E-cigarettes & Young People in Arizona, USA
What are e-tobacco products? How widespread is their use in U.S. schools? Electronic cigarettes, better known as e-cigarettes, are portable electronic devices designed to heat a liquid that usually contains nicotine, flavorings, and other chemicals that generate a vapor. They are also known by multiple names: e-cigs, e-hookahs, mods, vape/vape pens, pod vaporizers, or electronic nicotine delivery systems (ENDS).
As reported by the National Youth Tobacco Survey (NYTS) in the Morbidity and Mortality Weekly Report (MMWR), e-cigarettes were the most commonly used tobacco product in 2021 among middle- and high school students, with average usage rates of 2.8% and 11.3%, respectively. This prevalence means that approximately 2.3 million U.S. youths (middle and high school students) currently use e-cigarettes.
A systematic review of consumer preference for e-cigarette attributes concluded that adolescents considered flavor as the most relevant factor for trying e-cigarettes and that the wide variety of flavors available made it likelier for youth to begin vaping. Among middle school students who vape, 79.2% used flavored e-cigarettes, and this figure was even higher for high school students (85.8%) expressing a preference for flavored e-cigarettes. When examined by flavor type, the most popular was ‘fruit’ for both school levels.
Regarding usage by brand, Puff Bar ranked first at 30.3% use among all vapers at the middle school level and 26.1% for high school students.
How Do We Compare?
The most recent data for states was reported in 2019 through the Youth Risk Behavior Surveillance System (YRBSS).
In 2019, 50.1% of high school students in the U.S. reported having used electronic vapor products at least once in their lifetimes. The state of New Mexico and Colorado reported higher average rates than the nation, at 56.3% and 50.3%, respectively. Arizona reported a rate of 48.4%, slightly lower than the nation.
When comparing the history and frequency of use of e-cigarettes among eight western states tracked on the MAP Dashboard, an average of 21.5% of high school students reported current use and 46.2% reported having used e-cigarettes at least once in their lifetimes. The state of Utah posted the lowest rates (9.7% current use and 30.5% ever use), while Arizona posted 17.9% current use and 48.4% ever use, in 2019. Figure 1 displays the percentage of high school students using e-cigarettes by historical usage across MAP Western states in 2019. Data for Oregon and Washington are not available.
Figure 1: Percentage of High School Students Using Electronic Vapor Products (Ever, Current, Frequently, and Daily) by State (2019)
Across the nation, females in high school reported a higher rate of e-cigarette use than males by 1.5 percentage points. The use of e-cigarettes varied by gender across the eight western states. The states of Arizona, Idaho, and Texas did not follow the national trend, posting a percentage of current e-cigarette use higher for males than for females. In 2019, the state of New Mexico showed no difference between females and males in the current use of e-cigarettes. Figure 2 shows the percentage of high school students who currently use electronic vapor products by gender and state in 2019.
Figure 2: Percentage of High School Students Who Used Electronic Vapor Products by Gender and State in 2019
Research has shown that tobacco use disproportionately affects racial and ethnic minorities. In 2019, e-cigarette use was proportionally highest among American Indian/Alaska Natives, for whom almost half (47.3%) of the surveyed population representing that group reported at least one day of use during the 30 days before the survey. Asian high school students posted the lowest relative percentage of e-tobacco use at 13.0% (see Figure 3).
Figure 3: Percentage of U.S. Students Who Used Electronic Vapor Products by Race and Ethnicity in 2019
In 2019, the proportion of Hispanic high school students who used e-tobacco products in Arizona was 15.2 percentage points lower than the national average. Among White high school students, Arizona also did better, with a 22.6% share of e-tobacco users relative to the national share of 38.3%. Figure 4 highlights the percentage of students (Hispanic/Latino and White) who used electronic vapor products in the U.S. and Arizona in 2019.
Figure 4: Percentage of Hispanic/Latino and White Students Who Used Electronic Vapor Products in the U.S. and Arizona in 2019
The use of e-tobacco products among Arizona’s male high school students was lower than the national average for all academic grades. The largest difference was found in 10th grade, where U.S. male high school students posted 17.4 percentage points higher usage of e-tobacco than in Arizona. In males, there was a growing tendency to use e-tobacco from 9th grade (23.2%) to 12th grade (42.4%). In Arizona, the difference in usage between 9th and 12th grade was similar, although there was a marked decrease in 10th grade when the percentage dropped to 10.5%. Figure 5 illustrates the percentage of students who currently use electronic vapor products by academic grade and male gender in the U.S. and Arizona in 2019.
Figure 5: Percentage of Students Who Used Electronic Vapor Products by Academic Grade and Male Gender (US. and Arizona) in 2019
As in the case of males, Arizona female high school students reported lower e-cigarette use at all academic levels when compared to female high school students in the U.S. The largest difference was found in the 11th grade, with a 22.9 percentage point difference in smoking e-tobacco between the U.S. and Arizona females. Between 11th grade and 12th grade in Arizona, there was an increase in usage of 11.0 percentage points, coinciding with the minimum age required by law for the purchase of e-tobacco. Nationally, that difference was only 2.8 percentage points higher for 12th-grade students than for 11th-grade students (See Figure 6).
Figure 6: Percentage of Students Who Used Electronic Vapor Products by Academic Grade and Female Gender (US. and Arizona) in 2019
Health Effects of Vaping
According to the American Heart Association (AHA), vaping might pose serious but preventable health risks. Exposure to nicotine during adolescence can lead to addiction and cause long-term harm to brain development. E-tobacco contains nicotine, ultrafine particles, heavy metals, and volatile organic compounds.
Another risk associated with the use of e-tobacco is lung injury. Based on the Centers for Disease Control and Prevention (CDC), by early 2020, there had been around 2,800 hospitalized e-cigarette or vaping-associated lung injury (EVALI) cases and 68 deaths in the U.S. In addition, fires and explosions caused by defective vaping battery products might result in serious injuries.
On the other hand, as a recent report showed, e-tobacco might be useful for adult smokers who want to quit regular cigarettes and other smoked tobacco products. Nevertheless, researchers are still collecting data to understand the risk of vaping among youngsters and its long-term consequences.
Secondhand and Thirdhand Exposures
A 2020 report concluded that indoor vaping leads to secondhand and thirdhand e-cigarette aerosol exposures. Thirdhand exposure induced by e-cigarette vaping is comparable to or higher than those from smoking cigarettes. Thirdhand exposure levels differ depending on the surface on which the particles emitted by vaping are deposited, and the e-cigarette brand. Three of the four experiments conducted in a recent article showed significant increases in the quantity of nicotine on five surfaces tested, and floor and glass windows posted the highest accumulation of nicotine, on average. Secondhand exposure is associated with an increased risk of bronchitis symptoms and shortness of breath in young adults, even after accounting for active smoking and vaping.
E-Cigarettes and Drug Use
According to a study published in JAMA Network Open, teenagers who use e-tobacco are more inclined than non-vaping adolescents to try cannabis within the following year. Nevertheless, the researchers noted the caveat that “despite the strong association at the individual level, e-cigarette use seems to have had a minimal association with the prevalence of youth cannabis use at the population level."
An article published in the American Journal of Addictions found an association between e-tobacco and alcohol, marijuana, cocaine, amphetamines, inhalants, hallucinogens, ecstasy, and the misuse of over-the-counter and prescription medications.
How Big Is the Vape Market?
Since 2006-2007, the e-cigarette market has grown considerably in its distribution and purchase channels. The appearance of mainstream social media networks such as Facebook in 2004 and Twitter in 2006 has influenced the rapid acceleration of the e-cigarette market. E-cigarette manufacturers and brands use those social media platforms to interact directly with their customers; such direct-to-consumer marketing frequently offers online discounts, coupons, and loyalty programs. A study conducted by Grana and Ling (2014) found that 80% of websites indicated those promotions.
According to the report of the Surgeon General in their 2021 National Youth Tobacco Survey (NYTS), in the U.S., the e-cigarette market was estimated to be approximately $3.5 billion in size in 2015. That included $1.6 billion in sales in “vape shops” and other channels, $1.1 billion in convenience stores, food, drug, and big-box stores, and $800 million in online sales.
The Food and Drug Administration (FDA) is currently working to review the e-cigarette marketing strategies for the most popular brands. Three companies received warning letters for illegally marketing disposable e-tobacco (Puff Bar was one of them).
E-Tobacco Laws and Regulations
On December 20, 2019, the Federal Food, Drug & Cosmetic Act (FD&C Act) was amended to raise the minimum age of the sale of tobacco products from 18 to 21 years of age. It is illegal to sell tobacco products such as cigarettes, cigarette tobacco, roll-your-own tobacco, smokeless tobacco, and covered tobacco products (e-cigarettes) to anyone under the age of 21. There are no exemptions from this requirement.
The Smoke-Free Arizona Program does not have jurisdiction over the use of any products other than burning tobacco. Electronic cigarettes do not contain tobacco and therefore do not fall under the provision of the Act ( A.R.S. § 36-601.01). The proprietors of establishments can implement their in-house policy and prohibit the consumption of electronic cigarettes on their premises if they so choose.
According to the American Nonsmoker’s Right Foundation, among 10 MAP western states, just four (Arizona, Idaho, Texas, and Washington) have no e-cigarette restrictions in 100% smoke-free venues. There are some exceptions in local areas, such as Coconino County, where e-cigarettes are banned in non-hospitality workplaces and restaurants, and in the city of Flagstaff, they are also prohibited in bars. Figure 7 displays the states and municipalities with laws regulating use of e-cigarettes in 100% smokefree venues in 2023.
Figure 7: States & Municipalities with Laws Regulating Use of Electronic Cigarettes in 100% Smokefree Venues
Regarding vaping marijuana, only Arizona, Idaho, and Texas have no laws prohibiting its use in non-hospitality workplaces, restaurants, bars, and, or gambling facilities. Figure 8 displays the state and local laws prohibiting smoking and vaping marijuana in 2023.
Figure 8: State and Local Laws Prohibiting Smoking AND Vaping Marijuana
Intention to Quit Vaping Among U.S. Adolescents
In 2021, the percentage of individuals who used e-tobacco but considered quitting the use of all tobacco products varied by school level and gender. Female students thought about quitting more frequently than their male counterparts at all levels of schooling. Specifically, the percentage of female high school students considering quitting exceeded that of males in comparable educational levels by 6.9 percentage points. For students in middle school, this difference was 9.1 percentage points in favor of female students. Among students who actively tried to quit during the past 12 months, the prevalence of females was 60.7% and 71.6% at the middle school and high school levels, respectively. For male students, the past-year quitting attempt prevalence in 2021 was 55.9% in high school and 65.8% in middle school. (See Figure 9).
Figure 9: Percentage of Intentions to Quit Among Middle and High School Students by Gender (2021)
According to the CDC, the percentage of high school students in the U.S. who had at least once tried cigarette smoking decreased from 70.1% in 1991, to 24.1% in 2019. However, the national trend of e-cigarette use moved in the opposite direction between 2015 and 2019. Overall, the percentage of U.S. high school students who have at some point tried e-tobacco products increased from 44.9% in 2015 to 50.1% in 2019. During that same time interval, Arizona posted a decline in the percentage of high school students who ever used e-cigarettes, falling from 51.6% to 48.4% (See Figure 10).
Figure 10: Trend in the Use of E-cigarettes Among U.S. High School Students (2015-2019)
Many adolescents are not fully aware of their nicotine consumption when using e-cigarettes, and there is still little evidence documenting the health consequences of consuming tobacco-free nicotine. The rapidly growing pace of e-tobacco product consumption in the U.S. and Arizona makes this practice a critical aspect from a public health standpoint and underscores the necessity of monitoring its prevalence and impact from different socio-economic angles.