maduka J.
      • Winickoff J.
      The only similar estimates were reported from a 2011 national adult web-based survey that found nearly 58% of adults had ever heard of e-cigarettes, and 6.2% had ever used them.
      • King B.A.
      • Alam S.
      • Promoff G.
      • Arrazola R.
      • Dube S.R.
      Awareness and ever-use of electronic cigarettes among U.S. adults, 2010–2011.
      The higher estimates among middle and high school students in 2012 probably reflect the rapidly increasing popularity of e-cigarettes in recent years. It has been reported that ever use of e-cigarettes among U.S. adults more than quadrupled from 2009 (0.6%) to 2010 (2.7%)
      • Regan A.K.
      • Promoff G.
      • Dube S.R.
      • Arrazola R.
      Electronic nicotine delivery systems: adult use and awareness of the “e-cigarette” in the USA.
      and nearly doubled during 2010–2011.
      • King B.A.
      • Alam S.
      • Promoff G.
      • Arrazola R.
      • Dube S.R.
      Awareness and ever-use of electronic cigarettes among U.S. adults, 2010–2011.
      Ever and current use of e-cigarettes among U.S. middle and high school students doubled during 2011–2012.
      CDC
      Electronic cigarette use among middle and high school students—U.S., 2011–2012.
      Nationwide, the prevalence of ever (8.9%) and current (3.6%) hookah use among U.S. middle and high school students in 2012 is much higher than that (7.3% for ever use and 2.6% for current use) in 2011,
      • Amrock S.M.
      • Gordon T.
      • Zelikoff J.T.
      • Weitzman M.
      Hookah use among adolescents in the U.S.: results of a national survey.
      with a 22% and 38% increase over 1 year, respectively. The prevalence of ever and current hookah use among U.S. high school students in 2012 is lower than estimates reported among high school students in New Jersey and California in 2011,
      • Manderski M.T.B.
      • Hrywna M.
      • Delnevo C.D.
      Hookah use among New Jersey youth: associations and changes over time.
      • Jordan H.M.
      • Delnevo C.D.
      Emerging tobacco products: hookah use among New Jersey youth.
      • Smith J.R.
      • Novotny T.E.
      • Edland S.D.
      • Hofstetter C.R.
      • Lindsay S.P.
      • Al-Delaimy W.K.
      Determinants of hookah use among high school students.
      possibly due, in part, to a higher percentage of these states’ populations with an Arab background, which is associated with a tradition of hookah use.
      • Manderski M.T.B.
      • Hrywna M.
      • Delnevo C.D.
      Hookah use among New Jersey youth: associations and changes over time.
      • Jordan H.M.
      • Delnevo C.D.
      Emerging tobacco products: hookah use among New Jersey youth.
      • Smith J.R.
      • Novotny T.E.
      • Edland S.D.
      • Hofstetter C.R.
      • Lindsay S.P.
      • Al-Delaimy W.K.
      Determinants of hookah use among high school students.
      • Akl E.A.
      • Gunukula S.K.
      • Aleem S.
      • et al.
      The prevalence of waterpipe tobacco smoking among the general and specific populations: a systematic review.
      • Maziak W.
      The global epidemic of waterpipe smoking.
      • Martinasek M.P.
      • McDermott R.J.
      • Martini L.
      Waterpipe (hookah) tobacco smoking among youth.
      Compared with e-cigarettes and hookah, awareness and use of snus and dissolvables are lower. Although the reasons for these lower rates are uncertain, limited market penetration and varying promotional strategies may have played a major role. The NYTS questions on snus included Camel and Marlboro snus as brand examples. These two products were not marketed nationwide until 2009 and 2010, respectively.
      • Delnevo C.D.
      • Wackowski O.A.
      • Giovenco D.P.
      • Manderski M.T.
      • Hrywna M.
      • Ling P.M.
      Examining market trends in the U.S. smokeless tobacco use: 2005–2011.

      Choi K, Fabian LEA, Brock B, Engman KH, Jansen J, Forster JL. Availability of snus and its sale to minors in a large Minnesota city. Tob Control 2013:In press.

      Moreover, except for Ariva and Stonewall (discontinued in December 2012), most dissolvables have only been test marketed in a few states since 2009.
      Youth awareness and use of these non-conventional tobacco products could have been influenced by multiple factors, including tobacco industry marketing, peer influence, product appeal based on novelty and flavors, perceived social acceptability, perceptions about harm relative to conventional tobacco products, and lack of regulation for e-cigarettes and hookah.
      • King B.A.
      • Alam S.
      • Promoff G.
      • Arrazola R.
      • Dube S.R.
      Awareness and ever-use of electronic cigarettes among U.S. adults, 2010–2011.
      • Martinasek M.P.
      • McDermott R.J.
      • Martini L.
      Waterpipe (hookah) tobacco smoking among youth.
      • Grana R.A.
      • Glantz S.A.
      • Ling P.M.
      Electronic nicotine delivery system in the hands of Hollywood.
      • Benowitz N.L.
      • Gonlewlcz M.L.
      The regulatory challenge of electronic cigarettes.
      Longitudinal studies consistently suggest that exposure to tobacco advertising and promotion is associated with the likelihood that adolescents initiate smoking,
      • Goniewicz M.L.
      • Lingas E.O.
      • Hajek P.
      Patterns of electronic cigarette use and user beliefs about their safety and benefits: an Internet survey.
      and there is a causal relationship between depictions of smoking in the movies and smoking initiation among youth.
      • Lovato C.
      • Watts A.
      • Stead L.F.
      Impact of tobacco advertising and promotion on increasing adolescent smoking behaviours.
      In recent years, e-cigarette manufacturers have dedicated considerable resources to market the products in a variety of media, including magazines, Internet and manufacturers’ websites, social networking and video-sharing sites, banner advertisements on Internet search engine sites, industry-supported online forums, and via TV advertisements that feature celebrity endorsements.

      Internet Movie Database. Demo reel (Blu e-cig national TV commercial). imdb.com/video/demo_reel/vi2066392089/.

      Elliott S. E-cigarette makers’ ads echo tobacco’s heyday. The New York Times [Internet]. August 29, 2013. nytimes.com/2013/08/30/business/media/e-cigarette-makers-ads-echo-tobaccos-heyday.html?smid=pl-share.

      The widespread marketing of e-cigarettes in recent years may have contributed, at least in part, to e-cigarette use among youth.
      A primary public health concern with the increased diversity of tobacco products is the potential to increase the overall number of youth who initiate tobacco use by attracting those who may not have otherwise initiated tobacco use with a conventional tobacco product. Consistent with patterns found in previous studies,
      • Regan A.K.
      • Promoff G.
      • Dube S.R.
      • Arrazola R.
      Electronic nicotine delivery systems: adult use and awareness of the “e-cigarette” in the USA.
      • Manderski M.T.B.
      • Hrywna M.
      • Delnevo C.D.
      Hookah use among New Jersey youth: associations and changes over time.
      • Jordan H.M.
      • Delnevo C.D.
      Emerging tobacco products: hookah use among New Jersey youth.
      • Smith J.R.
      • Novotny T.E.
      • Edland S.D.
      • Hofstetter C.R.
      • Lindsay S.P.
      • Al-Delaimy W.K.
      Determinants of hookah use among high school students.
      USDHHS
      Preventing tobacco use among youth and young adults: a report of the Surgeon General.
      • Agaku I.T.
      • Ayo-Yusuf O.A.
      • Vardavas C.I.
      • Alpert H.R.
      • Connolly G.N.
      Use of conventional and novel smokeless tobacco products among U.S. adolescents.
      across all four product types, awareness and use were highest among youth who also reported use of conventional tobacco products.
      However, use of non-conventional products was also reported by up to one in five students who had not used conventional tobacco products. For these youth, use of non-conventional tobacco products may be their first exposure to tobacco, which puts them at risk for nicotine dependence and could lead to use of other tobacco products. Among students who reported use of both non-conventional and conventional tobacco products, it is important to understand how use of one type of product influences use of another, including transitions between products, as well as polytobacco use. Similarly, it is important to understand the implications of use of non-conventional products for nicotine dependence.
      This study is subject to six limitations. First, given the cross-sectional design, it is not possible to evaluate trajectories of product use or examine the chronological sequence of youth tobacco use (i.e., transitions from conventional to non-conventional product use or the converse). Second, the NYTS does not gather data from students attending alternate, special education, vocational, or Department of Defense–operated schools or those who were not enrolled in school. Nonetheless, data from the Current Population Survey indicate that 98.5% of U.S. youth aged 10–13 years and 97.1% of those aged 14–17 years were enrolled in a traditional school in 2011.

      U.S. Census Bureau. School enrollment: current population survey 2011. Detailed Tables. census.gov/hhes/school/data/cps/2011/tables.html.

      Third, tobacco use was self-reported, which could introduce reporting bias. Although studies have confirmed the validity of self-reported smoking,
      • Caraballo R.S.
      • Giovino G.A.
      • Pechacek T.F.
      Self-reported cigarette smoking vs. serum cotinine among U.S. adults.
      the validity of self-reported use of non-conventional tobacco products is unknown. Fourth, the estimates are based on bivariate analyses; observed differences may be driven by demographic or tobacco use characteristics that were not adjusted for. Fifth, sample sizes for certain subpopulations of tobacco users were relatively small, resulting in imprecise estimates that were not reported.
      Finally, the categories used to differentiate between products in this analysis (i.e., conventional and non-conventional tobacco products) do not necessarily account for other meaningful differences that exist between products grouped in the same category, including whether they are combusted (e.g., hookah) or non-combusted (e.g., dissolvables).

      Conclusions

      Millions of U.S. middle and high school students are aware of and use non-conventional tobacco products, including e-cigarettes and hookah. Use of non-conventional tobacco products is especially high among those who use conventional tobacco products, causing concern about polytobacco use. Moreover, use of non-conventional tobacco products among students who do not use conventional tobacco products raises serious concerns about risks for initiating tobacco use and potential nicotine dependence. Implementing evidence-based interventions can reduce tobacco use among youth.
      USDHHS
      Preventing tobacco use among youth and young adults: a report of the Surgeon General.
      CDC
      Best practices for comprehensive tobacco control programs—2014.
      These findings indicate that full implementation of comprehensive tobacco control programs at CDC-recommended funding levels is warranted to reduce all forms of tobacco use among U.S. youth.
      CDC
      Best practices for comprehensive tobacco control programs—2014.
      In addition, these findings underscore the importance of continued tobacco product surveillance in conjunction with efforts to reduce and prevent all tobacco use, as well as research to understand how non-conventional product use relates to initiation, cessation, and concurrent use of conventional tobacco products among youth.

      Acknowledgments

      Publication of this article was supported by the U.S. Food and Drug Administration, Center for Tobacco Products.
      Disclaimer: The findings and conclusions in this report are those of the authors. The information in this article is not a formal dissemination of information by either the U.S. Food and Drug Administration or CDC and does not represent either agency’s positions or policies.
      No financial disclosures were reported by the authors of this manuscript.

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