Vaping in New York State
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Background
A national outbreak of pulmonary illnesses linked to vaping products has prompted increased scrutiny from policymakers and public health officials surrounding the popularity and regulation of e-cigarettes and vaping products.
E-cigarettes are small, battery-powered devices that heat up a liquid (“e-liquid” or “vape juice”) to create vapor, which is then inhaled by the user. Many popular e-cigarettes are small and discreet, with little to no odor or visible indicators when they are used. As a result, vaping can be done indoors, in public, and in close quarters without detection.
E-cigarettes were originally intended as a potential smoking cessation device. Nicotine salts in e-liquid allow the user to consume nicotine in a similar manner to cigarettes, without tar or other carcinogens. As a result, e-cigarettes can be a harm-reducing alternative for former adult smokers.
In 2019, most teenagers and young adults are non-smokers, and cigarettes carry a severe social stigma among youth.[1] However, e-cigarettes are a relatively recent product that may not have similar negative connotations. E-cigarette manufacturers also previously geared marketing toward non-smoking youth, with a large assortment of sweet flavors of e-liquid and ad campaigns featuring young models. These ads did not mention cigarette cessation.[2] Additionally, certain youth-targeting e-cigarettes were designed to be small and sleek, and refillable with user-friendly pre-filled pods of liquid—making the device easy to conceal from authority figures. A single pod contains as much nicotine as a pack of cigarettes.[3]
Although the recent outbreak of pulmonary illnesses has at least partially been linked to black-market vaping products, which can contain toxic ingredients not found in commercially available products, e-cigarette use, especially among youth, has become an increasing public health concern. New York State has taken steps in recent years to address the growing use of e-cigarettes.[4] In 2017, a group of experts convened by the New York Public Health Association, the American Cancer Society, and the New York Health Foundation recommended that New York include e-cigarettes in the New York Clean Indoor Air Act and raise the legal age for purchase of all tobacco products to age 21.[5] Both of these proposals have been adopted; the Clean Indoor Air Act was expanded in 2017 and the proposal to raise the age to purchase tobacco and nicotine was signed into legislation in 2019.[6],[7] New York State officials also banned the sale of flavored e-cigarettes, but the State has been barred from enforcing the ban, pending a ruling on that litigation.[8]
A recent poll by Siena College Research Institute showed that 78% of New York State residents consider e-cigarette use and vaping as a serious public health problem. Similarly, 61% of New Yorkers support banning the sale of flavored e-cigarette liquids, and 52% support a total ban on the sale of e-cigarettes and vaping devices at retail locations.[9]
[1] McKelvey, K., & Halpern-Felsher, B. (2017). Adolescent Cigarette Smoking Perceptions and Behavior: Tobacco Control Gains and Gaps Amidst the Rapidly Expanding Tobacco Products Market From 2001 to 2015. Journal of Adolescent Health, 60(2), 226–228. https://doi.org/10.1016/j.jadohealth.2016.09.025
[2] Hiltzik, M. (2019, September 24). Los Angeles Times. Retrieved from https://www.latimes.com/business/story/2019-09-24/hiltzik-juul-target-teens
[3] Campaign for Tobacco Free Kids. JUUL and youth: rising e-cigarette popularity. Washington, DC: Campaign for Tobacco Free Kids; 2018. https://www.tobaccofreekids.org/assets/factsheets/0394.pdf
[4] Centers for Disease Control and Prevention, “Outbreak of Lung Injury Associated with E-Cigarette Use, or Vaping,” https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html, accessed October 2019.
[5] New York State Public Health Association, “Policy Recommendations to Address Electronic Nicotine Delivery Systems (ENDS) in New York State,” June 5, 2017. https://nyhealthfoundation.org/resource/policy-recommendations-to-address-electronic-nicotine-delivery-system-ends/, accessed October 2019.
[6] New York State Department of Health, “A Guide to the New York State Clean Indoor Air Act.” https://www.health.ny.gov/publications/3402/, accessed October 2019.
[7] Klepper D. “New York Raises Statewide Smoking Age to 21,” Associated Press, July 16, 2019. https://www.apnews.com/293bcb591c154c80bf23a5d51ecb5d94, accessed October 2019.
[8] Clark, DM. “New York’s Flavored Vaping Ban Put on Hold by State Appeals Court.” New York Law Journal, October 3, 2019. https://www.law.com/newyorklawjournal/2019/10/03/new-yorks-flavored-vaping-ban-put-on-hold-by-state-appeals-court/, accessed October 2019.
[9] Siena College Research Institute, Special Siena College Poll, September 22-October 1, 2019, https://scri.siena.edu/2019/10/07/78-say-vaping-serious-public-health-problem-61-support-order-to-ban-flavored-e-cigs-12-vape/, accessed October 2019.
Methods
This analysis uses publicly available youth survey data to examine trends in the prevalence of youth vaping in New York State. Data were obtained from the New York State Youth Tobacco Survey, a statewide survey of middle- and high-school students conducted every two years by the New York State Department of Health.[1] A comprehensive set of questions surrounding e-cigarette use was first introduced in 2014. All data, including student grade, race, and sex, are self-reported. Survey weights were used such that the estimates are reflective of the general State population of middle- and high-school students. Students were considered to have tried vaping if they responded “Yes” to the question, “Have you ever tried an e-cigarette, vape pen, hookah pen or e-hookah?” Students were considered to have vaped in the past 30 days if they responded to the question, “During the past 30 days, on how many days did you use an e-cigarette, vape pen, hookah pen or e-hookah?” with any response other than “0 days.”
Two survey questions were used to examine the use of flavored e-cigarettes: (1) “The first time you used a tobacco product, was it flavored to taste like candy, alcohol, fruit, chocolate, or some other sweet flavor?” and (2) “The first time you used a tobacco product, was it flavored to taste like mint or menthol?” Several students responded “Yes” to both questions, and were classified as having tried both flavors in their first exposure to tobacco. This could be because of a proliferation of vape flavorings with both sweet and menthol elements, such as “ice” or “cool” fruit flavors. It may also be the result of multiple product flavors being used in a student’s first tobacco experience. Finally, it could come from order effect bias (e.g., students may have initially misclassified mint as a “sweet” or “candy” flavor). It must be noted that this question does not ask about e-cigarettes exclusively, and students may be referring to another tobacco product when providing their answer. However, sweet- and fruit-flavored cigarettes have been off the market in the United States for a decade, making it unlikely that students who used a sweet flavor were smoking cigarettes in their first exposure to tobacco.
Limitations of this analysis include response bias—most students are aware that using tobacco products is illegal at their age and is not socially desirable. The fact that the survey is administered in a school setting underscores this bias and may impact the results. Additionally, students may be unfamiliar with clinical definitions of e-cigarettes and vaping, primarily because many e-cigarettes popular with youth are known colloquially only by their brand names.[2]
[1] New York State Department of Health, “Youth Tobacco Survey: Beginning 2000,” https://health.data.ny.gov/Health/Youth-Tobacco-Survey-Beginning-2000/pbq7-ddg9/data, accessed September 2019.
[2] Willett JG, Bennett M, Hair EC, et al. Recognition, use and perceptions of JUUL among youth and young adults. Tobacco Control 2019;28:115-116.
More New York Students are Trying E-Cigarettes.
Which tobacco or nicotine products have you ever tried? 2014–2018
Key Findings:
- In 2018, the proportion of students who have vaped but never smoked cigarettes was 21.9% of all students and 33.4% of all high school seniors. Between 2014 and 2018, the percentage of all students who had tried vaping but not smoking cigarettes more than tripled; among high school seniors, the 2018 prevalence of vaping but not smoking cigarettes represents a more than five-fold increase since 2014.
- Cigarette smoking is declining in popularity across all students (15.7% had tried in 2014, compared with 11.5% in 2018).
- The proportion of all students who have smoked cigarettes or vaped rose from 21.7% to 33.4% between 2014 and 2018.
- The number of high school seniors who have tried a nicotine product (either cigarette smoking or vaping) rose by more than half, from 37.1% to 57.8% in four years.
- More than half of high school seniors have tried vaping. Less than one-fourth have tried smoking cigarettes.
Growing Numbers of New York Students are Current Users of Vaping Products.
Which tobacco or nicotine products have you used in the past 30 days?
2014–2018
Key Findings:
- To identify current nicotine users, the survey asked students about their tobacco and nicotine use within the past 30 days. For those who had used a tobacco or nicotine product in the past 30 days, they were asked to report how many of those days they used a tobacco/nicotine product.
- Of students who vaped in the past 30 days, 11.2% were daily users in 2018, whereas 52% used a vaping product only on one or two days in the past 30 days.
- In 2018, the proportion of all students who reported currently vaping but not currently smoking cigarettes was 15 percentage points higher than the proportion who reported currently smoking cigarettes (15.5% versus 0.5%). Among high school seniors, 30% reported currently vaping but not smoking, whereas only 1% reported current cigarette smoking only.
- Cigarette smoking is declining in popularity. Among all students, 4.5% were current cigarette smokers in 2014, compared to 3.1% in 2018.
- The percent of all students who were not current cigarette smokers or vape users fell from 91.3% in 2014 to 81.4% in 2018.
- The percent of high school seniors who are neither current cigarette smokers nor vape users declined from 83.4% to 63.2% between 2014 and 2018.
Older Students Are More Likely to Vape.
Vape Use by Grade Level, 2014–2018
Key Findings:
- According to the 2018 survey, 56% of high school seniors have tried vaping and 37% recently vaped.
- In 2014, only 11.7% of eighth graders had ever tried vaping. In 2018, 19.5% of eighth graders had already tried vaping.
- The start of high school (9th grade) coincides with the largest year-over-year jump in vaping rates. In the most recent data, the number of students who have ever vaped goes from under 20% in 8th grade to 33% in 9th grade, and the number of students who reported current vape use increased from 10% to 19%.
Vaping has Increased Among All Racial Groups in Recent Years.
Vape Use by Race, High School Seniors, 2014–2018
Key Findings:
- Across all racial groups, at least 30% of high school seniors reported ever vaping in 2018.
- Rates were higher among white and Hispanic students, with approximately 60% of them reporting having tried vaping in 2018.
- Black and Asian students have lower rates of vaping (47% and 33%, respectively) in 2018.
- Among most racial groups, about two-thirds of students who have ever tried vaping have also vaped in the past 30 days. The exception is Black students: only 35% of Black students who have ever tried vaping say they have vaped in the last 30 days.
- Vaping use has increased substantially over time for most racial groups.
Girls Are Now More Likely to Vape Than Boys.
Vape Use by Sex, High School Seniors, 2014–2018
Key Findings:
- Vaping has increased quickly among girls.
- Compared with boys, high school senior girls were slightly more likely to have tried vaping and to have vaped in the past 30 days in 2018.
- 58.8% of high school senior girls have tried vaping compared with 53.4% of boys.
Most Students First Use Flavored Vape Products.
The first time you used a tobacco or nicotine product, which flavor did you use?
(All students who have tried tobacco/nicotine, 2018)
Key Findings:
- Among students who reported trying a tobacco or nicotine product, 80.6% were introduced to the substance via a flavored product; 71.2% used a sweet flavor.
- The use of sweet flavors implies a product other than cigarettes was used, as flavored cigarettes have been off the market in the U.S. since 2009.
Flavored Vape Use is Associated with Lower Perceptions of Harm from Vaping.
Students who believe vaping to be “less harmful” than cigarette smoking, by flavor used the first time they used tobacco or nicotine (All students, 2018)
Key Findings:
- About 62.5% of students who used a sweet flavor the first time they used a nicotine product are confident that vaping is less harmful than smoking.
- This is compared with 45.6% of students who used an unflavored tobacco product the first time, and 18.7% of non-nicotine users.
Conclusion
A large and growing proportion of middle- and high-school aged New Yorkers use e-cigarettes. More than half of high school seniors in New York State have tried vaping. Most of these students are not, and never have been, cigarette smokers. Older students are most likely to vape. As of 2018, youth vaping is most common among white and Hispanic students. Girls were also slightly more likely to report vaping compared with boys.
The long-term health risks of e-cigarettes are unknown. Vaping can be a harm-reduction strategy and provide a benefit to cigarette smokers looking for a cessation tool. However, of the 400,000 middle and high-school students in New York State who have tried vaping and the more than 225,000 who have vaped within the last 30 days, nearly two-thirds have never smoked cigarettes.
The prevalence of vaping among students shows that young adults find vape products to be accessible, and the high use of sweet-flavored products shows that they find these products to be attractive. More than three-quarters of students in New York State who have ever smoked, vaped, or used a tobacco product used a flavored product the first time. Use of flavored products also appears to have an impact on harm perception. Students who were first exposed to sweet flavored products are most likely to say that vaping is less harmful than cigarette smoking.
Flavored products have become a regulatory target for governments taking aim at reducing youth vaping rates. A ban on sweet flavored e-liquid, like New York State has proposed, would severely limit teen access to flavored e-cigarettes. As a result, teens will be faced with the choice of vaping unflavored e-cigarettes, or not vaping at all. Removing additives and any other factors that make nicotine more attractive to young people must be a major component of any public health policy related to vaping. Even while long-term health consequences of inhaling vaporized e-liquid remain unknown, nicotine addiction is highly likely to damage developing brains.[1]
[1] Yuan, M., Cross, S. J., Loughlin, S. E., & Leslie, F. M. (2015). Nicotine and the adolescent brain. The Journal of physiology, 593(16), 3397–3412. doi:10.1113/JP270492