Vaping Among U.S. High School Students, 2015–2021: Fewer Tried It, More Vaped Every Day

Commercial tobacco use is the leading cause of preventable disease and death in the United States, and starting as a teenager is linked to stronger nicotine dependence and use that lasts into adulthood. Cigarette smoking among high school students fell from 36.4% in 1997 to 6.0% in 2019 — but young people have turned to other products, above all electronic vapor products (EVPs): e-cigarettes, vapes, vape pens, e-cigars, e-hookahs, hookah pens and mods, "such as JUUL, SMOK, Suorin, Vuse, and blu." In 2018 the U.S. Surgeon General declared youth e-cigarette use an epidemic.

EVPs heat a flavored liquid into an aerosol that users inhale. The liquid usually contains nicotine, which is highly addictive, can affect the developing brain, and may make young people more likely to smoke and to become addicted to other substances. EVPs can also deliver THC; in 2019, vitamin E acetate, an additive in some THC products, was linked to e-cigarette or vaping use–associated lung injury.

CDC's Youth Risk Behavior Survey (YRBS) — run every two years since 1991 with a nationally representative sample of students in grades 9–12 — has asked about EVPs since 2015.

2021 at a glance

Who vapes

• Girls were more likely than boys to have ever vaped and to vape currently.
• Asian students were less likely than Black, Hispanic, Native Hawaiian or other Pacific Islander, White and multiracial students to have ever vaped, vape currently or vape daily. Other research suggests social and cultural influences may protect Asian youth against tobacco and other substance use.
• Bisexual students were more likely than heterosexual, gay or lesbian, and other or questioning students to have ever vaped or to vape currently — separating bisexual from gay and lesbian students revealed a difference that combining them would hide.
• Current use by race and ethnicity: Native Hawaiian or other Pacific Islander 24.7%, American Indian or Alaska Native 23.2%, White 20.3%, Hispanic 17.8%, multiracial 17.1%, Black 14.0%, Asian 5.5%.

Trends

• 2019 to 2021: ever, current and daily vaping all fell — consistent with other national surveys, such as Monitoring the Future. Current use fell in every sex and racial and ethnic group.
• 2015 to 2021: ever vaping fell overall, but daily vaping rose — overall and among girls (1.1% → 5.6%), boys (2.8% → 4.5%), and Black (1.1% → 3.1%), Hispanic (2.6% → 3.4%), multiracial (2.8% → 5.3%) and White (1.9% → 6.5%) students. Current use showed no overall trend; it fell among boys (25.6% → 14.9%) and Asian students (14.5% → 5.5%). Among girls it moved from 22.6% (2015) to 10.5% (2017), 33.5% (2019) and 21.4% (2021).

Why daily use may be rising

Nicotine concentrations in U.S. e-cigarettes have climbed: from 2013 to 2018, the average concentration in e-cigarettes sold rose by more than 80% across all flavor categories and in rechargeable devices. Nicotine exposure in adolescence can affect learning, memory and attention, and raises the risk of lasting dependence.

Why vaping may have dipped

Restrictions on selling flavored tobacco and the COVID-19 pandemic — fewer chances to buy EVPs or to spend time with peers who use them — may have contributed to the 2019–2021 decline.

Where students get them

Among students who vaped currently:

That more than half got EVPs from other people suggests students are finding ways around sales restrictions.

Why young people vape

Tobacco industry marketing aimed at youth, appealing flavors, the mistaken belief that vaping relieves stress, peer and family influence, and a low sense of harm all play a part. Social isolation, grief, trauma and stress — common during the pandemic — also prime young people to experiment. In the 2021 National Youth Tobacco Survey, the commonest reasons young e-cigarette users gave were anxiety, stress or depression and the "high or buzz" of nicotine. Girls reported more eating disorders, distress, anxiety and depression tied to the pandemic, which may help explain their higher vaping — and vaping to cope can become a trap, since nicotine withdrawal itself brings anxiety and depression.

What could help

• Youth-tailored, culturally specific cessation programs for young people already dependent on nicotine.
• Community-based participatory research to design prevention and cessation programs with young people. In a pilot among rural high school students in Kentucky, peers taught classmates about e-cigarette risks and ways to help friends quit, which raised awareness and students' desire to tackle vaping in their communities.
• Research on social determinants of health — neighborhood poverty, access to health care and healthy food, chances for physical activity — and their links to vaping.

Limits

Students could name only one usual source, though many may use several. EVP use here isn't limited to nicotine products, so nicotine vaping may be overestimated. And broad racial and ethnic categories can hide differences within groups.

Sources

Based on Oliver BE, Jones SE, Hops ED, Ashley CL, Miech R, Mpofu JJ, "Electronic Vapor Product Use Among High School Students — Youth Risk Behavior Survey, United States, 2021," MMWR Supplements volume 72, number 1, Centers for Disease Control and Prevention; a work of the United States government in the public domain. The report calls the change in current use among female students a "linear increase," but the figures it gives run 22.6%, 10.5%, 33.5% and 21.4%; the figures are given here without that description.