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. Author manuscript; available in PMC: 2023 Jun 1.
Published in final edited form as: J Sch Health. 2022 Mar 9;92(6):521–529. doi: 10.1111/josh.13180

Current Tobacco Use Trends and Harm Perceptions among High School Students by Asthma Status and Sex, 2012–2018

Sarah Selica T Miura 1, Debra Bernat 2, Keshia M Reid 3, Megan Macdonald 4, Lauren Porter 5, Kelvin Choi 6
PMCID: PMC9869457  NIHMSID: NIHMS1863520  PMID: 35266149

Abstract

BACKGROUND:

Tobacco use is known to worsen asthma management. No studies have investigated how trends in youth tobacco use and related harm perceptions vary by asthma status and sex. This study examined these trends among Florida high school students during 2012–2018.

METHODS:

Data from the 2012, 2014, 2016, and 2018 Florida Youth Tobacco Survey were analyzed. Public high school students (grades 9–12) with known asthma status were included along with their current tobacco product use, tobacco product harm perceptions, and demographics. Weighted multivariable logistic regression was used to assess trends in tobacco product use and harm perceptions and test differences by asthma status and sex.

RESULTS:

From 2012–2018, high school students with asthma had the slowest decline in cigarette and cigar use prevalence (asthma status-time interaction p=0.01) compared to those with no asthma. Cigarette and cigar smoking were perceived as less harmful over time, except among females with asthma who smoked cigarettes (p<0.05).

CONCLUSIONS:

Those with asthma showed a slower decline and were more likely to smoke cigarettes. Results indicate that further public health efforts are needed to address tobacco use among high school students with asthma.

Keywords: Child & Adolescent Health, Chronic Disease, Smoking & Tobacco

BACKGROUND

Asthma is a chronic respiratory disease prevalent among high school students in the United States that can lead to increased school absenteeism, financial strain, mortality, and decreased quality of life 1,2. As of 2019, 7.4% of youth between the ages of 15 and 19 in the United States have been diagnosed with asthma 3. Individuals with asthma are counseled against active smoking and secondhand smoke exposure from tobacco products, including cigarettes, electronic cigarettes (e-cigarettes), cigars, and hookah, as they may interfere with medication effectiveness, induce asthma symptoms, increase the frequency of asthma attacks, and decrease pulmonary function. Active smoking and secondary exposure to smoke from these tobacco products may also lead to other respiratory diseases, which can further exacerbate asthma severity and increase asthma mortality 4–7.

Tobacco use remains prevalent among high school students in the United States. In 2019, 31.2% of high school students reported current use of a tobacco product (cigarette, e-cigarette, cigar, smokeless tobacco, hookah, and pipe tobacco). 27.5% of high school students self-reported currently using e-cigarettes, followed by cigars at 7.6%, cigarettes at 5.8%, and hookah at 3.4% 8. Florida had a lower prevalence of tobacco product use in 2019 compared to national estimates 9. Although overall tobacco product use among high school students has been declining, e-cigarette use and polytobacco use (i.e., current use of any two or more tobacco products) have been increasing 10–11.

Previous research indicates differences in tobacco use and tobacco product harm perceptions by asthma status among youth. Data from the 2017 Youth Risk Behavior Survey found that there was a higher prevalence of current cigarette and cigar use among high school students with asthma when compared to high school students without asthma in the United States12. Previous research also indicates that tobacco use is shifting toward non-traditional tobacco products and polytobacco use 10,13,14. In 2016, 10.9% of high school students in Florida with asthma reported multiple tobacco product usage compared to 8.6% of high school students in Florida without asthma 15.

A variety of factors may lead high school students with asthma to use tobacco products, including perceived harm and risk perceptions 16,17. A previous study found that high school students with asthma are less likely to perceive tobacco use as harmful for their health than high school students without asthma. Analysis from the 2014 Florida Youth Tobacco Survey (FYTS) found that high school students with asthma perceived tobacco products positively when compared to high school students without asthma 18. Another 2014 study conducted among high school students in Virginia found that students with asthma were more likely to perceive smoking cigarettes as less harmful and were more willing to try smoking a cigarette than high school students without asthma 19.

The aim of this study is to examine trends in tobacco product use and related harm perceptions among Florida high school students during 2012–2018 and variations by asthma status and sex. Prior studies have either examined tobacco product use in this population by asthma status at different time points or trends of tobacco product use without including asthma status 15, 20. Additionally, no studies to date have examined how the trends in tobacco use and related perceptions differ by asthma status and sex, despite the known difference in tobacco use behaviors by sex in the high school population 21. The Youth Risk Behavior Surveillance System collects national data on high school tobacco use and if the participant ever had asthma 22, while the Population Assessment of Tobacco and Health Study collects data on tobacco use and related harm perception, but does not collect data on asthma status 23. FYTS is unique in that it collects data on asthma status, including ever having asthma and formerly having asthma, as well as tobacco use, and related harm perception. Due to the detrimental role of tobacco use in asthma management and the lower quality of life associated with asthma 24, it is crucial to understand how high school tobacco use and the perception of tobacco products have changed over time by asthma status and sex to guide intervention and prevention efforts.

METHODS

Participants

The study population included high school students who participated in even years between 2012 and 2018. The overall sample sizes of high school students were 36,439, 32,921, 36,085, and 28,051 for years 2012, 2014, 2016, and 2018 respectively. The student response rates were 73%, 78%, 74%, and 72% for each respective time point. Students in 9th-12th grades with known asthma status were included in the present study. 18%, 23%, 17%, and 23% of observations were dropped due to missing asthma status in 2012, 2014, 2016, and 2018 respectively. 1%, 1%, and 9% of observations were dropped due to missing grade in 2012, 2014, and 2016 respectively. <1% of observations were dropped due to missing age for each survey year. The final study sample sizes were 29,285, 25,071, 26,739, and 21,622 for years 2012, 2014, 2016, and 2018, respectively.

Instruments

Asthma Status

For years 2012, 2014, and 2018, asthma status was obtained using the questions: “Has a doctor or nurse ever told you that you have asthma?” (Yes/No/Not Sure) and “Do you still have asthma?” (Yes/No/I have never had asthma/Unsure). Those who responded “Yes” for both questions were categorized as currently having asthma; “Yes” for the first question and “No” for the second question as formerly having asthma; and “No” for the first question and “I have never had asthma” or “No” for the second question as not having asthma. Participants who were unsure about their asthma status were excluded. In 2016, participants were asked if they were told by a doctor or nurse they had asthma. Additionally, participants were asked “During the past 12 months, did you have an asthma attack?” (I have never had asthma/Yes/No/I no longer have asthma). Those who responded “Yes” they had been informed by a doctor or nurse that they had asthma and “Yes” or “No” about having an asthma attack were categorized as currently having asthma. Those who responded “Yes” for the first question and “I no longer have asthma” for the second question were categorized as formerly having asthma. Those who responded “No” for the first question and “I have never had asthma” or “No” for the second question were categorized as not having asthma. We examined the trends in prevalence of current and former asthma and found that our definition resulted in fairly steady trends, suggesting that the measurement artifact created by changes in survey items was minimal.

Tobacco Product Use

Current cigarette, cigar, and e-cigarette use were assessed in each survey year. The surveys included a clarifying statement of what each tobacco product was, so participants were aware of how each tobacco product was defined. Each respondent was asked about their current tobacco use. Current cigarette use was determined by the question “During the past 30 days, on how many days did you smoke cigarettes?” (0 days/1 or 2 days/3 to 5 days/6 to 9 days/10 to 19 days/20 to 29 days/30 days). Current cigar use was determined by the question “During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?” (0 days/1 or 2 days/3 to 5 days/6 to 9 days/10 to 19 days/20 to 29 days/30 days). Current e-cigarette use was determined by the question “During the past 30 days, have you used an electronic cigarette?” (Yes/No) for 2012 and 2014 and “During the past 30 days, on how many days did you use an electronic vapor product?” (0 days/1 or 2 days/3 to 5 days/6 to 9 days/10 to 19 days/20 to 29 days/30 days) for 2016 and 2018. Those who responded “0 days” or “no” were categorized as a non-user of the corresponding tobacco product. Participants who reported 1 or more days of use were categorized as a current user of the corresponding tobacco product.

Harm Perceptions

Harm perceptions were assessed by two questions: “Do you think smoke from other people’s cigarettes and cigars are harmful to you?” (2012 and 2014: Definitely yes/Probably yes/Probably not/Definitely not; 2016: Yes/No; 2018: Yes/No/Not Sure) and “Compared to cigarette smoking, using electronic vapor products are…” (More harmful/Equally harmful/Less harmful/Not sure). Response options varied between years for the question about the harm of cigarette and cigar smoke question. For 2012 and 2014, the response options included “Definitely yes,” “Probably yes,” “Probably not,” and “Definitely not.” “Definitely yes” and “Probably yes” were recoded as “Yes.” “Definitely not” and “Probably not” were recorded as “No.” For 2016, the response options were “Yes” and “No.” For 2018, the response options were “Yes,” “No,” and “Not sure.” “Not sure” responses from 2018 were excluded (n=4945). For the relative harm question, the response options “More harmful” and “Equally harmful” were recategorized as “More or equally harmful.” The response options “Less harmful” and “Not sure” were recategorized as “Less harmful.” This question was not included in the 2012 survey.

Demographic Characteristics

Demographic characteristics included age (in years), sex (female/male), race (American Indian or Alaska Native/Asian/Black or African American/Native Hawaiian or Other Pacific Islander/White/Other), ethnicity (yes/no as Hispanic), academic grade (9th-12th), housing (stand-alone single-family home/trailer or mobile home/townhouse or duplex/multi-story building like a condominium or apartment/other), and urbanicity (non-core, micropolitan, small metro, medium metro, large fringe metro, and large central metro). Participants self-reported their demographic characteristics except urbanicity. Race and ethnicity were determined if the participant self-identified as Hispanic or Latino and how they would describe themselves. Participants were asked to select one race that best described them. Based on their responses, participants were recategorized as “non-Hispanic White,” “Hispanic,” “non-Hispanic Black,” “non-Hispanic Asian,” or “Other.” Urbanicity was derived from the county data collected from the 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties 25. Counties with a population of at least 250,000 within a principal city of the metropolitan statistical areas (MSA) or with a total of 1 million within the largest principal city were categorized as large central metro. Counties with a population of 1 million in the MSA and not classified as large central metro were categorized as large fringe metro. Counties with a population between 250,000 and 999,999 in the MSA were categorized as medium metro. Counties with a population under 250,000 in the MSA were categorized as small metro. Counties in the micropolitan statistical area were categorized as micropolitan. Counties not in the micropolitan statistical area were categorized as noncore.

Procedure

FYTS is a statewide, school-based, confidential pencil-and-paper survey administered to Florida public middle (grades 6–8) and high school students (grades 9–12) in the spring of every calendar year. In even years, samples are drawn at the county-level. The FYTS collects information on tobacco use and exposure to secondhand smoke to monitor and guide tobacco prevention and control policies and strategies in Florida. Data are collected using a two-stage cluster probability sampling design, where a random sample of public schools are selected for participation. Then, within each selected school, a random sample of classrooms is selected. All students in those classrooms are invited to participate in the survey. Student participation is voluntary and consent processes vary by school district. Several districts use an active permission form; however, most districts obtain parental consent through passive opt-out permission forms.

Data Analysis

Analysis was conducted using survey procedures in SAS® version 9.4 (SAS Institute: Cary, NC) to account for the complex sampling design of the FYTS. Data were weighted to yield representative estimates of Florida high school students attending public schools. The independent variables were asthma status, time, and the two-way interaction between asthma status and time. Time was based on survey years (2012, 2014, 2016, 2018), recoded as 0, 2, 4, 6 and analyzed as a continuous variable. Current tobacco product use and harm perceptions were the dependent variables. All analyses were stratified by sex. Logistic regression was used to test if current tobacco product use and harm perceptions varied by time, asthma status, and sex. For each dependent variable, the first logistic regression model was used to examine if time and asthma status were associated with the dependent variable, adjusting for demographics. In the second logistic regression model, a two-way interaction between asthma status and time was included to assess if trends in the dependent variable varied by asthma status. Additionally, multivariable logistic regression models were used to examine if asthma status was associated with each dependent variable, adjusting for demographics.

RESULTS

The sample consisted of approximately an equal number of males and females and the sample was ethnically and racially diverse (Table 1). Among survey participants each year, about 80% reported not having asthma, 12% −15% reported currently having asthma, and less than 10% reported formerly having asthma. The majority of the respondents lived in a medium to large central metro area (Table 1).

Table 1:

Demographics. Weighted Demographics by Year.

2012
n = 29285		 2014
n = 25071		 2016
n = 26739		 2018
n = 21622
Asthma Status
 Current Asthma 76542 (12.1%) 77514 (12.7%) 99855 (15.0%) 78679 (12.1%)
 Former Asthma 41398 (6.5%) 41115 (6.7%) 39155 (5.9%) 52277 (8.0%)
 No Asthma 514391 (81.3%) 492499 (80.6%) 526296 (79.1%) 521812 (79.9%)
Sex
 Female 321329 (51.8%) 310684 (51.5%) 338465 (51.6%) 332559 (51.7%)
 Male 298400 (48.2%) 292853 (48.5%) 317383 (48.4%) 310904 (48.3%)
Race/Ethnicity
 Non-Hispanic White 292673 (47.1%) 250159 (41.5%) 287603 (44.0%) 267228 (60.7%)
 Hispanic 165780 (26.7%) 184391 (30.6%) 196613 (30.1%) 206209 (32.1%)
 Non-Hispanic Black 130543 (21.0%) 123520 (20.5%) 133320 (20.4%) 130745 (20.3%)
 Non-Hispanic Asian 11431 (1.8%) 15699 (2.6%) 13594 (2.1%) 17408 (2.7%)
 Other 6173 (3.4%) 28508 (4.7%) 22412 (3.5%) 21280 (3.3%)
Housing
 A stand-alone single-family house 437633 (69.6%) 420839 (69.4%) 464204 (70.4%) 454514 (70.3%)
 A trailer or mobile home 32385 (5.2%) 30007 (4.9%) 39191 (5.9%) 38887 (6.0%)
 An attached home 53645 (8.5%) 50305 (8.3%) 53394 (8.1%) 45200 (7.0%)
 A multi-story building 72776 (11.6%) 77674 (12.8%) 70957 (10.8%) 75896 (11.7%)
 Other 32051 (5.1%) 27406 (4.5%) 31743 (4.8%) 32333 (5.0%)
Urbanicity
 Non-core 69015 (10.9%) 65859 (10.8%) 64365 (9.7%) 63151 (9.7%)
 Micropolitan 85904 (13.6%) 88736 (14.5%) 52153 (7.8%) 44377 (6.8%)
 Small metro 33595 (5.3%) 31058 (5.1%) 43005 (6.5%) 44945 (6.9%)
 Medium metro 196449 (31.1%) 180999 (29.6%) 250760 (37.7%) 243313 (37.3%)
 Large fringe metro 167666 (26.5%) 168963 (27.6%) 176641 (26.6%) 176533 (27.0%)
 Large central metro 79702 (12.6%) 75514 (12.4%) 78380 (11.8%) 80450 (12.3%)
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From 2012–2018, overall prevalence of current cigarette and cigar use significantly declined over time. Those with asthma had a slower decline over time compared to those without asthma and those formerly with asthma (asthma status-time interaction p=0.01). Prevalence of current e-cigarette use significantly increased over time, with females formerly having asthma reporting the highest prevalence of e-cigarette use in 2018 (Figure 1). Among both females and males, there was a significant decrease change of cigarette, cigar, and e-cigarette harm perception over time, except among females with asthma, who did not have any significant change in their harm perception (Figure 2).

Figure 1: Tobacco Use by Asthma Status and Sex, Florida Youth Tobacco Survey 2012–2018.

Figure 1:

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Figure 2: Harm Perception by Asthma Status and Sex, Florida Youth Tobacco Survey 2012–2018.

Figure 2:

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Regarding the association between asthma status and tobacco use in 2018, participants who self-reported currently having asthma were 1.40 times (95% CIcigarettes=1.09, 1.81) more likely to currently use cigarettes and 1.36 times (95% CIcigars=1.07, 1.73) more likely to currently use cigars when compared to those who self-reported as not having asthma after adjusting for demographics. Participants who self-reported as formerly having asthma were 1.43 times (95% CI=1.06, 1.92) more likely to currently use cigarettes when compared to those who self-reported as not having asthma. After stratifying by sex, males with asthma and males formerly with asthma were 1.50 times (95% CIwith asthma=1.02, 2.22) and 1.51 times more likely to use cigarettes than males without asthma, respectively. Females with asthma were 1.41 times (95% CI=1.04, 1.93) more likely to use cigars than females without asthma. Harm perceptions of cigarette, cigar, and e-cigarettes did not significantly differ by asthma status (Table 2).

Table 2:

AORs and 95% CI by Sex and Asthma Status for 2018.

Tobacco Use
 Harm Perception
Cigarettes Cigars E-Cigarettes Cigarette/Cigar Smoke E-cig vs Cigarette
Overall
 Asthma 1.40 (1.09, 1.81) 1.36 (1.07, 1.73) 1.10 (0.96, 1.27) 1.01 (0.83, 1.22) 0.94 (0.83, 1.07)
 Former Asthma 1.43 (1.06, 1.92) 1.10 (0.84, 1.44) 1.12 (0.96, 1.31) 1.19 (0.95, 1.50) 1.01 (0.84, 1.22)
 No Asthma Referent Referent Referent Referent Referent
Male
 Asthma 1.50 (1.02, 2.22) 1.32 (0.93, 1.87) 1.03 (0.81, 1.32) 0.90 (0.68, 1.18) 0.88 (0.71, 1.09)
 Former Asthma 1.51 (1.03, 2.21) 1.19 (0.86, 1.64) 1.03 (0.83, 1.27) 1.33 (0.98, 1.81) 1.05 (0.79, 1.38)
 No Asthma Referent Referent Referent Referent Referent
Female
 Asthma 1.28 (0.91, 1.79) 1.41 (1.04, 1.93) 1.16 (0.98, 1.37) 1.16 (0.88, 1.53) 0.98 (0.83, 1.15)
 Former Asthma 1.25 (0.74, 2.11) 0.85 (0.48, 1.52) 1.27 (0.99, 1.62) 0.99 (0.71, 1.40) 0.97 (0.76, 1.23)
 No Asthma Referent Referent Referent Referent Referent
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Footnote: AOR adjusted for race/ethnicity, housing, urbanicity, sex

DISCUSSION

This is the first study to our knowledge to report trends in prevalence of tobacco use and harm perceptions by asthma status and sex among high school students. We found that cigarette and cigar use significantly declined over time among Florida high school students with and without asthma. However, Florida high school students with asthma showed the slowest decline in the prevalence of current cigarette smoking. Additionally, despite the decline, those with asthma continued smoking cigarettes and cigars at a higher prevalence than those without asthma in 2018. This is concerning because of the detrimental effects combustible tobacco product use can have on asthma management 5. Limited research has explored why prevalence of cigarette and cigar use continues to be higher among high school students with asthma. A 2012 systematic review suggested that asthma, as a chronic health condition that limits daily functioning, may induce stress and anxiety, and even depression, among youth 26. Adolescents may smoke tobacco products as a coping mechanism 27. A previous study conducted in Washington State also found that, among youth with asthma, anxiety/depressive disorders were associated with higher likelihood of cigarette smoking. Therefore, recognizing and assisting youth with asthma to cope with the stress associated with managing the condition may prevent maladaptive behaviors such as tobacco use 8,28.

The harm perception of cigarette and cigar smoke did not significantly change for female high students with asthma between 2012 and 2018. However, a significantly lower proportion of Florida male high school students with asthma perceived secondhand cigarette and cigar smoke exposure as harmful over time. Both findings are of great concern as individuals with asthma remain a vulnerable population. Secondhand smoke exposure, and even secondhand e-cigarette aerosol exposure, can worsen asthma management and increase asthma-related healthcare financial burden 5,29. Therefore, it is crucial to ensure youth with asthma are not exposed to secondhand smoke and e-cigarette aerosol. Educating youth to actively avoid such exposure is important and comprehensive tobacco-free policies that include combustible tobacco products and e-cigarettes at school, workplaces, and public spaces are essential.

In 2018, there was an observed difference in tobacco use among Florida high school students when stratified by asthma status and sex. Specifically, female students with asthma were more likely to use cigars than female students without asthma. It is possible that female students with asthma were attracted to cigars because of the flavorings found in many cigar products. While a previous national study reported similar prevalence of flavored tobacco product use by sex among current tobacco users 30, that study did not report prevalence of flavored cigar use by sex and asthma status. Future research needs to examine the reasons why female youth with asthma are smoking cigars to inform interventions. In the meantime, youth tobacco use screening in healthcare settings should address all tobacco products.

Among the examined trends, current e-cigarette use was the only trend to show a significant increase over time regardless of sex and asthma status. Due to its increased popularity, this is of concern as recent studies have shown that e-cigarette use has a detrimental impact on people with asthma. With the increased use in e-cigarettes among high school students with asthma, this could result in poor asthma control and an increase in asthma attacks among this population 6.

Limitations

This analysis has its limitations. As the data in FYTS are self-reported, it is susceptible to recall bias. FYTS is a cross-sectional survey, therefore cause of the observed trends cannot be established. It is not clear whether high school students developed asthma after initiating tobacco use or if students with asthma are more susceptible to using tobacco products. For this reason, we are unable to determine why there is a slower decline in cigarette use among high school students with asthma. Although FYTS asks about the students’ perception of secondhand smoke from cigarettes and cigars, there are no questions about their perceptions regarding absolute harm in cigarette and cigar use, so we could not assess how perceived absolute harm of these tobacco products changed over time. FYTS is only representative of public high school students in Florida and does not include students in private schools or homeschool, which may have different trends and perceptions. We also did not examine asthma severity nor polytobacco use. However, given the differences in perceived harm of various tobacco products by youth 31, we believe it is more important to examine use and perceptions associated with individual products.

Conclusions

Despite the overall decline in cigarette and cigar smoking among youth, Florida high school students with asthma were still more likely to smoke cigarettes compared to high school students without asthma and formerly with asthma, which is detrimental to asthma management. It is further complicated by the stagnant harm perceptions of tobacco products and decreasing harm perceptions related to secondhand exposure to cigarette and cigar smoke. Additional studies are needed to elucidate factors that influence the observed trends and high prevalence of tobacco product use among high school students with asthma to inform intervention and prevention strategies. In the meantime, screening for all tobacco product use, emphasizing the harm of firsthand and secondhand exposure to tobacco smoke to youth with asthma, and enacting comprehensive tobacco-free policies are needed to protect youth with and without asthma from tobacco harm.

IMPLICATIONS FOR SCHOOL HEALTH

This analysis, together with previous studies, demonstrates that the prevalence of combustible tobacco use among high school students has been declining, while the prevalence of e-cigarette use has been increasing. However, the current analysis shows that the trends are not equal across sex and asthma status. Schools are an effective place to combat youth tobacco use through comprehensive tobacco free campus policies which communicate the importance of tobacco-free norms. Such programs focus on helping youth recognize the different influences that may entice them to use tobacco and teach youth how to tactfully refuse tobacco products. The analysis also suggests that schools should update their tobacco free policies, at school asthma management, and educational programs as the diversity of tobacco products increases. Schools should also screen students with and without asthma for tobacco use, including e-cigarette use, and connect students to evidence-based cessation services, instead of suspensions, to help these students stop using tobacco32. With the rise of e-cigarette use and low harm perception of e-cigarette use, it is crucial for at-school management programs to educate high school students with asthma about the impact of various tobacco products, especially e-cigarettes, on asthma management. This effort is particularly important for students with asthma, as this analysis finds that they are at higher risk of smoking cigarettes and cigars. Finally, schools should implement curriculums related to the danger of tobacco use, including e-cigarettes, to combat the decline in harm perceptions of tobacco use19,20. Once again, this effort should prioritize students with asthma because of the known effect of combustible tobacco and e-cigarettes on respiratory health4–6,33.

ACKNOWLEDGMENTS

The Florida Youth Tobacco Surveys are funded by the Florida Department of Health. Dr. Choi’s effort was supported by the Division of Intramural Research, National Institute on Minority Health and Health Disparities. Comments and opinions included in this manuscript belong to the authors and do not necessarily reflect those of the U.S. Government, Department of Health and Human Services, National Institutes of Health, National Institute on Minority Health and Health Disparities, and Florida Department of Health.

Footnotes

Conflict of Interest Disclosure Statement

There are no potential financial and non-financial conflicts of interest to disclose for any of the authors.

Human Subjects Approval Statement

This was a secondary data analysis using de-identified data and therefore is exempted from review by the George Washington University Institutional Review Board.

Contributor Information

Sarah Selica T. Miura, Department of Epidemiology, Milken Institute School of Public Health, George Washington University, 950 New Hampshire Ave, NW, 5th Floor, Washington, DC 20052, USA.

Debra Bernat, Department of Epidemiology, Milken Institute School of Public Health, George Washington University, 950 New Hampshire Ave, NW, 5th Floor, Washington, DC 20052, USA.

Keshia M. Reid, Public Health Research Unit, Division of Community Health Promotion, Florida Department of Health, 4052 Bald Cypress Way, Bin A24, Tallahassee, FL 32399-1712, USA.

Megan Macdonald, Division of Children’s Medical Services, Florida Department of Health, 4025 Esplanade Way, Bin A06, Tallahassee, FL 32399-1712, USA.

Lauren Porter, Public Health Research, Division of Community Health Promotion, Florida Department of Health, 4052 Bald Cypress Way, Bin A24, Tallahassee, FL 32399-1712, USA.

Kelvin Choi, Division of Intramural Research, National Institute on Minority Health and Health Disparities, 9000 Rockville Pike, Building 3 Room 5W05, Bethesda, MD 20892.

REFERENCES

  • 1.Akinbami LJ, Santo L, Williams S, Rechtsteiner EA, Strashny A. Characteristics of Asthma Visits to Physician Offices in the United States: 2012–2015 National Ambulatory Medical Care Survey. Natl Health Stat Report. 2019;(128):1–20. [PubMed] [Google Scholar]
  • 2.Esty B, Permaul P, DeLoreto K, Baxi SN, Phipatanakul W. Asthma and Allergies in the School Environment. Clin Rev Allergy Immunol. 2019;57(3):415–426. doi: 10.1007/s12016-019-08735-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Centers for Disease Control and Prevention. Most Recent National Asthma Data | CDC. https://www.cdc.gov/asthma/most_recent_national_asthma_data.htm. Published 2021. Accessed July 20, 2021. [Google Scholar]
  • 4.St Claire S, Gouda H, Schotte K, et al. Lung health, tobacco, and related products: gaps, challenges, new threats, and suggested research. Am J Physiol Lung Cell Mol Physiol. 2020;318(5):L1004–L1007. doi: 10.1152/ajplung.00101.2020 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Carr TF, Kraft M. Management of Severe Asthma before Referral to the Severe Asthma Specialist. J Allergy Clin Immunol Pract. 2017;5(4):877–886. doi: 10.1016/j.jaip.2017.04.027 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Clapp PW, Jaspers I. Electronic Cigarettes: Their Constituents and Potential Links to Asthma. Curr Allergy Asthma Rep. 2017;17(11):79. doi: 10.1007/s11882-017-0747-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Qasim H, Alarabi AB, Alzoubi KH, Karim ZA, Alshbool FZ, Khasawneh FT. The effects of hookah/waterpipe smoking on general health and the cardiovascular system. Environ Health Prev Med. 2019;24(1). doi: 10.1186/s12199-019-0811-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Wang TW, Gentzke AS, Creamer MR, et al. Tobacco Product Use and Associated Factors Among Middle and High School Students — United States, 2019. MMWR Surveill Summ. 2019;68(12):1–22. doi: 10.15585/mmwr.ss6812a1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Florida Health. Florida Youth Tobacco Survey. http://www.floridahealth.gov/statistics-and-data/survey-data/florida-youth-survey/florida-youth-tobacco-survey/_documents/2019-fyts-tables.pdf. Accessed August 10, 2020.
  • 10.Walley SC, Wilson KM, Winickoff JP, Groner J. A Public Health Crisis: Electronic Cigarettes, Vape, and JUUL. Pediatrics. 2019;143(6):20182741. doi: 10.1542/PEDS.2018-2741 [DOI] [PubMed] [Google Scholar]
  • 11.Gentzke AS, Creamer M, Cullen KA, et al. Vital Signs: Tobacco Product Use Among Middle and High School Students - United States, 2011–2018. MMWR Morb Mortal Wkly Rep. 2019;68(6):157–164. Published 2019 Feb 15. doi: 10.15585/mmwr.mm6806e1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Jones SE, King BA, Leroy Z. Trends in the use of cigarettes, cigars, and marijuana among students with and without asthma, 2003–2017. https://doi.org/101080/0277090320191573254. 2019;57(4):391–397. doi: 10.1080/02770903.2019.1573254 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Soneji S, Sargent J, Tanski S. Multiple tobacco product use among US adolescents and young adults. Tob Control. 2016. doi: 10.1136/tobaccocontrol-2014-051638 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Gilreath TD, Leventhal A, Barrington-Trimis JL, et al. Patterns of alternative tobacco product use: Emergence of hookah and E-cigarettes as preferred products amongst youth. J Adolesc Heal. 2016. doi: 10.1016/j.jadohealth.2015.10.001 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Reid KM, Forrest JR, Porter L. Tobacco product use among youths with and without lifetime asthma — Florida, 2016. Morb Mortal Wkly Rep. 2018;67(21):599–601. doi: 10.15585/mmwr.mm6721a2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Osman A, Kowitt SD, Ranney LM, Heck C, Goldstein AO. Risk factors for multiple tobacco product use among high school youth. Addict Behav. 2019;99. doi: 10.1016/J.ADDBEH.2019.106068 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Parker MA, Villanti AC, Quisenberry AJ, et al. Tobacco Product Harm Perceptions and New Use. Pediatrics. 2018;142(6). doi: 10.1542/PEDS.2018-1505 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Fedele DA, Barnett TE, Dekevich D, Gibson-Young LM, Martinasek M, Jagger MA. Prevalence of and beliefs about electronic cigarettes and hookah among high school students with asthma. Ann Epidemiol. 2016. doi: 10.1016/j.annepidem.2016.10.004 [DOI] [PubMed] [Google Scholar]
  • 19.Jones RM, Wiseman KP, Kharitonova M. Association between high school students’ cigarette smoking, asthma and related beliefs: a population-based study. BMC Public Health. 2016;16(1):913. doi: 10.1186/s12889-016-3579-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Ambrose BK, Rostron BL, Johnson SE, et al. Perceptions of the relative harm of cigarettes and E-cigarettes among U.S. youth. Am J Prev Med. 2014. doi: 10.1016/j.amepre.2014.04.016 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Pacek LR, McClernon FJ. Decline in the perceived risk of cigarette smoking between 2006 and 2015: Findings from a U.S. nationally representative sample. Drug Alcohol Depend. 2018;185:406–410. doi: 10.1016/J.DRUGALCDEP.2018.01.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance System (YRBSS). https://www.cdc.gov/healthyyouth/data/yrbs/index.htm. Published 2018. Accessed June 10, 2020.
  • 23.National Institute of Health. Research Objectives. https://pathstudyinfo.nih.gov/UI/OverviewQuestionMobile.aspx. Published 2018. Accessed June 10, 2020.
  • 24.Sullivan PW, Ghushchyan V, Navaratnam P, et al. The national cost of asthma among school-aged children in the United States. Ann Allergy, Asthma Immunol. 2017. doi: 10.1016/j.anai.2017.07.002 [DOI] [PubMed] [Google Scholar]
  • 25.Centers for Disease Control and Prevention. NCHS Urban-Rural Classification Scheme for Counties. https://www.cdc.gov/nchs/data_access/urban_rural.htm. Published 2017. Accessed February 5, 2020.
  • 26.Goodwin RD, Bandiera FC, Steinberg D, Ortega AN, Feldman JM. Asthma and mental health among youth: etiology, current knowledge and future directions. Expert Rev Respir Med. 2012;6(4):397–406. doi: 10.1586/ers.12.34 [DOI] [PubMed] [Google Scholar]
  • 27.Weinstein SM, Mermelstein RJ. Dynamic Associations of Negative Mood and Smoking Across the Development of Smoking in Adolescence. J Clin Child Adolesc Psychol. 2013. doi: 10.1080/15374416.2013.794698 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Bush T, Richardson L, Katon W, et al. Anxiety and Depressive Disorders Are Associated with Smoking in Adolescents with Asthma. J Adolesc Heal. 2007;40(5):425–432. doi: 10.1016/j.jadohealth.2006.11.145 [DOI] [PubMed] [Google Scholar]
  • 29.Bayly JE, Bernat D, Porter L, Choi K. Secondhand Exposure to Aerosols From Electronic Nicotine Delivery Systems and Asthma Exacerbations Among Youth With Asthma. Chest. 2019;155(1):88–93. doi: 10.1016/j.chest.2018.10.005 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Single Dai H., Dual, and Poly Use of Flavored Tobacco Products Among Youths. Prev Chronic Dis. 2018;15(6):170389. doi: 10.5888/pcd15.170389 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Strong DR, Leas E, Elton-Marshall T, et al. Harm perceptions and tobacco use initiation among youth in Wave 1 and 2 of the Population Assessment of Tobacco and Health (PATH) Study. Prev Med (Baltim). 2019;123:185–191. doi: 10.1016/j.ypmed.2019.03.017 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Glynn TJ. Essential Elements of School-Based Smoking Prevention Programs. J Sch Health. 1989. doi: 10.1111/j.1746-1561.1989.tb04698.x [DOI] [PubMed] [Google Scholar]
  • 33.Bou Fakhreddine HM, Kanj AN, Kanj NA. The growing epidemic of water pipe smoking: Health effects and future needs. Respir Med. 2014;108(9):1241–1253. doi: 10.1016/j.rmed.2014.07.014 [DOI] [PubMed] [Google Scholar]

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