California holds youth vaping below half the national average while almost eliminating smoking

The recently-released Results of the Statewide 2019-20 California Student Tobacco Survey found that California is still making excellent progress in reducing youth tobacco use, doing much better than the US as a whole. This is particularly significant because California has never focused its tobacco control program on youth, but rather treated them as part of the larger society. In addition, California has explicitly rejected the “harm reduction” ideology since 2005, which has allowed it to take an unambiguous position against e-cigarettes.

The California high school cigarette use is 1.2% well below the national high school cigarette rate of 5.8%. E-cigarette use is in single digits, less than half of the national high school rate (see graph above) and falling. The drop in e-cigarette use is probably due to the fact that the survey was in the field during the EVALI outbreak, the 100+ local flavor tobacco sales policy restrictions across the state, and the aggressive anti-vaping media campaign.

The central messages of the California Tobacco Control Program about tobacco industry denormalization and reducing the social acceptability of tobacco use are also reflected in the survey results. Three quarters of students believed that vaping companies were part of the tobacco industry (75.8%) and that tobacco companies targeted people their age by advertising flavored tobacco products in stores and on social media (74.0%) (Table 26). Many students (60.0%) believed that tobacco companies targeted people their age by selling tobacco products near schools. Consistent with research on cigarettes in California and nationally showing that distrust of the tobacco industry was an effective prevention and cessation message, never and former users having higher rates of these opinions of the tobacco industry than current users.

While the survey revealed strong denormalization of cigarette smoking and protection from secondhand exposure, it showed that there is more work to do for vaping: “While most students believed that their close friends and other students at school viewed
smoking cigarettes negatively (91.7% and 80.9%, respectively), fewer students believed
vaping was viewed negatively by close friends and other students (74.9% and 46.4%,
respectively). Among students who had never vaped, half (50.0%) thought other students
at school viewed vaping negatively.” In addition, “Despite high rates of home bans [84% for both smoking and vaping], the rate of exposure to secondhand vapor was still high: one quarter of high school students (24.9%) were exposed to secondhand vapor in a room in the last 2 weeks. The rate of exposure to secondhand smoke in a room was lower (8.9%).”

The survey highlights the limitations of laws and policies to prevent youth from buying tobacco products, including e-cigarettes. Among current vapers, 48.8% reported not paying for their vapes and among current cigarette smokers, 55.8% did not pay for their cigarettes. While such laws are helpful and good public policy, by themselves they are not enough to prevent youth use. This fact is especially important since Juul (like other tobacco companies in the past) has promoted its computerized youth access restrictions as an effective way to prevent youth e-cigarette use. Policymakers, including the FDA should not accept these programs as adequately effective to prevent youth use when deciding whether authorizing the sale of Juul and other e-cigarettes is “appropriate for the protection of public health” because they would only block half the youth access, if that.

There is evidence that anti-vaping advertising campaigns (California, FDA, truth) are reaching youth more effectively than the tobacco industry, but the industry still has a presence. Most students (71.4%) had been exposed to any type of vape or cigarette-related ad within the last 30 days with exposure to vape ads (67.3%) being higher than cigarette ads (51.8%). Ads that were perceived to be anti-tobacco were the most common type of ad seen for both products. A greater percentage of students reported seeing ads that were perceived to be discouraging the use of the product for vapes (40.5%) than for cigarettes (31.4%). Similarly, a greater percentage of students reported seeing ads that were perceived to be promoting vaping (15.1%) than cigarettes (10.2%).

Here are the top points on use patterns, from the Executive Summary:

  • In 2019-20, 28.6% of California high school students had ever used any tobacco product and 9.7% currently used tobacco in the last 30 days.
  • The current cigarette smoking prevalence rate was low, as only 1.2% of high school students reported currently smoking in the last 30 days.
  • The use of other combustible tobacco products among high school students was also very low. In 2019-20, the prevalence was 2.2%, 0.6%, and 0.5%, for little cigars or cigarillos (LCC), hookah, and big cigars, respectively.
  • Vapes were the most commonly used tobacco product among high school students (8.2%). This was true across gender, race/ethnicity, and grade.
  • Overall tobacco use (9.7%) was mainly driven by the rate of vape use (8.2%).
  • Use of heated tobacco products (HTP), an emerging product, was low (0.2%).
  • Use of multiple tobacco products was common, representing about one quarter (24.7%) of current high school tobacco product users.
  • Students who rated their mental health as poor had a higher current tobacco use prevalence (16.1%) compared to those who rated their mental health as good to excellent (9.7%).
  • The vast majority of current tobacco product users reported using flavored tobacco products (91.6%), with the use of flavored vapes being the highest (96.2%). Of note, half of current cigarette smokers (49.4%) reported using menthol cigarettes. Use of flavored tobacco products was high across all genders, races/ethnicities, and grades. Fruit was the most popular flavor among vape (63.9%), LCC (51.7%), and hookah (48.8%) users, while mint/menthol was the most popular flavor among smokeless tobacco users (51.4%). Fruit and alcohol or liquor were similarly popular among those who currently used big cigars. [emphasis added]

The report also highlights the new problem of marijuana: “Marijuana was the most popular product, used by more high school students than all tobacco products combined (15.0% vs. 9.7%). Among current marijuana users, about half (49.7%) reported not paying for their marijuana and half (50.3%) reported paying for it.”

There are lots of other important details in the report, demonstrating the key roles of flavors and menthol in youth tobacco use and the fact that most kids are either very light (1 or 2 days a month) or heavy (20 or more days a month) users for most products..

The report concludes:

The most striking result from the 2019-20 CSTS is that cigarette smoking among California  high school students continued to decline  from the very low rates of previous years and has now reached a negligible level of 1.2%. This is lower than any record of adolescent smoking prevalence in recent years. It is a level that few in the tobacco control community would have thought possible 10 years ago. Thirty years of campaigning against smoking in California since Proposition 99 have succeeded in changing the social  norms so much that an overwhelming proportion of high school students (>90%) in 2019-20  believed that their close friends viewed cigarette smoking negatively. This can be the first generation of California youth who will be essentially smoke-free when they reach adulthood, as smoking is started and established primarily during adolescence.

As smoking declines, vaping has replaced cigarettes as the number one tobacco product used by adolescents. More than half of the high school students in 2019-20 believed that their fellow students did not view vaping negatively. More than 70% believed that the numerous flavors in these vaping products attract young people to use them.  

There are signs of progress, however, in California’s  effort to reduce the use of vapes among adolescents. The progress can  be measured in students’ perception  and behavior  related to vaping.  In terms of  perception, three quarters  of high  school  students believed that  vaping companies are part of the tobacco industry and that tobacco companies target their age group by advertising  flavored tobacco  products  in  stores and on social  media. The perception of a vaping  company as part  of the tobacco  industry may  mobilize youth against  the use of their products because of the negativity associated with the latter, as an industry that manipulates the facts to addict young people. In terms of behavior, it appears that the vaping prevalence did not increase from the 2017-18  to the 2019-20 CSTS, breaking the trend of increasing e-cigarette use since  2015-16. It  should  be  acknowledged that  the questions  for  assessing the  use  of  electronic nicotine delivery systems were worded differently in the 2017-18  (e-cigarettes) and 2019-20  (vaping).

The CSTS  is a cross-sectional study and changes in question wording across cycles,  making  it  difficult  to  directly  compare  the  prevalence.  Still, extrapolations using different data sets can be made to estimate the change. The 2017-18 CSTS found that 10.5% high school students reported currently using e-cigarettes while the 2019-20 CSTS found that 8.2% reported vaping nicotine or just flavoring. Because a certain proportion of these 10.5% e-cigarette users in 2017-18  used the device to vape marijuana only, it means that the rate of vaping nicotine or just flavoring in 2017-18  would have been lower if vaping marijuana were measured separately and factored out in the computation (as was the case in the 2019-20 CSTS). Using data from Monitoring the Future in 2017  and 2018, we can estimate that about 1.0% of the 10.5% in the 2017-18  CSTS likely vaped marijuana only. If this vaping-marijuana-only is subtracted  from  the  total  e-cigarette use  prevalence in  2017-18,  the prevalence  for  vaping nicotine or just flavoring was still slightly higher than that in 2019-20.  Thus, it can be reasonably concluded that vaping among California high school students did not increase from 2017-18 to 2019-20.   

Finally, the 2019-20  CSTS found that the overall use of tobacco products among California  high school students continued to decline, from 12.2%  in 2017-18  to 9.7% in 2019-20.5  The decline occurs for most tobacco products and across demographic dimensions, which suggests that the social norms for tobacco use among California  youth generally trend negative. It is imperative, therefore, that the tobacco control community remain vigilant as new products come into the market, to maintain  the momentum of driving  down the use of all tobacco products without allowing new products to replace the old.

The full citation for the report is: Zhu S-H, Braden K, Zhuang Y-L, Gamst A, Cole AG, Wolfson T, Li S. (2021). Results of the Statewide 2019-20 California Student Tobacco Survey. San Diego, California: Center for Research and Intervention in Tobacco Control (CRITC), University of California San Diego. It is available for free here.

Published by Stanton Glantz

Stanton Glantz is a retired Professor of Medicine who served on the University of California San Francisco faculty for 45 years. He conducts research on tobacco and cannabis control and cardiovascular disease/

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