Notes from the Field: E-Cigarette and Nicotine Pouch Use Among Middle and High School Students — United States, 2024

Eunice Park-Lee, PhD1; Ahmed Jamal, MBBS2; Hannah Cowan, MPH1; Michael D. Sawdey, PhD1; Maria R. Cooper, PhD1; Jan Birdsey, MPH2; Andrenita West, PhD2; Karen A. Cullen, PhD1 (

Summary

What is already known about this topic?

E-cigarettes remain the most used tobacco product among U.S. youths. The wide availability and growing sales of nicotine pouches has also raised concerns about potential use of these products among youths.

What is added by this report?

During 2023–2024, current e-cigarette use among middle and high school students declined from 7.7% to 5.9%. Current nicotine pouch use (1.8%) did not change significantly during this period.

What are the implications for public health?

Youth e-cigarette use has declined; however, comprehensive tobacco control strategies, regulations, and enforcement remain critical to preventing and reducing e-cigarette and nicotine pouch use among youths.

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Current e-cigarette use among U.S. youth has declined considerably since 2019*; however, approximately 2.13 million youths used e-cigarettes in 2023 (1). As sales of nicotine pouches (small, dissolvable, flavored pouches containing nicotine derived from tobacco that users place in the mouth between the lip and gum)† have continued to rise nationally since 2016, their use among U.S. youths has become concerning (2,3). All pouches and most e-cigarettes contain nicotine,§ which is highly addictive and can harm the developing adolescent brain (4,5).

Investigation and Outcomes

The Food and Drug Administration and CDC analyzed nationally representative data from the 2024 National Youth Tobacco Survey (NYTS), a cross-sectional, school-based, self-administered web-based survey of U.S. students in middle school (grades 6–8) and high school (grades 9–12), which was conducted among 29,861 students from 283 schools during January 22–May 22, 2024.¶ Current (i.e., past–30-day) use of e-cigarettes and nicotine pouches was assessed overall, and by frequency of use, device type used for e-cigarettes, any brand and usual brand used,** and flavor types. Weighted prevalence estimates, 95% CIs, and population totals were calculated using SAS-callable SUDAAN software (version 11.0.4; RTI International).†† Changes in current use since 2023 were evaluated using t-tests; p-values 1). This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy.§§

In 2024, 5.9% of middle and high school students reported current e-cigarette use, including 7.8% of high school students and 3.5% of middle school students (

In 2024, 1.8% of middle and high school students reported current nicotine pouch use, including 2.4% of high school students and 1.0% of middle school students. Among students who currently used nicotine pouches, 29.3% reported frequent use, and 22.4% reported daily use. Among students reporting current nicotine pouch use, 68.7% used ZYN, followed by on! (14.2%), Rogue (13.6%), Velo (10.7%), and Juice Head ZTN (9.8%); 85.6% used a flavored product: mint (53.3%), fruit (22.4%), and menthol (19.3%) were the flavor types most frequently reported.

From 2023 to 2024, current e-cigarette use declined among middle and high school students overall (from 7.7% to 5.9%; p

Conclusions and Actions

In 2024, an estimated 1.63 million U.S. middle and high school students currently used e-cigarettes, a significant decline from 2.13 million in 2023. In contrast, from 2023 to 2024, no significant changes occurred in current nicotine pouch use among middle and high school students overall (an estimated 480,000 students in 2024), despite rising sales of nicotine pouches (2).††† Continued surveillance of youth tobacco product use patterns and implementation of comprehensive tobacco control strategies, regulations, and enforcement§§§ are important for preventing and reducing tobacco product use by youths and associated adverse health outcomes, including a potential lifetime of nicotine addiction.

Corresponding author: Eunice Park-Lee, Eunice.Park-Lee@fda.hhs.gov.

1Center for Tobacco Products, Food and Drug Administration, Silver Spring, Maryland; 2Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

• http://dx.doi.org/10.15585/mmwr.ss6812a1

† Unlike other smokeless tobacco products, such as snuff and snus, nicotine pouches do not contain any tobacco leaf.

§ E-cigarettes: https://www.fda.gov/tobacco-products/products-ingredients-components/e-cigarettes-vapes-and-other-electronic-nicotine-delivery-systems-ends; nicotine pouches: https://www.fda.gov/tobacco-products/products-ingredients-components/other-tobacco-products.

¶ In 2024, the student-level participation rate was 78.3%, and the school-level participation rate was 42.7%, for an overall response rate of 33.4%.

** Brand response options were: blu, Breeze, Elf Bar, Esco Bars, Fume, JUUL, HQD, Kangvape (including Onee Stick), Logic, Mr. Fog, NJOY, SMOK (including NOVO), Suorin (including Air Bar), Vuse, “some other brand(s) not listed here,” and “I don’t know the brand.” Those who selected “some other brand(s) not listed here” could provide a write-in response. Write-in responses were recoded into valid responses. Estimates for Geek Bar and Lost Mary were based on the write-in responses and might be underestimated.

†† Data were weighted to account for complex survey design and to adjust for nonresponse. The weighted proportions of students in each grade matched national population proportions for U.S. public and private schools derived from data from the National Center for Education Statistics (2021–2022 Common Core of Data and 2019–2020 Private School Universe Study) and Market Data Retrieval, Inc. Population number estimates were rounded down to the nearest 10,000 students.

§§ 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.

¶¶ Frequent use was defined as use on ≥20 days during the previous 30 days. Daily use was defined as use on all of the previous 30 days. These estimates are not mutually exclusive.

*** An e-cigarette with a tank that the user refills with liquids or a mod system that can be customized by the user with their own combination of batteries or other parts.

††† The scope of the current report examined changes in prevalence from 2023 to 2024. Although outside the scope of this report, a small but statistically significant increase in current nicotine pouch use occurred from 2022 to 2024. The 2022 NYTS methodology report and a copy of the 2022 data file can be found at https://www.cdc.gov/tobacco/about-data/surveys/national-youth-tobacco-survey.html.

§§§ https://www.cdc.gov/tobacco/php/state-and-community-work/guides-for-states.html?CDC_AAref_Val=https://www.cdc.gov/tobacco/stateandcommunity/guides/index.htm; https://www.fda.gov/tobacco-products/ctp-newsroom/fdas-comprehensive-plan-tobacco-and-nicotine-regulation

References

• Birdsey J, Cornelius M, Jamal A, et al. Tobacco product use among U.S. middle and high school students—National Youth Tobacco Survey, 2023. MMWR Morb Mortal Wkly Rep 2023;72:1173–82. https://doi.org/10.15585/mmwr.mm7244a1 PMID:37917558
• Marynak KL, Wang X, Borowiecki M, et al. Nicotine pouch unit sales in the US, 2016–2020. JAMA 2021;326:566–8. https://doi.org/10.1001/jama.2021.10366 PMID:34374729
• Robichaud MO, Seidenberg AB, Byron MJ. Tobacco companies introduce ‘tobacco-free’ nicotine pouches. Tob Control 2020;29:e145–6. PMID:31753961
• CDC. E-cigarette use among youth and young adults: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 2016. https://www.cdc.gov/tobacco/data_statistics/sgr/e-cigarettes/pdfs/2016_sgr_entire_report_508.pdf
• CDC. The health consequences of smoking—50 years of progress: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. https://www.ncbi.nlm.nih.gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdf

† Estimated number of students was rounded down to the nearest 10,000 persons. Subgroup estimates might not sum to overall population estimates because of rounding or exclusion of students who currently used e-cigarettes and who did not report grade level (154), device type (61), any brand (65), usual brand (77), flavor types used (105), use of flavor including the word “ice” or “iced” (83), or use of flavors without specific flavor descriptor (97).
§ Frequent use was defined as use on ≥20 days during the previous 30 days. Daily use was defined as use during all of the previous 30 days. These estimates are not mutually exclusive.
¶ Device type was ascertained by response to the question, “Which of the following best describes the type of e-cigarette you have used in the past 30 days? If you have used more than one type, please think about the one you use most often.”
** Students currently using e-cigarettes or nicotine pouches were asked, “During the past 30 days, what [e-cigarette/nicotine pouch] brands did you use? (Select one or more).” Those who selected “some other brand(s) not listed here” could provide a write-in response. Write-in responses corresponding to an original response option were recoded.
†† Geek Bar and Lost Mary were not included in the list of prespecified response options but were the two most common write-in responses for “some other brand(s) not listed here.” Estimates for Geek Bar and Lost Mary might be underestimated.
§§ Data were statistically unreliable because of an unweighted denominator 30%.
¶¶ If a student currently using e-cigarettes or nicotine pouches reported a single brand when asked, “During the past 30 days, what [e-cigarette/nicotine pouch] brands did you use (Select one or more),” it was reported as the usual brand. Those who selected two or more brands were asked, “During the past 30 days, what brand of [e-cigarettes/nicotine pouches] did you usually use? (Choose only one answer).” Write-in responses of “some other brand(s) not listed here” were recoded to a corresponding original response option.
*** Students currently using e-cigarettes or nicotine pouches were asked, “In the past 30 days when you used [e-cigarettes/nicotine pouches], what flavors did you use? (Select one or more)?” Those who provided no valid responses were classified as using “unspecified” flavors.
††† Flavor type was ascertained by response to the question, “In the past 30 days when you used [e-cigarettes/nicotine pouches], what flavors did you use? (Select one or more).” Those who selected “some other flavor not listed here” could provide a write-in response; write-in responses corresponding to an original response option were recoded.
§§§ These flavor options provided examples: “alcoholic drinks (such as wine, margarita, or other cocktails)”; “non-alcoholic drinks (such as coffee, soda, lemonade, or other beverage)”; and “spice (such as cinnamon, vanilla, or clove).”
¶¶¶ Students currently using e-cigarettes or nicotine pouches were asked, “Did any of the flavors you used in the past 30 days have names or descriptions that included the word ‘ice’ or ‘iced’ (for example, blueberry ice or strawberry ice)?”
**** Students currently using e-cigarettes or nicotine pouches were asked, “Did any of the flavors that you used in the past 30 days have a name that did not describe a specific flavor, such as ‘solar,’ ‘purple,’ ‘jazz,’ ‘island bash,’ ‘fusion,’ or some other word or phrase?”
†††† Estimated population number of students was rounded down to the nearest 10,000 persons. The total of subgroup estimates might not sum to overall population estimates because of rounding or exclusion of students who currently used nicotine pouches and who did not report grade level (129), any brand (nine), usual brand (12), flavor types used (24), use of flavor including the word “ice” or “iced” (20), or use of flavors without specific flavor descriptor (33).

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