Abstract
Objectives:
In 2018, approximately 4.9 million US middle and high school students reported past 30-day use of any tobacco product. This study describes how and where youth obtained tobacco products and whether refusal of sale occurred during 2016-2018.
Methods:
Data from 3 annual waves (2016-2018) of the National Youth Tobacco Survey, a school-based survey of US youth in grades 6-12, were analyzed among current (past 30-day) tobacco product users aged 9 to 17 years.
Results:
During 2016-2018, youth tobacco product users most commonly obtained tobacco products from social sources. Although the percentage of users who reported buying tobacco products significantly decreased from 2016 to 2018 (2016: 15.6%; 2018: 11.4%), no significant differences in the prevalence of being refused sale were observed (2016: 24.7%; 2018: 25.5%).
Conclusions:
Whereas the number of youth users who report buying tobacco products has declined, sales of tobacco products to youth remain a public health concern, as only one in 4 youth who attempted to buy were refused sale in 2018. Monitoring youth tobacco product purchases, retailer compliance check inspections, and retailer penalties for sales to minors remain important for reducing youth access at retail sources.
Keywords: youth, access, tobacco products, National Youth Tobacco Survey
Tobacco product use among youth, in any form, is not safe.1 Most tobacco products contain nicotine, which is highly addictive and can harm the developing brain, impacting learning, memory, and attention.1 In 2018, approximately 4.9 million middle (840,000; 7.2%) and high school students (4.04 million; 27.1%) in the United States (US) reported past 30-day use of any tobacco product, a significant 29% and 38% increase from 2017 among middle and high school students, respectively.2 Since 2014, e-cigarettes have been the most commonly used tobacco product among US middle and high school students.3
On August 8, 2016, the US Food and Drug Administration (FDA) finalized a deeming rule to extend its regulatory authorities to cover all tobacco products, including e-cigarettes, cigars, hookah, pipe tobacco, nicotine gels, and dissolvables not already regulated as smokeless tobacco products.4 This rule extended the federal prohibition on the sale and distribution of cigarettes, cigarette tobacco, smokeless tobacco, and roll your own tobacco to anyone younger than 18 years to these newly deemed tobacco products, except for components and parts that are not made or derived from tobacco.
Given the recent increases in tobacco product use, which were driven by an increase in e-cigarette use,2,5 understanding how and where youth access tobacco products, particularly e-cigarettes, is important for informing enforcement of federal, state, and local youth access restrictions. Research on youth access to tobacco products is limited. The most recent published studies examined youth access to tobacco products prior to the now publicized increases observed in tobacco use.6–11 This study describes national prevalence estimates on how and where US youth past 30-day tobacco users aged 9 to 17 years obtained tobacco products and whether refusal of sale occurred during 2016-2018.
METHODS
Data
Data came from 3 annual waves (2016-2018) of the National Youth Tobacco Survey (NYTS), a cross-sectional, school-based, self-administered pencil-and-paper survey of US public and private school students in grades 6-12. NYTS employs a stratified, 3-stage cluster sample design to produce nationally representative samples. Sample sizes and responses rates were: 20,675 (71.6%) in 2016; 17,872 (68.1%) in 2017; and 20,189 (68.2%) in 2018.
For this study, analyses were restricted to current (past 30-day) tobacco product users. Current tobacco product use was defined as use of cigarettes, e-cigarettes, hookah, cigars, pipe tobacco, smokeless tobacco, snus, dissolvable tobacco products, and bidis on ≥ 1 day during the past 30 days. Because federal law currently restricts the sale of all tobacco products to anyone younger than 18 years, current tobacco product users aged ≥ 18 years or with missing data on age were excluded (N = 1593).
Measures
Access to tobacco products.
Respondents were asked: “During the past 30 days, how did you get your own tobacco products? (Select one or more).” Response options were “I did not get any tobacco products during the past 30 days;” “I bought them myself;” “I had someone else buy them for me;” “I asked someone to give me some;” “Someone offered them to me;” “I bought them from another person;” “I took them from a store or another person;” “I got them some other way.”
A separate question assessed access to e-cigarettes: “During the past 30 days, where did you get or buy the e-cigarettes that you have used? (Select one or more).” Response options were “I have never tried an e-cigarette in the past 30 days;” “A gas station or convenience store;” “A grocery store;” “A drug-store;” “A mall or shopping center kiosk/stand;” “On the Internet;” “A vape shop or other store that only sells e-cigarettes;” “Some other place not listed here;” “From a family member;” “From a friend;” “From some other person that is not a family member or a friend.”
A composite variable (“social sources”) was generated to indicate that the respondent obtained tobacco products or e-cigarettes from someone else (ie, “I had someone else buy them for me;” “I asked someone to give me some;” “Someone offered them to me;” “I bought them from another person;” “From a family member;” “From a friend;” “From some other person that is not a family member or a friend.”).
Purchasing locations.
Respondents were asked: “During the past 30 days, where did you buy your own tobacco products? (Select one or more).” Response options were “I did not buy tobacco products during the past 30 days;” “A gas station or convenience store;” “A drugstore;” “A vending machine;” “On the Internet;” “Through the mail;” “Some other place not listed here.”
Refusal of sale.
Respondents were asked, “During the past 30 days, did anyone refuse to sell you any tobacco products because of your age?” Response options were “I did not try to buy any tobacco products during the past 30 days;” “Yes;” “No”.
Data Analyses
Weighted prevalence estimates and 95% confidence intervals for how and where youth obtained tobacco products and whether refusal of sale occurred during 2016-2018 were generated overall. Independent t-tests were performed to examine differences in youth access between 2016 and 2018 (p < .05). Youth access to tobacco products in 2018 were stratified by demographic characteristics, including sex, school level, and race/ethnicity, and chi-square tests assessed differences within subgroups (sex, school level, race/ethnicity) (p < .05). Analyses were conducted in SAS-callable SUDAAN, version 9.3.
RESULTS
During 2016-2018, youth tobacco product users most commonly obtained tobacco products from social sources (Table 1). In 2018, this included 40.3% (1.64 million) of current users who reported obtaining tobacco products at least one of the following ways: having someone else buy them (19.9%), being offered tobacco products by someone (16.0%), asking someone to give them some tobacco products (12.2%), or buying from another person (9.3%). The proportion of youth users who reported obtaining tobacco products through these first 3 means significantly decreased from 2016 to 2018.
Table 1.
Access to Tobacco Products in the Past 30 Days among US Middle and High School Students Aged 9 to 17 Years who Reported Past 30-day Tobacco Product Use – National Youth Tobacco Survey, 2016-2018
| 2016 | 2017 | 2018 | p-valuef | |
|---|---|---|---|---|
| % (95% CI) | % (95% CI) | % (95% CI) | ||
| How Obtained Tobacco Productsa | ||||
| I bought them myself | 15.6 (13.8-17.5) | 11.8 (9.9-14.1) | 11.4 (9.8-13.2) | < .001 |
| I had someone else buy them | 27.4 (24.3-30.7) | 23.5 (21.0-26.1) | 19.9 (18.1-21.7) | < .001 |
| I asked someone to give me some | 16.4 (14.7-18.3) | 15.0 (13.0-17.3) | 12.2 (11.0-13.6) | < .001 |
| Someone offered them to me | 21.2 (19.1-23.4) | 19.1 (17.0-21.4) | 16.0 (14.6-17.6) | < .001 |
| I bought them from another person | 8.1 (6.8-9.7) | 8.3 (7.0-9.7) | 9.3 (8.0-10.7) | g |
| I took them from a store or another person | 3.9 (2.8-5.5) | 4.1 (3.1-5.3) | 2.6 (2.0-3.4) | g |
| I got them some other way | 12.7 (10.8-15.0) | 10.3 (9.0-11.7) | 10.7 (9.3-12.4) | g |
| From social sourcesb | 51.0 (48.1-53.9) | 46.3 (43.2-49.4) | 40.3 (38.0-42.6) | < .001 |
| Missingc | 4.4 (3.1-6.1) | 5.2 (3.8-7.0) | 6.3 (5.3-7.5) | < .05 |
| Where Obtained Tobacco Products (among those who reported buying themselves in the past 30 days)a | ||||
| Gas station/convenience store | 57.3 (50.6-63.7) | 57.1 (47.6-66.0) | 57.7 (49.6-65.5) | g |
| Grocery store | 14.0 (10.0-19.2) | 8.7 (4.9-14.9) | 9.5 (6.2-14.4) | g |
| Drug store | 13.3 (9.9-17.8) | 15.9 (11.2-22.2) | 13.6 (9.9-18.6) | g |
| Vending machine | 7.9 (4.6-13.3) | e | 3.5 (2.1-5.8) | g |
| On the Internet | 19.0 (14.4-24.5) | 6.9 (4.0-11.7) | 13.0 (9.5-17.5) | g |
| Through the mail | 8.9 (5.9-13.2) | e | 4.2 (2.8-6.4) | < .05 |
| Some other place not listed here | 28.6 (23.7-34.0) | 27.5 (19.2-37.6) | 26.9 (21.3-33.3) | g |
| Missingc | e | e | e | h |
| How and Where Obtained E-Cigarettes (among past 30-day e-cigarette users)a | ||||
| Gas station/convenience store | 11.5 (9.2-14.3) | 8.4 (6.0-11.6) | 9.8 (7.6-12.5) | g |
| Grocery store | 2.7 (1.9-3.8) | 0.9 (0.5-1.6) | 1.0 (0.6-1.5) | < .01 |
| Drug store | 3.3 (2.3-4.8) | 1.8 (1.1-3.1) | 1.8 (1.3-2.5) | < .05 |
| Mall or shopping center kiosk/stand | 3.9 (2.7-5.5) | 2.3 (1.3-4.1) | 1.9 (1.2-3.0) | < .05 |
| On the Internet | 10.2 (8.1-12.7) | 6.5 (5.0-8.4) | 5.7 (4.6-7.2) | < .001 |
| Vape shop or other store that only sells e-cigarettes | 22.4 (20.0-24.9) | 14.8 (12.4-17.5) | 16.5 (13.9-19.3) | < .01 |
| Some other place not listed here | 5.2 (3.8-7.1) | 3.1 (2.2-4.3) | 2.8 (2.1-3.7) | < .01 |
| From a family member | 16.1 (13.5-19.1) | 11.7 (9.6-14.3) | 13.3 (11.5-15.3) | g |
| From a friend | 51.8 (47.3-56.3) | 56.4 (51.7-61.0) | 58.6 (55.6-61.6) | < .05 |
| From some other person that is not a family member or a friend | 11.9 (9.9-14.1) | 7.4 (5.8-9.5) | 9.2 (8.0-10.6) | < .05 |
| From social sourcesd | 67.7 (64.6-70.8) | 69.6 (65.1-73.8) | 72.6 (70.2-74.9) | < .05 |
| Missingc | 2.3 (1.4-3.7) | e | 2.0 (1.3-3.0) | g |
| Refused Tobacco Products Sale Because of Age (among those who tried to buy tobacco products) | ||||
| Yes | 24.7 (21.7-28.0) | 23.3 (20.1-26.9) | 25.5 (22.0-29.2) | g |
| No | 75.3 (72.0-78.3) | 76.7 (73.1-79.9) | 74.5 (70.8-78.0) | g |
Note.
Respondents could select more than one option.
A composite variable indicating that the respondent obtained tobacco products through at least one of the following ways: “I had someone else buy them for me;” “I asked someone to give me some;” “Someone offered them to me;” “I bought them from another person.”
No response provided.
A composite variable indicating that the respondent obtained e-cigarettes through at least one of the following sources: “From a family member;” “From a friend;” “From some other person that is not a family member or a friend.”
Data suppressed because the sample size was < 50 or the relative standard error was > 30%.
Independent t-tests were performed to examine differences between 2016 and 2018.
Not significant.
Not applicable. Data suppressed for 2016 and 2018.
Moreover, 11.4% of youth tobacco product users (460,000) reported buying tobacco products themselves in 2018, a significant decrease from 2016 (15.6%; 500,000). Buying tobacco products was highest among males (15.2%), high school students (12.7%), and non-Hispanic Whites (12.6%) (Table 2, Table 3). In 2018, more than half of current tobacco product users who reported buying tobacco products within the past 30 days did so at gas stations/convenience stores (57.7%), followed by drug stores (13.6%), and on the Internet (13.0%). Although the proportion of youth who bought tobacco products through the mail decreased (2016: 8.9%, 2018: 4.2%), no other significant differences in location of purchase where observed from 2016 to 2018.
Table 2.
Access to Tobacco Products in the Past 30 Days among US Middle and High School Students Aged 9 to 17 Years who Reported Past 30-day Tobacco Product Use by Sex and School Type – National Youth Tobacco Survey, 2018
| Sex | School Type | ||||
|---|---|---|---|---|---|
| Overall | Female | Male | Middle School | High School | |
| Weighted Nd | % (95% CI) | % (95% CI) | % (95% CI) | % (95% CI) | |
| Overall | 4,080,000 | 46.5 (44.3-48.7) | 53.5 (51.3-55.7) | 20.6 (17.1-24.5) | 79.4 (75.5-82.9) |
| How Obtained Tobacco Productsa | |||||
| I bought them myself | 460,000 | 6.9 (5.4-8.8)* | 15.2 (12.8-17.9)* | 6.0 (4.2-8.5)* | 12.7 (10.9-14.9)* |
| I had someone else buy them | 810,000 | 21.4 (18.7-24.4)* | 18.6 (16.4-21.0)* | 12.4 (9.6-16.0)* | 21.8 (19.7-24.1)* |
| I asked someone to give me some | 500,000 | 15.0 (13.0-17.1)* | 9.7 (8.2-11.4)* | 9.7 (7.3-12.9) | 12.9 (11.4-14.5) |
| Someone offered them to me | 650,000 | 19.8 (17.3-22.5)* | 12.9 (11.2-14.7)* | 12.7 (9.2-17.3) | 16.9 (15.2-18.7) |
| I bought them from another person | 370,000 | 10.0 (8.3-12.1)* | 8.7 (6.9-10.9)* | 7.1 (5.3-9.6)* | 9.8 (8.4-11.5)* |
| I took them from a store or another person | 100,000 | 2.3 (1.7-3.1)* | 2.5 (1.7-3.7)* | 4.4 (2.8-6.8)* | 2.0 (1.4-2.9)* |
| I got them some other way | 430,000 | 9.3 (7.6-11.4)* | 11.7 (9.7-14.0)* | 15.6 (11.5-20.8)* | 9.5 (8.1-11.1)* |
| From social sourcesb | 1,640,000 | 45.1 (41.8-48.4)* | 36.2 (33.1-39.4)* | 30.7 (25.8-36.1)* | 42.8 (40.3-45.4)* |
| Where Obtained Tobacco Products (among those who reported buying themselves in the past 30 days)a | |||||
| Gas station/convenience store | 260,000 | 52.6 (40.8-64.1) | 59.3 (50.0-68.1) | e | 58.0 (48.8-66.6) |
| Grocery store | 40,000 | e | 8.0 (5.0-12.6) | e | 9.5 (5.9-14.9) |
| Drug store | 60,000 | 15.6 (8.5-26.9) | 12.6 (8.7-18.0) | e | 13.1 (9.1-18.4) |
| Vending machine | 10,000 | e | e | e | e |
| On the Internet | 60,000 | 16.0 (8.9-26.8) | 11.5 (7.5-17.4) | e | 13.2 (9.6-18.0) |
| Through the mail | 10,000 | e | 4.7 (2.9-7.6) | e | 3.9 (2.4-6.4) |
| Some other place not listed here | 120,000 | 23.5 (15.4-34.2) | 28.2 (22.0-35.2) | e | 26.1 (20.3-32.8) |
| How and Where Obtained E-cigarettes (among past 30-day e-cigarette users)a | |||||
| Gas station/convenience store | 290,000 | 9.4 (6.9-12.5) | 10.2 (7.5-13.7) | 6.1 (3.8-9.7) | 10.6 (8.1-13.9) |
| Grocery store | 20,000 | e | 1.0 (0.6-1.8) | e | 1.1 (0.6-1.7) |
| Drug store | 50,000 | 1.1 (0.6-1.9)* | 2.5 (1.7-3.6)* | e | 1.7 (1.2-2.5) |
| Mall or shopping center kiosk/stand | 50,000 | e | 2.3 (1.5-3.6) | e | 1.8 (1.1-3.1) |
| On the Internet | 170,000 | 3.8 (2.5-5.7)* | 7.2 (5.2-9.8)* | 3.5 (2.1-5.6)* | 6.2 (4.8-7.9)* |
| Vape shop or other store that only sells e-cigarettes | 500,000 | 15.0 (12.5-18.0) | 17.9 (14.4-22.0) | 7.7 (5.1-11.3)* | 18.5 (15.6-21.9)* |
| Some other place not listed here | 80,000 | 1.7 (1.0-2.8)* | 3.8 (2.6-5.5)* | e | 2.7 (2.0-3.6) |
| From a family member | 400,000 | 16.1 (13.0-19.7)* | 10.6 (8.7-12.8)* | 24.7 (20.5-29.5)* | 10.6 (8.9-12.6)* |
| From a friend | 1,780,000 | 64.3 (60.9-67.6)* | 53.7 (49.2-58.2)* | 52.3 (45.4-59.1) | 60.2 (56.8-63.4) |
| From some other person that is not a family member or a friend | 280,000 | 8.4 (6.7-10.5) | 10.0 (8.3-12.0) | 9.8 (6.7-14.0) | 9.0 (7.7-10.6) |
| From social sourcesc | 2,210,000 | 78.6 (75.7-81.2)* | 67.3 (63.4-71.0)* | 77.5 (72.4-81.8)* | 71.5 (68.6-74.2)* |
| Refused Tobacco Products Sale Because of Age (among those who tried to buy tobacco products) | |||||
| Yes | 370,000 | 19.5 (15.0-24.9)* | 29.4 (24.5-34.8)* | 27.2 (19.0-37.3) | 25.0 (21.5-28.9) |
| No | 1,100,000 | 80.5 (75.1-85.0)* | 70.6 (65.2-75.5)* | 72.8 (62.7-81.0) | 75.0 (71.1-78.5) |
Note.
Respondents could select more than one option.
A composite variable indicating that the respondent obtained tobacco products through at least one of the following ways: “I had someone else buy them for me;” “I asked someone to give me some;” “Someone offered them to me;” “I bought them from another person.”
A composite variable indicating that the respondent obtained e-cigarettes through at least one of the following sources: “From a family member;” “From a friend;” “From some other person that is not a family member or a friend.”
Estimated numbers of past 30-day youth tobacco users aged 9-17 years, rounded down to the nearest 10,000.
Data suppressed because the sample size was < 50 or the relative standard error was > 30%.
significant differences within subgroups (chi-square p-value < .05).
Table 3.
Access to Tobacco Products in the Past 30 Days among US Middle and High School Students Aged 9 to 17 Years who Reported Past 30-day Tobacco Product Use by Race/Ethnicity – National Youth Tobacco Survey, 2018
| Race/Ethnicity | ||||
|---|---|---|---|---|
| White, non-Hispanic | Black, non-Hispanic | Hispanic | Other, non-Hispanic | |
| % (95% CI) | % (95% CI) | % (95% CI) | % (95% CI) | |
| Overall | 60.2 (55.9-64.5) | 8.0 (6.2-10.2) | 22.7 (19.5-26.3) | 9.1 (7.5-11.0) |
| How Obtained Tobacco Productsa | ||||
| I bought them myself | 12.6 (10.3-15.2)* | 4.4 (2.5-7.6)* | 11.2 (8.8-14.3)* | 10.8 (7.4-15.6)* |
| I had someone else buy them | 23.0 (20.7-25.4)* | 14.8 (10.9-19.8)* | 14.8 (12.1-18.0)* | 18.9 (14.2-24.6)* |
| I asked someone to give me some | 13.0 (11.2-15.0)* | 7.3 (4.7-11.0)* | 13.1 (10.7-16.0)* | 13.2 (9.0-19.0)* |
| Someone offered them to me | 18.0 (16.2-20.0)* | 12.7 (8.4-19.0)* | 13.6 (11.2-16.4)* | 15.5 (10.5-22.1)* |
| I bought them from another person | 10.3 (8.6-12.2) | e | 8.8 (6.6-11.6) | 10.8 (7.0-16.2) |
| I took them from a store or another person | 2.3 (1.5-3.3) | e | 3.8 (2.6-5.6) | e |
| I got them some other way | 9.8 (8.1-11.8) | 14.7 (9.8-21.7) | 11.1 (8.6-14.2) | 13.3 (8.5-20.2) |
| From social sourcesb | 44.3 (41.6-47.0)* | 31.4 (25.4-38.0)* | 34.9 (31.3-38.6)* | 40.8 (33.2-48.9)* |
| Where Obtained Tobacco Products (among those who reported buying themselves in the past 30 days) a | ||||
| Gas station/convenience store | 61.2 (50.9-70.6) | e | 47.6 (37.0-58.4) | e |
| Grocery store | e | e | 24.2 (13.2-40.2) | e |
| Drug store | 11.1 (7.1-17.1) | e | 23.6 (14.6-35.9) | e |
| Vending machine | e | e | 12.4 (6.8-21.5) | e |
| On the Internet | 12.0 (7.7-18.1) | e | 17.1 (9.7-28.5) | e |
| Through the mail | e | e | e | e |
| Some other place not listed here | 25.5 (18.3-34.3) | e | 30.1 (20.0-42.5) | e |
| How and Where Obtained E-cigarettes (among past 30-day e-cigarette users)a | ||||
| Gas station/convenience store | 10.3 (7.4-14.0) | d | 9.1 (6.5-12.4) | 9.3 (5.3-16.0) |
| Grocery store | d | d | d | d |
| Drug store | 1.1 (0.6-1.9) | d | 3.4 (2.1-5.2) | d |
| Mall or shopping center kiosk/stand | d | d | 2.9 (1.7-5.0) | d |
| On the Internet | 5.4 (3.9-7.5) | d | 7.5 (5.6-10.1) | d |
| Vape shop or other store that only sells e-cigarettes | 17.5 (14.1-21.1) | d | 15.0 (11.6-19.1) | 18.7 (13.4-25.6) |
| Some other place not listed here | 2.0 (1.4-3.0) | d | 5.5 (3.6-8.2) | d |
| From a family member | 12.3 (10.0-14.9) | 17.5 (9.8-29.3) | 15.9 (12.8-19.7) | 15.2 (10.3-22.0) |
| From a friend | 62.5 (59.0-65.9)* | 47.5 (35.2-60.2)* | 50.8 (44.3-57.1)* | 57.9 (49.3-66.0)* |
| From some other person that is not a family member or a friend | 7.8 (6.6-9.3) | d | 11.4 (8.7-14.7) | 11.4 (6.9-18.5) |
| From social sourcesc | 74.7 (72.0-77.2) | 68.8 (57.9-77.9) | 67.4 (61.8-72.6) | 74.2 (66.7-80.6) |
| Refused Tobacco Products Sale Because of Age (among those who tried to buy tobacco products) | ||||
| Yes | 24.1 (19.5-29.4) | 24.6 (14.7-38.1) | 27.3 (21.4-34.0) | 23.9 (15.2-35.4) |
| No | 75.9 (70.6-80.5) | 75.4 (61.9-85.3) | 72.7 (66.0-78.6) | 76.1 (64.6-84.8) |
Note.
Respondents could select more than one option.
A composite variable indicating that the respondent obtained tobacco products through at least one of the following ways: “I had someone else buy them for me;” “I asked someone to give me some;” “Someone offered them to me;” “I bought them from another person.”
A composite variable indicating that the respondent obtained e-cigarettes through at least one of the following sources: “From a family member;” “From a friend;” “From some other person that is not a family member or a friend.”
Data suppressed because the sample size was < 50 or the relative standard error was > 30%.
significant differences within subgroups (chi-square p-value < .05).
Among youth e-cigarette users, 72.6% (2.21 million) reported obtaining e-cigarettes in the past 30 days from a social source in 2018 (Table 1). Youth e-cigarette users in 2018 most commonly reported obtaining e-cigarettes in the past 30 days from a friend (58.6%), vape shop (16.5%), family member (13.3%), gas station/convenience store (9.8%), and from a non-family member/friend (9.2%). The proportion of youth e-cigarette users obtaining e-cigarettes from a grocery store; drug store; mall/shopping center kiosk/stand; on the Internet; vape shop or other store that only sells e-cigarettes; and from a non-family member/friend significantly decreased from 2016 to 2018; the proportion who reported obtaining e-cigarettes from a friend significantly increased from 51.8% to 58.6% from 2016 to 2018.
About one-fourth of youth users who tried to buy tobacco products were refused sale because of age (2016: 24.7%; 2017: 23.3%; 2018: 25.5%).
DISCUSSION
Our findings show that during 2016-2018, current youth tobacco product users most commonly obtained tobacco products through social sources, such as by asking someone to buy tobacco products for them, having someone offer them tobacco, or asking someone to give them tobacco. This is consistent with previous studies reporting social sources as the most common way youth obtain tobacco products.8,10
Notably, the proportion of youth who reported buying tobacco products themselves in this study decreased by approximately 27% from 2016 to 2018. Nevertheless, in 2018 more than one in 10 US youth tobacco product users reported buying tobacco products themselves through various retail sources despite youth access laws, and one-fourth of youth tobacco product users who tried to buy tobacco products reported being refused sale because of age. Previous estimates from 2013-2014 Population Assessment of Tobacco and Health (PATH) Study and 2015 and 2017 Youth Risk Behavior Survey (YRBS) also found that many youth report buying tobacco products themselves from various retail locations.6,7,10 Data from the PATH Study showed that less than one-fourth of 15-17-year-old current users who attempted to purchase cigarettes (24.3%), cigarillos (23.9%) and smokeless tobacco (13.8%) were refused sale during 2013-2014.10
Additionally, findings specific to e-cigarettes are important to consider given the unprecedented surge in youth e-cigarette use prevalence that occurred during 2017-2018.2,5 The percentage of youth e-cigarette users in this study who reported obtaining e-cigarettes from a social source increased from 67.7% in 2016 to 72.6% in 2018, while the percentage of youth e-cigarette users who reported buying e-cigarettes from a retail location decreased. Although the percentage of youth e-cigarette users obtaining e-cigarettes on the Internet decreased from 10.2% to 5.7% from 2016 to 2018, these sales are nevertheless concerning due to lack of face-to-face exchange and potentially insufficient age verification.
These findings emphasize the importance of implementing proven population-based strategies while enforcing federal, state, and local minors’ access policies to prevent youth use of, and access to, all tobacco products. Specifically, tobacco product price increases, comprehensive smoke-free policies, and high-impact mass media campaigns, have been proven to reduce demand for tobacco products and denormalize their use.1,13–17 At the federal level, the FDA helps ensure compliance with youth access laws by developing and providing compliance training and education, monitoring compliance through surveillance, inspections, and investigations, and taking action such as warning letters, civil penalties, and “No Tobacco Sales Orders.”18 In September 2018, the FDA announced enforcement actions related to the sale of e-cigarettes, and issued more than 1300 warning letters and civil money penalty complaints to retailers who illegally sold e-cigarettes to youth.19 As flavors contribute to the appeal of tobacco products among youth1, FDA also announced intentions to have all flavored e-cigarettes (other than tobacco-, mint- and menthol-flavored or non-flavored products) sold in age-restricted, in-person locations.19
Of note, the 2009 Family Smoking Prevention and Tobacco Control Act, which gave the FDA the authority to regulate tobacco products, did not preempt states and communities from adopting policies that are in addition to, or more stringent than, many requirements of the Act. Accordingly, many states and local communities are implementing policies to address youth tobacco product use, including increasing age of sale beyond 18 years. The Institute of Medicine found that laws increasing the minimum legal age of sale to 21 years can limit social sources for youth to access tobacco products, due in part because young adults who can legally obtain tobacco products are unlikely to be in the same social networks as middle and high schoolers.11 It is important to continue to monitor the ways that youth access tobacco products as more states increase the age of sale to 21.20 As of June 1, 2019, 14 states (Arkansas, California, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, New Jersey, Oregon, Utah, Vermont, Virginia, Washington) and over 450 communities have enacted Tobacco 21 policies.20
Our findings are subject to limitations. First, data were collected from youth who attend public or private schools; thus, findings might not generalize to all US youth. Second, data were self-reported and may be subject to response and recall bias. Third, youth access to specific tobacco products, other than e-cigarettes, was not separately assessed. Lastly, estimates on how and where youth obtained tobacco products and how and where youth obtained e-cigarettes are not directly comparable given differences in question wording and response options in the survey questionnaire.
During 2016-2018, at least 2 in 5 US youth tobacco product users obtained tobacco products from a social source. However, more than one in 10 US youth tobacco users reported buying tobacco products themselves through various retail sources in 2018. Moreover, despite current federal law restricting youth access to all tobacco products to anyone younger than 18 years, only one in 4 youth users who tried to buy tobacco products were refused sale because of age in 2018.
IMPLICATIONS FOR TOBACCO REGULATION
Youth tobacco product use in any form is unsafe. When considered alongside recent increases in youth tobacco product use, which were driven by an increase in e-cigarette use, this study demonstrates the importance of preventing youth use of and access to all tobacco products, including e-cigarettes. Findings on where youth obtain tobacco products can inform prioritization and implementation of compliance and enforcement activities, and other tobacco regulatory activities related to the sale of tobacco products.
Acknowledgements
The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Food and Drug Administration or the US Centers for Disease Control and Prevention. Findings from this paper were accepted as an abstract entitled “Access to Tobacco Products among U.S Middle and High School Students, 2016-2018” for a poster presentation at the 2019 National Conference on Tobacco or Health in Minneapolis, Minnesota (August 27-29, 2019).
Footnotes
Human Subjects Approval Statement
CDC’s IRB approved the NYTS data collection.
Conflict of Interest Disclosure Statement
The authors have no conflicts of interests to declare.
Contributor Information
Sherry T. Liu, Office of Science, Center for Tobacco Products, US Food and Drug Administration, Silver Spring, MD.
Kimberly Snyder, Office of Science, Center for Tobacco Products, US Food and Drug Administration, Silver Spring, MD.
Michael A. Tynan, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, US Centers for Disease Control and Prevention, Atlanta, GA.
Teresa W. Wang, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, US Centers for Disease Control and Prevention, Atlanta, GA.
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