Reasons for Electronic Cigarette Use Among Middle and High School Students — National Youth Tobacco Survey, United States, 2016

Electronic cigarettes (e-cigarettes) were the most commonly used tobacco product among U.S. middle school and high school students in 2016 (1). CDC and the Food and Drug Administration (FDA) analyzed data from the 2016 National Youth Tobacco Survey (NYTS) to assess self-reported reasons for e-cigarette use among U.S. middle school (grades 6-8) and high school (grades 9-12) student e-cigarette users. Among students who reported ever using e-cigarettes in 2016, the most commonly selected reasons for use were 1) use by "friend or family member" (39.0%); 2) availability of "flavors such as mint, candy, fruit, or chocolate" (31.0%); and 3) the belief that "they are less harmful than other forms of tobacco such as cigarettes" (17.1%). The least commonly selected reasons were 1) "they are easier to get than other tobacco products, such as cigarettes" (4.8%); 2) "they cost less than other tobacco products such as cigarettes" (3.2%); and 3) "famous people on TV or in movies use them" (1.5%). Availability of flavors as a reason for use was more commonly selected by high school users (32.3%) than by middle school users (26.8%). Efforts to prevent middle school and high school students from initiating the use of any tobacco product, including e-cigarettes, are important to reduce tobacco product use among U.S. youths (2).

that used e-cigarettes and noncombustible tobacco products are not presented because of small sample size.
Participants were asked, "What are the reasons why you have used electronic cigarettes or e-cigarettes?"Response options were "I have never tried an electronic cigarette," "friend or family member used them," "to try to quit using tobacco products, such as cigarettes," "they cost less than other tobacco products, such as cigarettes," "they are easier to get than other tobacco products, such as cigarettes," "famous people on TV or in movies use them," "they are less harmful than other forms of tobacco, such as cigarettes," "they are available in flavors, such as mint, candy, fruit, or chocolate," "they can be used in areas where other tobacco products, such as cigarettes, are not allowed," and "I used them for some other reason."Participants could select multiple reasons.
After excluding participants who had never tried an e-cigarette or had missing information on school level (middle or high), sex, or race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, and non-Hispanic other race), 4,049 ever users, including 1,281 current users, were included in the analysis.Data were weighted to account for the complex survey design and adjusted for nonresponse.Point estimates, 95% confidence intervals, and population totals corresponding to reasons for use were computed among ever and current e-cigarette users, both overall and by school level, sex, race/ ethnicity, and current use of other tobacco products.Chisquare tests were used to assess statistically significant (p<0.05)differences across groups.
Among U.S. middle and high school e-cigarette ever users in 2016, the most commonly selected reasons for using e-cigarettes were "friend or family member used them" (39.0%), "they are available in flavors, such as mint, candy, fruit, or chocolate" (31.0%), and "they are less harmful than other forms of tobacco such as cigarettes" (17.1%).Reasons for use varied by school level and sex.For example, "friend or family member used them" was more commonly selected by middle school students (43.7%) than high school students (37.5%), and by females (46.7%) than males (32.2%) (Table 1)."They are available in flavors, such as mint, candy, fruit, or chocolate" was more commonly selected by high school students (32.3%) than by middle school students (26.8%).Among e-cigarette ever users, the least commonly selected reasons for use were "they are easier to get than other tobacco products, such as cigarettes" (4.8%), "they cost less than other tobacco products such as cigarettes" (3.2%), and "famous people on TV or in movies use them" (1.5%) (Table 1).
Among U.S. middle and high school students who reported using e-cigarettes (e-cigarettes only, e-cigarettes with combustible tobacco only, and e-cigarettes with combustible and noncombustible tobacco) during the past 30 days, the most commonly selected reasons for e-cigarette use were "they are available in flavors, such as mint, candy, fruit, or chocolate" (41.1%, 46.0%, and 29.1%, respectively), "friend or family member used them" (35.1%, 26.6%, and 20.2%, respectively), * Participants who responded "yes" to the question "Have you ever used an electronic cigarette or e-cigarette, even once or twice?" † Response to the question, "What are the reasons why you have used electronic cigarettes or e-cigarettes?(Check all that apply)" are not mutually exclusive.§ Persons of Hispanic ethnicity can be of any race or combination of races.¶ Estimated number of users based on sample weight.** p-value <0.05 from chi-square test for difference in percentages within specified levels of school (middle or high), sex, or race/ethnicity.and "they are less harmful than other forms of tobacco, such as cigarettes" (23.7%, 24.6%, and 22.8%, respectively) (Table 2).

Discussion
Among U.S. middle and high school students who had ever used e-cigarettes in 2016, the most commonly selected reasons for e-cigarette use were "friend or family member used them," "they are available in flavors, such as mint, candy, fruit, or chocolate," and "they are less harmful than other forms of tobacco, such as cigarettes."Regardless of whether users reported using e-cigarettes exclusively or with other tobacco products during the past 30 days, these reasons remained the most commonly selected reasons for e-cigarette use.The availability of flavors, use by a friend or family member, and belief that e-cigarettes are less harmful than other forms of tobacco might be important factors for initiation or maintenance of e-cigarette use among middle school and high school students.Although percentages reported here are lower, the findings from this study are consistent with those of previous studies reporting that availability of flavors is among the most prominently cited reasons for youths' e-cigarette use (4,5).
The U.S. Surgeon General has concluded that e-cigarette use among youths and young adults is a public health concern (2).The prevalence of e-cigarette use among youths increased substantially during 2011-2015 (6,7).In 2016, e-cigarettes were the most common tobacco product used among adolescents, although the overall prevalence of use declined from previous years (1,8).The Surgeon General has also concluded that e-cigarettes can contain harmful and potentially harmful constituents, including nicotine (2,8); exposure to nicotine during adolescence can cause addiction and can harm the developing adolescent brain (2,8).Recent research indicated that e-cigarette use declined among adolescent students in 2016, likely in part because of population-based efforts to prevent youths' e-cigarette initiation and use (1,9).Continued efforts are important to further reduce all forms of tobacco product use, including e-cigarettes, among U.S. youths.As noted by the Surgeon General, population-level strategies They cost less than other tobacco products, such as cigarettes They are easier to get than other tobacco products, such as cigarettes Famous people on TV or in movies use them Abbreviation: CI = confidence interval.* Mutually exclusive categories.Subgroup for e-cigarettes and noncombustible tobacco (smokeless tobacco, snus, or dissolvable tobacco on ≥1 day in the past 30 days) is not shown because of small subgroup size.† Response to question, "What are the reasons why you have used electronic cigarettes or e-cigarettes?(Check all that apply)" are not mutually exclusive.§ Reported use of only e-cigarettes on ≥1 day in the past 30 days.¶ Reported use of e-cigarettes and only combustible tobacco including cigarettes, cigars, pipes, bidis, or hookah on ≥1 day in the past 30 days.** Estimated number of users based on sample weight.
† † Unstable estimate because of subgroup size <50 or relative standard error >0.3.