Youth tobacco use has gone down, but the work isn’t over

There was some welcome news in October about young people and tobacco products: Fewer U.S. teens and tweens are currently using these products than at any time in the last 25 years (SN: 10/25/24).

That still leaves more than 2 million high school and middle school students who reported vaping, smoking or using nicotine pouches or other tobacco products on one or more of the past 30 days, according to the 2024 National Youth Tobacco Survey, which collected data from January to May of this year.

E-cigarettes continue to be the most popular tobacco product, a position the devices have held since 2014. E-cigarette manufacturers have targeted young people with candy and fruit flavored vapes and found new customers among adolescents who were uninterested in smoking regular cigarettes (SN: 12/19/18). The latest e-cigarettes are sleek, colorful devices that are more efficient at delivering doses of nicotine that can match that of regular cigarettes.

The 2024 survey reported a decrease in vaping among high school students since 2023. But of the 1.6 million middle and high school students currently using e-cigarettes, 38 percent reported frequent use, meaning use on 20 or more of the last 30 days. And 26 percent reported daily use, which could be a sign of nicotine addiction.

The overall decrease in tobacco use by teens and tweens is “very good,” says pediatric hospitalist Rachel Boykan of Stony Brook Children’s Hospital in New York, who has worked to decrease adolescent tobacco exposure and use for years. “But it doesn’t mean our work is over.”

Science News spoke with Boykan about what has contributed to the decrease in tobacco use and newer products that are causing concern, including vaping devices with video games.

What has helped with reducing tobacco use among teens and tweens?

“We know that over 90 percent of tobacco users start using before the age of 21,” Boykan says. Taking up tobacco products during adolescence is especially risky, as it can lead to a greater dependence on nicotine and make it harder to quit later in life. “Hence the push for Tobacco 21 laws, which now include e-cigarettes,” Boykan says. “That has helped to decrease access.”

In 2005, Needham, Mass., became the first town to raise the age required to purchase tobacco products to 21. Over time, more cities and states enacted this restriction; it was implemented nationwide in 2019.

Conventional cigarettes were the main concern when Needham raised the purchase age for tobacco products. The law significantly reduced smoking among high school students in Needham compared with those in surrounding communities from 2006 to 2010, researchers reported in Tobacco Control in 2016. When older teens were no longer able to legally buy tobacco products, that helped curb their own use but also knocked out a main supply of cigarettes for younger teens.

With the internet now a major marketplace for e-cigarettes, it’s become challenging to restrict sales, Boykan says. For example, sellers post TikTok videos that offer the devices without verifying the buyer’s age and send a shipment with the device hidden in other products.

Another strategy that’s helped reduce youth tobacco use, Boykan says, is a prevention campaign called The Real Cost, from the U.S. Food and Drug Administration. Along with increasing awareness of the harms of nicotine, vaping and smoking among teens and tweens, the campaign has made young people less open to tobacco products. A clinical trial of more than 1,500 adolescents aged 13 to 17 found that those who viewed The Real Cost vaping prevention ads — centered on health harms or addiction — were less susceptible to vaping than those who watched neutral videos about vaping, researchers reported in JAMA Network Open in 2022. That drop in susceptibility spilled over to cigarette smoking too.

And reports of serious lung injuries and deaths related to vaping, first identified in 2019, got people’s attention (SN: 12/16/19). “I think one of the things that drove down the initial [vaping] craze was EVALI,” Boykan says, which stands for e-cigarette or vaping product use–associated injury. Cases peaked in September that year; the U.S. Centers for Disease Control and Prevention reported there had been almost 2,700 hospitalized with EVALI by mid-January 2020. A survey of 11th and 12th graders found the spate of EVALI cases had increased the teens’ perception that vaping is risky, researchers reported in Preventive Medicine in 2021. (With the steep decline in cases after the peak, the CDC stopped collecting state data on EVALI cases in February 2020.)

What newer products are causing concern?

Nicotine pouches are now the second most popular tobacco product among teens and tweens, currently used by about 480,000 middle and high school students in 2024. The small pouches hold a dissolvable powder containing nicotine, flavorings like citrus or mint and other ingredients and are placed between the lips or cheeks and the gums. Nicotine is absorbed into the bloodstream via the lining of the mouth. Zyn is the most popular brand among current teen and tween users.

The number of teens and tweens using nicotine pouches remained steady from 2023 to 2024, which “is worrisome to me,” Boykan says. “They’re not perceived as harmful.” Sales in the United States have shot up recently, from 126 million pouches in late 2019 to 808 million in early 2022, researchers reported in JAMA Network Open in 2022.

The latest products showing up online and in vape shops are e-cigarettes that look like gaming devices or smartphones. The new devices are “combining gaming — which is already a concerning addiction — and vaping, in a way that is really scary,” Boykan says.

The e-cigarettes have games styled after classics like Tetris and Pac-Man. One brand offers a virtual pet, that the user feeds by taking puffs, plus a puff count competition game. On October 30, the FDA sent warning letters to nine online retailers and a manufacturer for selling these devices, which are not authorized in the United States.

What should tweens, teens and parents know about tobacco products?

“The risk to the adolescent brain is really significant,” Boykan says. Nicotine can impair brain development and harm adolescents’ ability to think and focus. She asks her adolescent patients about their goals and dreams and talks about how a nicotine addiction can disrupt their plans. For example, “I can point them to videos of kids who had to drop out of college because they were so addicted,” she says.

Along with the health harms, Boykan would like parents to understand how addictive nicotine is and that “their kids need support” if they become hooked. Not all parents realize how much nicotine today’s e-cigarettes have, or how easy it is for kids to vape discreetly throughout the day. Teens and tweens “don’t need to be punished,” she says. “They need to know you’re there for them.”