Patterns of Current Use of Tobacco Products Among U.S. High School Students for 2000e2012dFindings From the National Youth Tobacco Survey

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1 Journl of Adolescent Helth 54 (2014) 54e60 Originl rticle Ptterns of Current Use of Tobcco Products Among U.S. High School Students for 2000e2012dFindings From the Ntionl Youth Tobcco Survey René A. Arrzol, M.P.H. *, Nicole M. Kuiper, M.P.H., nd Shnt R. Dube, Ph.D., M.P.H. Office on Smoking nd Helth, Ntionl Center for Chronic Disese Prevention nd Helth Promotion, Centers for Disese Control nd Prevention, Atlnt, Georgi Article history: Received My 31, 2013; Accepted August 2, 2013 Keywords: Current tobcco use; High school students; United Sttes A B S T R A C T Purpose: The purpose of this study ws to ssess ptterns nd trends of tobcco use mong high school students to better understnd which s re used individully or concurrently. Methods: Dt from the Ntionl Youth Tobcco Survey from 2000 through 2012 were used to ssess ptterns nd trends of current tobcco use (cigrettes, cigrs, smokeless tobcco, nd other tobcco s) mong U.S. high school students. We ssessed use of s individully nd concurrently. Results: During 2000e2012, overll liner declines were observed in current use of ny tobcco from 33.6% to 20.4% (p <.05), current use of only 1 tobcco, from 18.8% to 10.5% (p <.05), nd current poly tobcco use, from 14.7% to 9.9% (p <.05), mong high school students. Overll current use of only cigrettes hd both liner decline, from 14.0% to 4.7%, s well s qudrtic trend. Conclusions: During 2000e2012, the most significnt overll decline observed ws for students who reported smoking only cigrettes. The results suggest tht more dt on the use of multiple tobcco s, not just cigrettes, is needed to guide tobcco prevention nd control policies nd progrms. Published by Elsevier Inc. on behlf of Society for Adolescent Helth nd Medicine. IMPLICATIONS AND CONTRIBUTION Recent declines in current tobcco use mong U.S. high school students pper to be driven by those who smoke cigrettes. To chieve greter declines, policies nd progrms focused on cigrettes my consider expnding to ll tobcco s. Monitoring of ll tobcco use mong youth provides informtion to prevent initition. Tobcco use continues to be the single leding preventble cuse of deth nd disese in the United Sttes [1], nd most tobcco use begins before the ge of 18 [2]. Cigrette smoking remins prevlent mong youth, with pproximtely one of five high school students reporting current smoking in 2011 [3]. Although declines in youth smoking rtes were observed over the pst two decdes, more recently, the decline in current cigrette smoking is occurring t slower rte thn ws observed during 1997e2003 [4].The rtes Disclimer: The findings nd conclusions in this report re those of the uthors nd do not necessrily represent the officil position of the Centers for Disese Control nd Prevention. Conflicts of Interest: The uthors hve no conflicts of interest or finncil disclosures to report. * Address correspondence to: René A. Arrzol, M.P.H., Office on Smoking nd Helth, Ntionl Center for Chronic Disese Prevention nd Helth Promotion, Centers for Disese Control nd Prevention, 4770 Buford Highwy, N.E., MS F-79, Atlnt, GA E-mil ddress: RArrzol@cdc.gov (R.A. Arrzol). observed for use of other tobcco s (e.g., cigrs, smokeless tobcco) hve not chnged during this period [5]. A conclusion from the 2010 Surgeon Generl s Report supports previous findings tht nicotine is the key compound tht produces the ddictive effects of tobcco s [6], nd ll tobcco s contin nicotine [7]. The concurrent use of multiple tobcco s is public helth concern, especilly during dolescence when young people my experiment with vrious tobcco s [2], which my increse their risk of nicotine dependence. Reserch hs suggested tht use of multiple tobcco s concurrently my led to greter ddiction mong users of these s [2]. Furthermore, mong high school students, use of tobcco in the pst 30 dys is ssocited with the use of lcohol nd other illegl substnces [8], nd the reltionship is even stronger when students report using two or more tobcco s [9]. These findings indicte need to monitor the use of ll types of tobcco s, both individul nd concurrently, becuse young people who use X/$ e see front mtter Published by Elsevier Inc. on behlf of Society for Adolescent Helth nd Medicine.

2 R.A. Arrzol et l. / Journl of Adolescent Helth 54 (2014) 54e60 55 multiple tobcco s re potentilly incresing their exposure to nicotine nd their risk of dependence on nicotine [10]. Given tht the rte of decline hs slowed in recent yers for current use of cigrettes but not for other tobcco s (e.g., cigrs, smokeless tobcco) mong young people [2], reserchers need to understnd better the use of multiple s over time mong youth. At present, limited informtion exists on the current use of specific tobcco s tht high school students use individully or concurrently. The purpose of this study is to ssess the prevlence of the current use of cigrettes, cigrs, smokeless tobcco, pipe tobcco, bidis, nd kreteks lone or in combintion with one nother nd to identify ny chnges over time. Methods Dt source nd study popultion We used dt from the Ntionl Youth Tobcco Survey (NYTS) from 2000 through The NYTS is school-bsed, crosssectionl survey tht collects informtion on key tobcco indictors, such s behviors nd ttitudes, from middle school (grdes 6e8) nd high school (grdes 9e12) students nd provides ntionl estimtes on these indictors. A more comprehensive description of the NYTS nd its methodology cn be found t nyts/index.htm. Our study focused on ptterns nd trends in tobcco use mong high school students for six specific s: cigrettes, cigrs, smokeless tobcco, pipe tobcco, bidis, nd kreteks. We limited our nlysis to high school students who responded to ll questions bout their use of these s in the pst 30 dys; those with missing responses were excluded. Initil smple sizes rnged from 19,350 (highest) students in 2000 to 9,720 (lowest) in 2011 (Tble 1). For our study, smple sizes rnged from 18,219 (highest) students in 2000 to 9,198 (lowest) in Mesures The following questions were used to ssess current tobcco use: (1) During the pst 30 dys, on how mny dys did you smoke cigrettes? (2) During the pst 30 dys, on how mny dys did you smoke cigrs, cigrillos, or little cigrs? (3) During the pst 30 dys, on how mny dys did you use chewing tobcco, snuff, or dip? (4) During the pst 30 dys, on how mny dys did you smoke tobcco in pipe? (5) During the pst 30 dys, on how mny dys did you smoke bidis? nd (6) During the pst 30 dys, on how mny dys did you smoke kreteks? Note tht in 2012 the bidis nd kreteks questions chnged to In the pst 30 dys, which of the following s hve you used on t lest one dy? nd students could select different s of which bidis (smll brown cigrettes wrpped in lef) nd clove cigrettes (kreteks) were possible selections. We defined ny current tobcco use s using one or more of these six s on t lest 1 dy in the pst 30 dys; respondents who did not use ny s on t lest 1 dy of the pst 30 dys were ctegorized s no current tobcco use (Figure 1). Becuse of smll smple sizes, we collpsed use of pipe tobcco, bidis, nd kreteks in the pst 30 dys into the ctegory other tobcco. Any current tobcco use ws then exmined s two mutully exclusive ctegories: current use of only 1 tobcco nd current poly tobcco use (Figure 1). Current use of only 1 tobcco ws then exmined s four mutully exclusive ctegories: current use of only cigrettes, current use of only smokeless tobcco, current use of only cigrs, nd current use of only 1 other tobcco (Figure 1). Current use of 2 or more tobcco s ws ctegorized s current poly tobcco use (Figure 1). Current poly tobcco use ws then exmined s two mutully exclusive ctegories: current use of only 2 tobcco s nd current use of t lest 3 tobcco s (Figure 1). Current use of only 2 tobcco s ws exmined s two mutully exclusive ctegories: current use of cigrettes nd 1 tobcco nd no current use of cigrettes but only 2 tobcco s (Figure 1). Current use of cigrettes nd 1 tobcco ws then exmined s three mutully exclusive ctegories: current use of only cigrettes nd smokeless tobcco, current use of only cigrettes nd cigrs, nd current use of only cigrettes nd only 1 other tobcco (Figure 1). Current use of t lest 3 tobcco s ws exmined s two mutully exclusive ctegories: current use of cigrettes nd t lest 2 tobcco s nd no current use of cigrettes but t lest 3 tobcco s (Figure 1). Current use of cigrettes nd t lest 2 tobcco s ws then exmined s five mutully exclusive ctegories: current use of only cigrettes, cigrs, nd smokeless tobcco; current use of only cigrettes, smokeless tobcco, nd t lest 1 other tobcco ; current use of only cigrettes, cigrs, nd t lest 1 other tobcco ; current use of only cigrettes nd t lest 2 other tobcco s; nd current use of cigrettes, smokeless tobcco, cigrs, nd t lest 1 other tobcco (Figure 1). Anlysis All nlyses took into ccount this study s multistge probbility design. Dt were djusted for nonresponse nd weighted to provide ntionlly representtive prevlence estimtes of current tobcco use (nd ech of its strtifictions) overll nd for selected demogrphic chrcteristics. Results where the denomintor ws less thn 50 or the reltive stndrd error ws higher thn 30% were mrked s sttisticlly unstble. We used orthogonl polynomils to perform multinomil logistic regression nlyses to simultneously ssess for liner nd qudrtic trends during 2000e2012. Our models used the following outcomes: Outcome 1 hd two possible outcomes: no current tobcco use nd ny current tobcco use. Outcome 2 hd three possible outcomes: no current tobcco use, current use of only 1 tobcco, nd current poly tobcco use. Outcome 3 hd four possible outcomes: no current tobcco use, current use of only 1 tobcco, current use of only 2 tobcco s, nd current use of t lest 3 tobcco s. Outcome 4 hd six possible outcomes: no current tobcco use, current use of only 1 tobcco, current use of cigrettes nd 1 tobcco, no current cigrette use but only 2 tobcco s, current use of cigrettes nd t lest 2 tobcco s, nd no current use of cigrettes but t lest 3 tobcco s. Outcome 5 hd fifteen possible outcomes: no current tobcco use, current use of only cigrettes, current use of only smokeless tobcco, current use of only cigrs, current use of only 1 other tobcco, current use of only cigrettes nd

3 Tble 1 Current tobcco use mong U.S. high school students, overll, Ntionl Youth Tobcco Survey, 2000e Chrcteristics Survey yer Overll Smple size 18,219 out of 19,350 12,430 out of 13,460 12,318 out of 13,738 12,880 out of 14,489 11,446 out of 12,346 9,198 out of 9,720 12,129 out of 12,899 Any current tobcco use 33.6 (31.6e35.6) 27.2 (25.5e29.0) 26.5 (24.2e29.0) 24.3 (22.4e26.3) 21.7 (18.8e24.9) 22.2 (20.0e24.5) 20.4 (18.6e22.2) Current use of only 1 tobcco 18.8 (17.6e20.1) 16.6 (15.4e17.9) 15.5 (14.0e17.0) 13.5 (12.5e14.7) 12.4 (11.2e13.6) 12.3 (11.2e13.4) 10.5 (9.5e11.6) Current use of only cigrettes 14.0 (12.9e15.1) 12.3 (11.2e13.6) 11.3 (10.0e12.7) 9.3 (8.4e10.4) 8.1 (7.2e9.1) 6.3 (5.4e7.2) 4.7 (4.1e5.4) Current use of only smokeless 1.4 (1.1e1.7) 1.4 (1.0e1.9) 1.3 (1.0e1.8) 1.5 (1.1e2.0) 1.6 (1.1e2.4) 2.2 (1.6e2.9) 1.6 (1.2e2.2) tobcco Current use of only cigrs 3.0 (2.6e3.4) 2.5 (2.1e2.9) 2.7 (2.3e3.1) 2.4 (2.0e2.9) 2.2 (1.8e2.8) 3.2 (2.7e3.9) 3.7 (3.1e4.3) Current use of only 1 other.4 (.3e.6).4 (.3e.6).2 (.1e.3).3 (.2e.5).4 (.3e.7).6 (.4e.9).5 (.4e.6) tobcco c Current poly tobcco use 14.7 (13.7e15.8) 10.6 (9.7e11.6) 11.1 (9.8e12.5) 10.8 (9.8e11.8) 9.3 (7.4e11.7) 9.9 (8.5e11.6) 9.9 (8.8e11.1) Current use of only 2 tobcco 9.0 (8.4e9.7) 6.5 (5.9e7.1) 6.8 (5.9e7.8) 6.3 (5.7e7.0) 5.4 (4.3e6.9) 6.0 (5.1e7.1) 6.0 (5.3e6.8) s Current use of cigrettes nd 7.9 (7.3e8.6) 5.6 (5.0e6.2) 6.0 (5.2e6.9) 5.5 (4.9e6.2) 4.6 (3.7e5.8) 5.1 (4.2e6.1) 4.7 (4.0e5.4) 1 tobcco Current use of only cigrettes 1.2 (1.0e1.5) 1.2 (.8e1.6).9 (.6e1.3) 1.0 (.7e1.4) 1.3 (.9e1.9) 1.5 (1.0e2.1) 1.0 (.8e1.3) nd smokeless tobcco Current use of only cigrettes 4.9 (4.4e5.5) 3.4 (3.0e3.9) 4.6 (4.0e5.3) 3.5 (3.1e4.0) 2.9 (2.4e3.6) 3.2 (2.6e3.8) 3.1 (2.6e3.7) nd cigrs Current use of only cigrettes 1.8 (1.6e2.0) 1.0 (.8e1.3).5 (.3e.8) 1.0 (.7e1.3).4 (.3e.7).4 (.3e.6).6 (.4e.7) nd only 1 other tobcco No current use of cigrettes 1.1 (.9e1.3).9 (.7e1.2).8 (.6e1.1).8 (.6e1.0).8 (.5e1.3).9 (.7e1.2) 1.3 (1.1e1.6) but only 2 tobcco s Current use of t lest 3 tobcco 5.7 (5.2e6.3) 4.1 (3.6e4.7) 4.3 (3.7e5.0) 4.4 (3.9e5.0) 3.9 (3.0e5.0) 3.9 (3.2e4.8) 3.9 (3.2e4.7) s Current use of cigrettes nd 5.5 (5.0e6.0) 4.0 (3.5e4.6) 4.0 (3.5e4.7) 4.2 (3.7e4.8) 3.7 (2.9e4.7) 3.8 (3.2e4.7) 3.6 (3.0e4.4) t lest 2 tobcco s Current use of only cigrettes, 1.3 (1.0e1.6) 1.2 (.9e1.6).9 (.7e1.2) 1.1 (.9e1.4) 1.1 (.7e1.7) 1.2 (.8e1.7) 1.0 (.7e1.3) cigrs, nd smokeless tobcco Current use of only cigrettes,.3 (.2e.4).1 (0.0e.2) d.1 (.1e.2) d.1 (.1e.3).2 (.1e.4).2 (.1e.3) d.2 (.1e.3) smokeless tobcco, nd t lest 1 other tobcco Current use of only cigrettes, 2.4 (2.1e2.8) 1.5 (1.3e1.8) 1.7 (1.4e2.0) 1.5 (1.2e1.9) 1.2 (.9e1.5) 1.2 (.9e1.6) 1.2 (1.0e1.5) cigrs, nd t lest 1 other tobcco Current use of only cigrettes.3 (.2e.4).1 (.1e.2).1 (.1e.2).2 (.1e.4).1 (0.0e.2) d.1 (0.0e.2) d.1 (0.0e.1) d nd t lest 2 other tobcco s Current use of cigrettes, 1.2 (1.0e1.4) 1.1 (.8e1.4) 1.2 (.9e1.6) 1.2 (1.0e1.5) 1.1 (.8e1.5) 1.2 (.9e1.6) 1.2 (.9e1.5) smokeless tobcco, cigrs, nd t lest 1 other tobcco No current use of cigrettes but.3 (.2e.4).1 (.1e.2).2 (.2e.4).2 (.1e.3).2 (.1e.3).1 (.1e.2) d.2 (.1e.4) t lest 3 tobcco s CI ¼ confidence intervl. Liner trend. b Liner nd qudrtic trend. c Other tobcco is defined s use of pipe, bidis, or kreteks on t lest 1 dy of the pst 30 dys. d Dt sttisticlly unstble (denomintor <50 nd/or reltive stndrd error >30%). b R.A. Arrzol et l. / Journl of Adolescent Helth 54 (2014) 54e60

4 R.A. Arrzol et l. / Journl of Adolescent Helth 54 (2014) 54e60 57 Figure 1. Flowchrt for ctegories used to define current tobcco use mong U.S. high school students, Ntionl Youth Tobcco Survey, 2000e2012.

5 58 R.A. Arrzol et l. / Journl of Adolescent Helth 54 (2014) 54e60 smokeless tobcco, current use of only cigrettes nd cigrs, current use of only cigrettes nd only 1 other tobcco, no current cigrette use but only 2 tobcco s, current use of only cigrettes, cigrs, nd smokeless tobcco, current use of only cigrettes, smokeless tobcco, nd t lest 1 other tobcco, current use of only cigrettes, cigrs, nd t lest 1 other tobcco, current use of only cigrettes nd t lest 2 other tobcco s, current use of cigrettes, smokeless tobcco, cigrs, nd t lest 1 other tobcco, nd no current use of cigrettes but t lest 3 tobcco s. Multinomil logistic regression nlysis ws used to compre ll outcomes for Outcomes 1e5 with no current tobcco use. Our overll model controlled for sex, rce/ethnicity, nd grde. The models strtified by sex controlled for rce/ethnicity nd grde, wheres those strtified by rce/ethnicity controlled for sex nd grde, nd those strtified by grde controlled for sex nd rce/ethnicity. Liner nd qudrtic trends were considered to be present if p <.05. We used SAS-Cllble SUDAAN 11.0 (RTI Interntionl, Reserch Tringle Prk, NC) to clculte ll results. Results Overll During 2000e2012, significnt liner downwrd trends were observed for current tobcco use (33.6% to 20.4%), current use of only 1 tobcco (18.8% to 10.5%), current poly tobcco use (14.7% to 9.9%), current use of only 2 tobcco s (9.0% to 6.0%), current use of cigrettes nd 1 tobcco (7.9% to 4.7%), current use of only cigrettes nd smokeless tobcco (1.2% to 1.0%), current use of only cigrettes nd cigrs (4.9% to 3.1%), nd current use of only cigrettes, cigrs, nd t lest 1 other tobcco (2.4% to 1.2%); significnt liner nd qudrtic (nonliner) trend ws observed for current use of only cigrettes (14.0% to 4.7%) mong U.S. high school students. No significnt trends were observed for ny other ctegories (Tble 1). In 2012, 8.3% of high school students currently used cigrettes nd t lest 1 tobcco. Sex Among mles, during 2000e2012, significnt liner downwrd trends were observed for current tobcco use (37.5% to 25.3%), current use of only 1 tobcco (16.8% to 11.5%), current use of only cigrettes (9.4% to 3.8%), current use of only 2 tobcco s (11.8% to 7.7%), current use of cigrettes nd 1 tobcco (9.9% to 5.5%), current use of only cigrettes nd cigrs (6.5% to 3.5%), nd current use of only cigrettes, cigrs, nd t lest 1 other tobcco (3.1% to 1.6%) (Tble 2, which cn be found in the online edition of this rticle). Among femles, significnt liner downwrd trends were only observed for current tobcco use (29.6% to 15.4%), current use of only 1 tobcco (20.8% to 9.5%), current use of only cigrettes (18.6% to 5.7%), nd current use of only cigrettes nd only 1 other tobcco (2.2% to.7%). In 2012, 11.3% of high school mles currently used cigrettes nd t lest 1 tobcco, nd mong femles it ws 5.3%. Rce/Ethnicity During 2000e2012, mong non-hispnic whites, significnt liner downwrd trends were observed for current tobcco use (37.1% to 21.9%), current use of only 1 tobcco (20.5% to 10.7%), current use of cigrettes nd 1 tobcco (8.8% to 5.1%), current use of only cigrettes nd cigrs (5.2% to 3.0%), nd current use of only cigrettes, cigrs, nd t lest 1 other tobcco (2.6% to 1.4%); significnt liner nd qudrtic trend ws observed for current use of only cigrettes (16.0% to 5.4%) (Tble 3, which cn befound inthe online edition of this rticle).among non- Hispnic blcks, significnt liner downwrd trend ws observed for current use of only cigrettes (8.0% to 2.7%); significnt liner nd qudrtic trends were observed for current tobcco use (25.4% to 19.8%) nd current use of only 1 tobcco (15.8% to 13.2%). Among Hispnics, significnt liner nd qudrtic trend ws observed for current use of only cigrettes (9.8% to 4.1%). Among non-hispnic others (Asins, Americn Indins/Alsk Ntives, or Ntive Hwiin/Other Pcific Islnders), significnt liner downwrd trends were observed for current tobcco use (25.6% to 11.2%), current use of only 1 tobcco (14.0% to 6.7%), current poly tobcco use (11.5% to 4.5%), nd current use of only 2 tobcco s (6.0% to 2.4%). In 2012, 9.3% of high school non-hispnic whites currently used cigrettes nd t lest 1 tobcco. The proportion ws 5.7% mong non-hispnic blcks, 8.4% mong Hispnics, nd 3.9% mong non-hispnic others. Grde During 2000e2012, mong 9th grders, significnt liner downwrd trends were observed for current tobcco use (26.5% to 14.2%), current use of only 1 tobcco (15.0% to 7.1%), current use of only cigrettes (10.9% to 3.1%), current poly tobcco use (11.5% to 7.1%), current use of only 2 tobcco s (6.7% to 4.4%), nd current use of cigrettes nd 1 tobcco (5.9% to 3.2%); significnt liner nd qudrtic trend ws observed for current use of only cigrettes nd cigrs (3.8% to 2.3%) (Tble 4, which cn be found in the online edition of this rticle). Among 10th grders, significnt liner downwrd trends were observed for current tobcco use (33.6% to 18.8%), current use of only 1 tobcco (18.3% to 9.7%), current use of only cigrettes (13.6% to 4.8%), current use of only 2 tobcco s (9.1% to 5.1%), nd current use of cigrettes nd 1 tobcco (7.9% to 4.2%). Among 11th grders, significnt liner downwrd trends were observed for current tobcco use (35.8% to 21.8%), current use of only 1 tobcco (19.8% to 11.3%), nd current use of only cigrettes, cigrs, nd 1 other tobcco (2.5% to 1.2%); significnt liner nd qudrtic trend ws observed for current use of only cigrettes (14.6% to 5.1%). Among 12th grders, significnt liner downwrd trends were observed for current tobcco use (41.0% to 28.0%), current use of only cigrettes (18.3% to 6.1%), current use of cigrettes nd 1 tobcco (9.7% to 6.7%), current use of only cigrettes nd cigrs (5.9% to 4.3%), nd current use of t lest 3 tobcco s (5.9% to 4.8%); significnt liner nd qudrtic trend ws observed for current use of only 1 tobcco (23.9% to 14.6%). In 2012, 11.3% of 12th grders currently used cigrettes nd t lest 1 tobcco. The proportion ws 8.9% mong 11th grders, 7.8% mong 10th grders, nd 5.8% mong 9th grders. Discussion We estimte tht, in 2012, pproximtely one of five high school students in the United Sttes were currently using some form of tobcco, nd nerly hlf of this group were poly tobcco users. Our findings tht the prevlence of poly tobcco use mong high school students is reltively high nd tht over 80% of poly

6 R.A. Arrzol et l. / Journl of Adolescent Helth 54 (2014) 54e60 59 tobcco users in 2012 lso smoked cigrettes re consistent with results from previous studies [10,11]. Among specific tobcco s, significnt downwrd trends observed during the study period were for the use of certin cigrette ctegories. Few studies hve investigted concurrent, or poly, tobcco use in dolescents [11], nd none hve investigted it t the detiled level of this study. Previous reserch hs found tht poly tobcco use is more likely to occur in specific subgroups of young people, especilly when strtified by both sex nd rce/ethnicity [2], which our study did not explore. The results of our study indicte differences in poly tobcco use by sex. This finding is supported by recent report from the U.S. Surgeon Generl [2], which presented similr estimtes for high school mles nd femles tht were bsed on dt from the Ntionl Youth Risk Behvior Survey. In tht nlysis, more thn 50% of high school mles nd pproximtely 30% of high school femles who used tobcco used multiple s concurrently [2]. By exmining tobcco use in detil, reserchers cn get comprehensive view of use mong youth, s well s insight into the use of specific s. For exmple, our nlysis found tht in 2012 nerly 50% of ll high school students who were current tobcco users were poly tobcco users, nd 35.8% of current tobcco users did not smoke cigrettes. Poly use of tobcco s my contribute to the development of nicotine dependence mong dolescents. A 2008 study found tht the use of other tobcco s by cigrette smokers is ssocited with higher levels of nicotine dependence in young dults [12]. Another study found tht current estblished smokers hd the highest rte of current use of other tobcco s, suggesting hstening of nicotine dependence for poly tobcco users who smoke cigrettes [8]. Although cross-sectionl study cnnot follow the trjectories of ddiction, the longitudinl studies tht hve looked t this topic hve only focused on cigrette use [2], nd none hve looked t the trjectories of ddiction for other types of tobcco use. Furthermore, no studies hve looked t the risks nd behviorl fctors ssocited with poly tobcco use mong youth, nd the vilble studies tht ttempted to look t fctors ssocited with poly tobcco use hve focused only on cigrette users who use other tobcco s [8,10,11,13]. Some of these studies hve found tht young people who use cigrettes nd other tobcco s my be t risk for multiple unhelthy behviors tht compromise their current nd future helth [8,10]. The results of our study cn be used to guide policy, progrmmtic, nd regultory efforts to prevent nd control tobcco use. The decline in current use of ny tobcco since the erly 2000s ppers to be bsed in lrge prt on declines in current use of only cigrettes, which lends credibility to the evidence tht policy nd progrmmtic efforts designed to reduce cigrette use mong young people hve been effective [2]. However, progrms my need to do more to ddress the use of noncigrette tobcco s nd the use of two or more tobcco s concurrently mong dolescents. Furthermore, to fill the demnd for cigrette flvors bnned by the Fmily Smoking Prevention nd Tobcco Control Act [14] in 2009, the tobcco industry expnded mrketing nd ion of flvored cigrs tht look nd re smoked like cigrettes [15]. The industry hs lso incresed ion nd promotion of roll-your-own tobcco, which is not subject to federl excise txes nd thus is cheper thn cigrettes [16e18]. Consequently, per cpit consumption of loose-lef tobcco nd cigrs hs incresed since 2000 [19]. Recent dt lso show tht dvertisement nd promotionl expenditures for smokeless tobcco s incresed by pproximtely $200 million during 1997e2006 nd gin by the sme mount during 2006e2008 [20]. Further reserch my help determine whether these fctors nd the reltively lower price of smokeless tobcco nd cigrs compred with cigrettes [21] my be contributing to the lck of decline in their use observed in our study. Strtegies to prevent the use of ny tobcco s by young people need to be developed, tested, nd implemented popultion-wide s wy to further reduce ll tobcco use mong young people. These strtegies should be used in conjunction with current tobcco control strtegies tht focus minly on cigrette smoking. Our findings re subject to t lest six limittions. First, the dt were collected from students ttending either public or privte high schools nd might not be representtive of ll youth in the United Sttes, especilly those who were not enrolled in school. Second, the nlysis only focused on youth who ttended high school nd did not include students who ttended middle school. Third, reporting nd recll bis might hve been introduced becuse of the sensitivity of the questions or becuse some questions sked bout pst behviors. Fourth, our nlysis did not exmine frequency nd intensity of the tobcco used or the use of other emerging tobcco s (e.g., electronic cigrettes, hookhs, dissolvble tobcco s). Informtion bout frequency nd intensity were not vilble, except for cigrette use, nd informtion bout trends in the use of emerging s re not vilble becuse some only recently hve been introduced to the mrket. Fifth, in order to increse smple size, non- Hispnic Asins, Americn Indin/Alsk ntives, nd ntive Hwiins nd other Pcific islnders were collpsed together, mking interprettions difficult for these groups individully. Finlly, our estimtes my differ from those derived from other surveillnce systems tht collect dt on young people. These differences cn be explined, in prt, by differences in survey methods, modes, nd topics nd in the ge nd setting of the study popultion. However, the trends identified in our study re similr to those identified in other surveys of young people [2]. Our results suggest tht the collection nd detiled nlysis of dt on the use of multiple tobcco s nd not just cigrettes is needed to guide policies nd progrms intended to prevent nd control tobcco use. All tobcco use surveys should include questions on lifetime nd current use of rnge of tobcco s, including emerging s, nd on frequency nd intensity of use. Longitudinl surveys should exmine trjectories of initition, experimenttion, nd ddiction nd ssess which tobcco s, lone or in ny combintion, my serve s gtewys to the use of other tobcco s, s well s to the use of lcohol nd other illegl substnces nd risk behviors. Funding Sources There were no sources of funding, either direct or indirect, for this study. References [1] U.S. Deprtment of Helth nd Humn Services. The helth consequences of smoking: A report of the Surgeon Generl. Atlnt, GA: Centers for Disese Control nd Prevention. Avilble t: dt_sttistics/sgr/2004/index.htm; [2] U.S. Deprtment of Helth nd Humn Services. Preventing tobcco use mong youth nd young dults: A report of the Surgeon Generl. Atlnt, GA: Centers for Disese Control nd Prevention. Avilble t: cdc.gov/tobcco/dt_sttistics/sgr/2012/index.htm; 2012.

7 60 R.A. Arrzol et l. / Journl of Adolescent Helth 54 (2014) 54e60 [3] Centers for Disese Control nd Prevention. Youth Risk Behvior Surveillnce - United Sttes, Morb Mortl Wkly Rep 2012;61 (No. SS-4). [4] Centers for Disese Control nd Prevention. Cigrette use mong high school studentsdunited Sttes, 1991e2009. Morb Mortl Wkly Rep 2010; 59:797e801. [5] Substnce Abuse nd Mentl Helth Services Administrtion. Results from the 2010 Ntionl Survey on Drug Use nd Helth: Ntionl findings. Rockville, MD: Office of Applied Studies. NSDUH Series: H-41. HHS publiction no. SMA Avilble t: 2k10nsduh/2k10Results.pdf; [6] U.S. Deprtment of Helth nd Humn Services. How tobcco smoke cuses disese: The biology nd behviorl bsis for smoking-ttributble disese: A report of the Surgeon Generl. Atlnt, GA: Centers for Disese Control nd Prevention. Avilble t: sgr/2010/index.htm; [7] Fgerström K, Eisseenberg T. Dependence on tobcco nd nicotine s: A cse for -specific ssessment. Nicotine Tob Res 2012;14: 1382e90. [8] Gilpin EA, Pierce JP. Concurrent use of tobcco s by Cliforni dolescents. Preventive Medicine 2003;36:575e84. [9] Everett SA, Mlrcher AM, Shrp DJ, et l. Reltionship between cigrette, smokeless tobcco, nd cigr use, nd other helth risk behviors mong U.S. high school students. Journl of School Helth 2000;70: 234e40. [10] Bombrd JM, Pederson LL, Kovl JJ, O Hegrty M. How re lifetime polytobcco users different thn current cigrette-only users? Results from Cndin young dult popultion. Addictive Behviors 2009;34: 1069e72. [11] Bombrd JM, Rock VJ, Pederson LL, Asmn KJ. Monitoring polytobcco use mong dolescents: Do cigrette smokers use other forms of tobcco? Nicotine nd Tobcco Reserch 2008;10:1581e9. [12] Timberlke DS. A ltent clss nlysis of nicotine-dependence criteri nd use of lternte tobcco. Journl of Studies on Alcohol nd Drugs 2008;69:709e17. [13] Nsim A, Blnk MD, Cobb CO, Eissenberg T. Ptterns of lternte tobcco use mong dolescent cigrette smokers. Drug nd Alcohol Dependence 2012;124:26e33. [14] Fmily Smoking Prevention nd Tobcco Control Act of Public Lw 111e31 (June 22, 2009). Avilble t: PLAW-111publ31/content-detil.html. [15] Centers for Disese Control nd Prevention. Current tobcco use mong middle nd high school studentsdunited Sttes, Morb Mortl Wkly Rep 2012;61:581e5. [16] Government Accountbility Office. Tobcco txes: Lrge disprities in rtes for smoking s trigger significnt mrket shifts to void higher txes. Wshington, DC: Government Accountbility Office. Avilble t: [17] Morris DS. Tobcco mnufcturing dt demonstrte industry switching in response to tx increses. Tobcco Control 2010;19: 421e2. [18] Morris DS, Tynn MA. Fiscl nd policy implictions of selling pipe tobcco for roll-your-own cigrettes in the United Sttes. PLoS ONE 7:e [19] Centers for Disese Control nd Prevention. Consumption of cigrettes nd combustible tobccodunited Sttes, 2000e2011. Morb Mortl Wkly Rep 2012;61:565e9. [20] U.S. Federl Trde Commission. Federl Trde Commission smokeless tobcco report for 2007 nd Wshington, DC: U.S. Federl Trde Commission. Avilble t: smokelesstobccoreport.pdf; [21] Delnevo CD, Hrywn M, Foulds J, Steinberg MB. Cigr use before nd fter cigrette excise tx increse in New Jersey. Addictive Behviors 2004;29: 1799e807.

8 Tble 2 Current tobcco use mong U.S. high school students, by sex, Ntionl Youth Tobcco Survey, 2000e2012 Chrcteristics Survey yer Mle Smple size 9,219 out of 9,973 6,095 out of 6,718 5,858 out of 6,694 6,155 out of 7,027 5,494 out of 6,049 4,489 out of 4,832 5,958 out of 6,458 Any current tobcco use 37.5 (35.2e39.8) 31.2 (28.8e33.6) 29.3 (24.2e29.0) 28.2 (26.0e30.5) 26.8 (22.6e31.4) 27.0 (24.2e30.1) 25.3 (23.1e27.6) Current use of only 1 tobcco 16.8 (15.8e17.9) 15.6 (14.1e17.2) 13.9 (12.5e15.4) 13.4 (12.2e14.8) 13.4 (11.9e15.1) 13.2 (11.8e14.7) 11.5 (10.2e12.9) Current use of only cigrettes 9.4 (8.6e10.3) 9.3 (8.1e10.7) 7.2 (6.2e8.3) 7.0 (6.1e8.0) 7.4 (6.6e8.2) 4.7 (3.9e5.6) 3.8 (3.2e4.4) Current use of only smokeless 2.5 (2.0e3.1) 2.5 (1.8e3.6) 2.6 (1.9e3.5) 2.9 (2.1e4.0) 3.0 (2.0e4.5) 3.9 (2.9e5.3) 3.1 (2.3e4.3) tobcco Current use of only cigrs 4.5 (3.9e5.1) 3.4 (2.8e4.1) 3.9 (3.4e4.5) 3.3 (2.7e4.0) 3.5 (2.7e4.5) 4.2 (3.3e5.3) 4.2 (3.5e5.0) Current use of only 1 other.4 (.3e.6).3 (.2e.6).2 (.1e.3) d.3 (.1e.5) d 1.1 (.6e1.9).4 (.2e.7).4 (.3e.6) tobcco c Current poly tobcco use 20.7 (19.1e22.4) 15.6 (14.0e17.4) 15.4 (13.6e17.3) 14.8 (13.3e16.3) 13.3 (10.5e16.9) 13.8 (11.9e16) 13.8 (12.3e15.6) Current use of only 2 tobcco s 11.8 (10.7e13.0) 8.8 (7.9e9.9) 8.9 (7.8e10.2) 8.0 (7.0e9.2) 7.4 (5.7e9.6) 7.7 (6.5e9.0) 7.7 (6.7e8.8) Current use of cigrettes nd 9.9 (8.9e11.0) 7.3 (6.4e8.3) 7.5 (6.5e8.7) 6.7 (5.8e7.8) 6.0 (4.6e7.6) 6.1 (5.0e7.3) 5.5 (4.7e6.5) 1 tobcco Current use of only cigrettes 2.1 (1.6e2.6) 2.1 (1.5e2.9) 1.5 (1.0e2.2) 1.8 (1.3e2.4) 2.2 (1.5e3.2) 2.6 (1.8e3.7) 1.6 (1.2e2.1) nd smokeless tobcco Current use of only cigrettes nd 6.5 (5.8e7.3) 4.3 (3.6e5.0) 5.7 (5.0e6.5) 4.2 (3.6e4.8) 3.6 (2.9e4.4) 3.2 (2.6e3.9) 3.5 (2.9e4.2) cigrs Current use of only cigrettes 1.3 (1.1e1.6).9 (.7e1.3).3 (.2e.6) d.8 (.5e1.3).4 (.2e.7) d.3 (.2e.5).4 (.3e.6) nd only 1 other tobcco No current use of cigrettes but 1.9 (1.6e2.3) 1.5 (1.2e2.0) 1.4 (1.0e2.0) 1.3 (1.0e1.7) 1.5 (.9e2.3) 1.6 (1.2e2.1) 2.2 (1.7e2.7) only 2 tobcco s Current use of t lest 3 tobcco 8.9 (7.9e9.9) 6.8 (5.8e7.9) 6.5 (5.5e7.6) 6.7 (5.8e7.7) 5.9 (4.5e7.7) 6.2 (5.1e7.5) 6.1 (5.1e7.4) s Current use of cigrettes nd 8.4 (7.5e9.4) 6.5 (5.6e7.7) 6.0 (5.1e7.1) 6.4 (5.5e7.4) 5.6 (4.3e7.3) 6.0 (5.0e7.3) 5.8 (4.8e6.9) t lest 2 tobcco s Current use of only cigrettes, 2.3 (1.9e2.9) 2.4 (1.8e3.1) 1.5 (1.2e2.0) 2.0 (1.6e2.6) 2.0 (1.3e3.1) 2.2 (1.6e3.0) 1.8 (1.4e2.5) cigrs, nd smokeless tobcco Current use of only cigrettes,.5 (.3e.7).1 (0.0e.2) d.2 (.1e.4) d.2 (.1e.3) d.3 (.2e.7) d.3 (.1e.6) d.2 (.1e.4) d smokeless tobcco, nd t lest 1 other tobcco Current use of only cigrettes, 3.1 (2.7e3.7) 2.2 (1.8e2.7) 2.0 (1.6e2.5) 1.8 (1.4e2.2) 1.5 (1.2e1.9) 1.6 (1.2e2.2) 1.6 (1.3e2.1) cigrs, nd t lest 1 other tobcco Current use of only cigrettes.3 (.2e.5).1 (0.0e.2) d.1 (0.0e.2) d.1 (.1e.3) d.2 (.1e.4) d.1 (0.0e.2) d.1 (0.0e.2) d nd t lest 2 other tobcco s Current use of cigrettes, 2.1 (1.8e2.6) 1.8 (1.4e2.5) 2.2 (1.6e3.1) 2.3 (1.7e2.9) 2.0 (1.4e2.7) 2.4 (1.8e3.2) 2.0 (1.6e2.6) smokeless tobcco, cigrs, nd t lest 1 other tobcco No current use of cigrettes but t lest 3 tobcco s.5 (.3e.7).2 (.1e.4).5 (.3e.7).4 (.2e.6).3 (.2e.5).2 (.1e.4) d.4 (.2e.7) d (continued on next pge) R.A. Arrzol et l. / Journl of Adolescent Helth 54 (2014) 54e60 60.e1

9 Tble 2 continued Chrcteristics Survey yer 60.e2 Femle Smple size 8,996 out of 9,371 6,318 out of 6,719 6,395 out of 6,964 6,638 out of 7,359 5,936 out of 6,273 4,651 out of 4,819 6,170 out of 6,439 Any current tobcco use 29.6 (27.6e31.6) 23.3 (21.5e25.2) 24.0 (21.5e26.6) 20.8 (18.7e23.0) 16.8 (14.6e19.1) 17.3 (15.4e19.5) 15.4 (13.6e17.4) Current use of only 1 tobcco 20.8 (19.2e22.6) 17.6 (15.9e19.3) 16.9 (15.0e18.9) 13.7 (12.2e15.3) 11.4 (9.8e13.2) 11.3 (10.0e12.8) 9.5 (8.4e10.9) Current use of only cigrettes 18.6 (17.0e20.3) 15.3 (13.6e17.2) 15.0 (13.2e17.0) 11.5 (10.2e13.1) 9.4 (8.0e10.9) 7.8 (6.5e9.3) 5.7 (4.9e6.6) Current use of only smokeless.3 (.2e.5).3 (.2e.5).1 (.1e.3) d.2 (.1e.4) d.3 (.2e.7) d.5 (.3e.8).1 (.1e.3) d tobcco Current use of only cigrs 1.4 (1.1e1.8) 1.5 (1.2e1.9) 1.5 (1.2e2) 1.6 (1.2e2.1) 1.3 (.9e1.9) 2.2 (1.7e3) 3.2 (2.6e3.9) Current use of only 1 other.5 (.3e.7).4 (.3e.7).2 (.1e.4).4 (.2e.5).4 (.2e.7) d.8 (.5e1.5).6 (.4e.8) tobcco Current poly tobcco use 8.7 (7.9e9.7) 5.7 (5.0e6.6) 7.1 (5.9e8.4) 7.1 (6.1e8.2) 5.3 (4.3e6.7) 6.0 (4.9e7.5) 5.9 (5.0e6.9) Current use of only 2 tobcco 6.2 (5.5e6.9) 4.2 (3.6e4.9) 4.9 (4.0e6.0) 4.7 (4.0e5.6) 3.4 (2.7e4.4) 4.4 (3.4e5.5) 4.3 (3.5e5.1) s Current use of cigrettes nd 5.9 (5.3e6.6) 3.9 (3.3e4.6) 4.6 (3.8e5.6) 4.4 (3.7e5.3) 3.3 (2.5e4.2) 4.1 (3.2e5.3) 3.8 (3.1e4.6) 1 tobcco Current use of only cigrettes.4 (.2e.6).2 (.1e.5) d.3 (.1e.7) d.4 (.1e.9) d.2 (.1e.6) d.3 (.2e.6) d.4 (.2e.6) nd smokeless tobcco Current use of only cigrettes 3.3 (2.8e3.9) 2.6 (2.1e3.3) 3.6 (2.9e4.5) 2.9 (2.4e3.7) 2.4 (1.9e3.0) 3.2 (2.5e4.3) 2.7 (2.1e3.4) nd cigrs Current use of only cigrettes 2.2 (1.9e2.6) 1.1 (.8e1.5).7 (.4e1.2) 1.1 (.8e1.7).6 (.4e1.0).6 (.3e.9).7 (.5e1.0) nd only 1 other tobcco No current use of cigrettes but.3 (.2e.4).3 (.2e.5).3 (.2e.5).3 (.2e.5).2 (.1e.3).3 (.2e.5).5 (.3e.7) only 2 tobcco s Current use of t lest 3 tobcco 2.6 (2.1e3.1) 1.5 (1.2e2.0) 2.2 (1.7e2.9) 2.4 (1.9e2.9) 1.9 (1.4e2.6) 1.7 (1.2e2.3) 1.6 (1.2e2.1) s Current use of cigrettes nd 2.5 (2.1e3.1) 1.5 (1.1e2.0) 2.1 (1.6e2.8) 2.3 (1.9e2.8) 1.8 (1.3e2.4) 1.6 (1.2e2.2) 1.5 (1.2e2.0) t lest 2 tobcco s Current use of only cigrettes,.2 (.1e.5) d.2 (.1e.3) d.3 (.2e.6) d.2 (.1e.5) d.2 (.1e.5) d.3 (.1e.8) d.1 (.1e.2) d cigrs, nd smokeless tobcco Current use of only cigrettes,.1 (0.0e.2) d.1 (0.0e.2) d.1 (0.0e.2) d.1 (.1e.3) d.2 (0.0e.7) d.1 (0.0e.3) d.1 (.1e.3) d smokeless tobcco, nd t lest 1 other Current use of only cigrettes, 1.7 (1.3e2.1).9 (.6e1.2) 1.3 (1e1.8) 1.3 (.9e1.9) 1.0 (.7e1.4) 1 (.7e1.4).9 (.7e1.1) cigrs, nd t lest 1 other tobcco Current use of only cigrettes.3 (.2e.5).1 (0.0e.2) d.2 (.1e.4).3 (.2e.5).1 (0.0e.1) d.2 (.1e.4) d 0.0 (0.0e.1) d nd t lest 2 other tobcco s Current use of cigrettes,.2 (.1e.3).3 (.2e.5).2 (.1e.4) d.3 (.2e.4).4 (.2e.8) d.2 (.1e.5) d.4 (.2e.6) smokeless tobcco, cigrs, nd t lest 1 other tobcco No current use of cigrettes but 0.0 (0.0e.1) d 0.0 (0.0e.1) d 0.0 (0.0e.1) d.1 (0.0e.2) d.1 (0.0e.3) d.1 (0.0e.2) d.1 (0.0e.2) d t lest 3 tobcco s CI ¼ confidence intervl. Liner trend. b Liner nd qudrtic trend. c Other Tobcco is defined s use of pipe, bidis, or kreteks on t lest 1 dy of the pst 30 dys. d Dt sttisticlly unstble (denomintor <50 nd/or reltive stndrd error >30%). R.A. Arrzol et l. / Journl of Adolescent Helth 54 (2014) 54e60

10 Tble 3 Current tobcco use mong U.S. high school students, by rce/ethnicity, Ntionl Youth Tobcco Survey, 2000e2012 Chrcteristics Survey yer non-hispnic whites Smple size 10,999 out of 11,512 7,050 out of 7,466 5,819 out of 6,065 6,385 out of 6,851 5,945 out of 6,206 4,097 out of 4,230 6,462 out of 6,802 Any current tobcco use 37.1 (34.8e39.4) 30.1 (28.0e32.2) 29.9 (26.8e33.2) 27.3 (25.0e29.8) 25.3 (22.2e28.7) 24.8 (21.9e27.9) 21.9 (19.6e24.2) Current use of only 1 tobcco 20.5 (19.1e22.0) 18.1 (16.7e19.6) 17.5 (15.5e19.7) 15.0 (13.5e16.5) 14.2 (12.8e15.7) 13.3 (11.8e14.8) 10.7 (9.5e12.0) Current use of only cigrettes 16.0 (14.8e17.4) 13.8 (12.6e15.2) 13.0 (11.3e15.0) 10.5 (9.3e11.8) 9.1 (8.1e10.2) 6.8 (5.6e8.2) 5.4 (4.6e6.3) b Current use of only smokeless 1.8 (1.4e2.2) 1.8 (1.3e2.5) 1.7 (1.3e2.3) 1.9 (1.4e2.6) 2.3 (1.6e3.2) 2.9 (2.2e3.9) 2.2 (1.6e3.1) tobcco Current use of only cigrs 2.5 (2.1e2.9) 2.1 (1.8e2.6) 2.6 (2.2e3.1) 2.3 (1.9e2.9) 2.5 (2.0e3.2) 3.1 (2.4e4.0) 2.8 (2.2e3.5) Current use of only 1 other tobcco c.3 (.2e.4).3 (.2e.5).1 (.1e.3) d.3 (.2e.5).2 (.1e.4) d.4 (.2e.9) d.3 (.2e.5) Current poly tobcco use 16.5 (15.3e17.9) 12.0 (10.8e13.2) 12.4 (10.8e14.2) 12.4 (11.1e13.7) 11.1 (9.1e13.5) 11.5 (9.6e13.8) 11.1 (9.6e12.8) Current use of only 2 tobcco s 10.0 (9.1e10.9) 7.2 (6.4e8.1) 7.5 (6.5e8.8) 7.1 (6.3e8.0) 6.6 (5.4e8.0) 7.2 (5.9e8.7) 6.7 (5.7e7.9) Current use of cigrettes nd 8.8 (8.0e9.7) 6.2 (5.5e7.0) 6.7 (5.6e7.9) 6.2 (5.4e7.1) 5.5 (4.5e6.6) 6.1 (4.9e7.5) 5.1 (4.2e6.3) 1 tobcco Current use of only cigrettes nd 1.6 (1.3e2.1) 1.5 (1.1e2.0) 1.2 (.8e1.8) 1.3 (.9e1.9) 1.7 (1.3e2.4) 2.1 (1.5e2.9) 1.4 (1.1e1.8) smokeless tobcco Current use of only cigrettes nd 5.2 (4.5e5.9) 3.6 (3.0e4.2) 4.9 (4.2e5.8) 3.8 (3.2e4.5) 3.2 (2.7e3.8) 3.5 (2.8e4.5) 3.0 (2.4e3.8) cigrs Current use of only cigrettes nd 2.0 (1.7e2.3) 1.2 (.9e1.6).6 (.3e1.0) d 1.1 (.7e1.6).6 (.3e.9).5 (.3e.8).7 (.5e1.0) only 1 other tobcco No current use of cigrettes but only 1.2 (.9e1.4) 1.0 (.7e1.4).9 (.6e1.3).9 (.7e1.2) 1.1 (.7e1.7) 1.1 (.8e1.5) 1.6 (1.2e2.1) 2 tobcco s Current use of t lest 3 tobcco 6.6 (5.9e7.3) 4.8 (4.1e5.5) 4.9 (4.1e5.7) 5.2 (4.6e6.0) 4.5 (3.4e5.9) 4.4 (3.4e5.6) 4.4 (3.6e5.5) s Current use of cigrettes nd t lest 6.3 (5.7e7.0) 4.7 (4.0e5.4) 4.6 (3.8e5.5) 5.0 (4.4e5.7) 4.2 (3.2e5.5) 4.2 (3.3e5.5) 4.2 (3.3e5.2) 2 tobcco s Current use of only cigrettes, 1.7 (1.4e2.1) 1.7 (1.3e2.3) 1.2 (.9e1.5) 1.4 (1.1e1.9) 1.4 (1.0e2.2) 1.6 (1.1e2.4) 1.3 (.9e1.8) cigrs, nd smokeless tobcco Current use of only cigrettes,.4 (.3e.5).1 (.1e.3) d.1 (.1e.3) d.2 (.1e.3) d.2 (.1e.4) d.2 (.1e.4) d.2 (.1e.3) d smokeless tobcco, nd t lest 1 other Current use of only cigrettes, 2.6 (2.2e3.1) 1.7 (1.4e2.0) 1.8 (1.4e2.3) 1.7 (1.3e2.2) 1.4 (1.0e1.8) 1.1 (.8e1.6) 1.4 (1.1e1.8) cigrs, nd t lest 1 other tobcco Current use of only cigrettes nd.4 (.3e.5).1 (0.0e.2) d.2 (.1e.3) d.3 (.1e.5).1 (0.0e.2) d.1 (.1e.3) d 0.0 (0.0e.1) d t lest 2 other tobcco s Current use of cigrettes, 1.3 (1.0e1.5) 1.1 (.8e1.5) 1.4 (1.0e1.9) 1.4 (1.1e1.9) 1.1 (.8e1.6) 1.2 (.8e1.8) 1.2 (.9e1.6) smokeless tobcco, cigrs, nd t lest 1 other tobcco No current use of cigrettes but.3 (.2e.4).1 (0.0e.3) d.3 (.2e.4).2 (.1e.4).3 (.2e.5).1 (0.0e.3) d.3 (.2e.5) d t lest 3 tobcco s non-hispnic blcks Smple size 2,475 out of 2,721 2,005 out of 2,185 2,315 out of 2,556 2,643 out of 2,901 1,668 out of 1,850 1,512 out of 1,617 1,737 out of 1,855 Any current tobcco use 25.4 (22.1e29.0) 20.2 (17.4e23.3) 15.5 (13.0e18.5) 13.4 (11.4e15.6) 10.3 (6.9e15.1) 16.7 (13.5e20.5) 19.8 (17.2e22.7) b Current use of only 1 tobcco 15.8 (13.9e17.8) 13.9 (11.6e16.6) 9.7 (8.0e11.6) 8.8 (7.3e10.6) 6.9 (5.2e9.1) 11.2 (9.1e13.8) 13.2 (11.2e15.6) b Current use of only cigrettes 8.0 (6.7e9.6) 7.8 (5.9e10.4) 5.2 (4.1e6.7) 4.7 (3.8e5.8) 3.5 (2.1e5.7) 4.8 (3.2e7.2) 2.7 (1.9e3.8) Current use of only smokeless.5 (.2e1.2) d.3 (.1e.7) d.2 (.1e.6) d.2 (.1e.7) d.2 (.1e.7) d.9 (.3e2.4) d.6 (.3e1.3) d tobcco Current use of only cigrs 6.4 (5.2e7.9) 5.0 (3.7e6.8) 4.0 (3.0e5.3) 3.4 (2.4e4.8) 2.2 (1.0e4.8) d 5.1 (3.8e6.7) 9.6 (7.9e11.6) (continued on next pge) R.A. Arrzol et l. / Journl of Adolescent Helth 54 (2014) 54e60 60.e3

11 Tble 3 continued Chrcteristics Survey yer 60.e4 Current use of only 1 other tobcco.8 (.5e1.3).8 (.4e1.5) d.2 (.1e.6) d.5 (.3e1.0) d 1.0 (.3e3.6) d.4 (.1e1.3) d.3 (.1e.8) d Current poly tobcco use 9.7 (7.9e11.8) 6.3 (5.1e7.6) 5.8 (4.5e7.5) 4.6 (3.4e6.0) 3.4 (1.6e7.2) d 5.5 (3.9e7.7) 6.6 (5.4e8.1) Current use of only 2 tobcco s 6.8 (5.4e8.4) 4.3 (3.4e5.5) 4.4 (3.3e5.8) 3.3 (2.5e4.4) 2.3 (1.1e4.9) d 3.6 (2.5e5.3) 5.0 (4.0e6.3) Current use of cigrettes nd 5.7 (4.4e7.4) 3.5 (2.7e4.7) 3.8 (2.8e5.1) 3.0 (2.2e4.1) 2.0 (.9e4.3) d 3.3 (2.2e4.9) 4.3 (3.3e5.8) 1 tobcco Current use of only cigrettes nd.2 (.1e.5) d.1 (0.0e.5) d.1 (0.0e.4) d.1 (0.0e.4) d.3 (0.0e1.4) d.3 (0.0e1.9) d.2 (.1e.7) d smokeless tobcco Current use of only cigrettes nd 4.5 (3.3e6.1) 2.6 (1.9e3.6) 3.6 (2.6e4.9) 2.3 (1.7e3.1) 1.6 (.7e3.3) d 2.8 (2.0e4.0) 4.0 (2.9e5.5) cigrs Current use of only cigrettes nd.9 (.6e1.6).8 (.3e1.6) d.2 (.1e.5) d.6 (.3e1.1) d.1 (0.0e.5) d.2 (0.0e.7) d.1 (0.0e.4) d only 1 other tobcco No current use of cigrettes but only 1.1 (.7e1.6).8 (.5e1.4).6 (.3e1.1).3 (.2e.6) d.3 (.1e.9) d.4 (.1e1.3) d.7 (.3e1.4) d 2 tobcco s Current use of t lest 3 tobcco 2.9 (2.2e3.9) 1.9 (1.3e2.9) 1.4 (.9e2.2) 1.3 (.8e2.0) 1.1 (.4e2.9) d 1.8 (1.1e3.0) 1.5 (1.0e2.5) s Current use of cigrettes nd 2.7 (2.0e3.6) 1.7 (1.1e2.6) 1.3 (.8e2.1) 1.2 (.8e1.9) 1.0 (.4e2.8) d 1.8 (1.1e3.0) 1.4 (.8e2.3) t lest 2 tobcco s Current use of only cigrettes,.2 (.1e.7) d 0.0 (0.0e.3) d.1 (0.0e.7) d.1 (0.0e.4) d.2 (.1e.6) d.6 (.2e1.4) d.1 (0.0e.2) d cigrs, nd smokeless tobcco Current use of only cigrettes,.1 (0.0e.3) d 0.0 (0.0e.1) d 0.0 (0.0e.3) d.1 (0.0e.5) d.1 (0.0e.3) d 0.0 (.e.) d.2 (0.0e1.3) d smokeless tobcco, nd t lest 1 other Current use of only cigrettes, 1.5 (1.0e2.2).6 (.4e1.1).5 (.3e.9) d.6 (.4e1.0).2 (0.0e.5) d.6 (.3e1.4) d.5 (.2e1.1) d cigrs, nd t lest 1 other tobcco Current use of only cigrettes nd.2 (.1e.5) d.2 (0.0e.7) d.1 (0.0e.4) d.1 (0.0e.3) d 0.0 (0.0e.2) d 0.0 (.e.) d.1 (0.0e.6) d t lest 2 other tobcco s Current use of cigrettes, smokeless.6 (.3e1.3) d.8 (.4e1.7) d.5 (.2e1.3) d.2 (.1e.6) d.6 (.1e2.4) d.6 (.3e1.6) d.5 (.2e1.1) d tobcco, cigrs, nd t lest 1 other tobcco No current use of cigrettes but.2 (.1e.7) d.2 (.1e.7) d.1 (0.0e.3) d.1 (0.0e.3) d.1 (0.0e.3) d 0.0 (.e.) d.2 (.1e.6) d t lest 3 tobcco s Hispnics Smple size 3,090 out of 3,317 2,302 out of 2,595 3,129 out of 3,610 2,774 out of 3,471 3,073 out of 3,403 2,990 out of 3,217 2,873 out of 3,098 Any current tobcco use 25.5 (22.4e28.9) 21.3 (18.6e24.3) 23.6 (21.1e26.3) 22.9 (20.5e25.5) 21.3 (19.1e23.6) 20.5 (17.9e23.3) 18.5 (15.9e21.3) Current use of only 1 tobcco 13.7 (11.7e16.0) 12.3 (10.3e14.6) 13.2 (11.5e15.0) 12.8 (11.3e14.3) 12.2 (10.7e13.9) 11.4 (9.9e13.1) 8.7 (7.4e10.3) Current use of only cigrettes 9.8 (8.0e12.0) 9.6 (7.8e11.9) 9.9 (8.5e11.5) 9.1 (8.0e10.4) 9.2 (7.4e11.4) 6.6 (5.7e7.6) 4.1 (3.2e5.4) Current use of only smokeless tobcco.8 (.5e1.2).9 (.5e1.6).5 (.2e1.1) d 1.1 (.6e2.0) d.5 (.2e1.0) d 1.1 (.6e2.0) d.9 (.5e1.6) Current use of only cigrs 2.2 (1.7e2.9) 1.3 (.9e2.0) 2.3 (1.7e3.1) 2.2 (1.6e2.9) 1.7 (1.0e2.7) 2.5 (1.8e3.5) 2.6 (1.9e3.6) Current use of only 1 other tobcco.9 (.6e1.5).4 (.2e.9) d.4 (.2e.8) d.4 (.2e.7).8 (.4e1.6) d 1.3 (.8e2.0) 1.0 (.7e1.5) Current poly tobcco use 11.8 (10.3e13.5) 9.0 (7.5e10.7) 10.4 (8.9e12.1) 10.2 (8.7e11.9) 9.1 (7.4e11.0) 9.1 (7.7e10.7) 9.7 (8.1e11.6) Current use of only 2 tobcco s 7.6 (6.6e8.8) 5.5 (4.5e6.7) 5.9 (4.8e7.2) 6.0 (4.9e7.3) 4.8 (3.5e6.5) 4.6 (3.7e5.8) 5.6 (4.5e6.9) Current use of cigrettes nd 6.7 (5.7e7.9) 5.1 (4.2e6.2) 5.4 (4.3e6.7) 5.3 (4.3e6.6) 4.4 (3.2e6.0) 3.7 (3.0e4.7) 4.4 (3.4e5.5) 1 tobcco Current use of only cigrettes nd.4 (.2e.9) d.3 (.1e.9) d.2 (.1e.6) d.5 (.2e1.0) d.7 (.3e2.0) d.5 (.2e1.2) d.4 (.2e.9) d smokeless tobcco Current use of only cigrettes nd 4.8 (3.9e5.8) 4.1 (3.3e5.1) 4.4 (3.4e5.6) 4.0 (3.2e5.1) 3.5 (2.4e4.9) 2.9 (2.2e3.8) 3.5 (2.7e4.4) cigrs Current use of only cigrettes nd 1.5 (1.2e2.1).7 (.4e1.1).8 (.6e1.2).8 (.4e1.5) d.2 (.1e.5) d.4 (.2e.7) d.5 (.3e.9) d only 1 other tobcco b R.A. Arrzol et l. / Journl of Adolescent Helth 54 (2014) 54e60

12 Tble 3 continued Chrcteristics Survey yer No current use of cigrettes but only.9 (.6e1.5).4 (.2e.8) d.5 (.3e.9).7 (.4e1.2).4 (.2e.7) d.9 (.6e1.3) 1.2 (.8e1.9) 2 tobcco s Current use of t lest 3 tobcco 4.2 (3.3e5.3) 3.5 (2.6e4.6) 4.5 (3.8e5.4) 4.2 (3.3e5.2) 4.3 (3.4e5.4) 4.4 (3.5e5.6) 4.2 (3.3e5.2) s Current use of cigrettes nd t lest 3.9 (3e5.1) 3.2 (2.4e4.3) 4.2 (3.5e5.0) 3.8 (3.1e4.8) 4.2 (3.3e5.3) 4.2 (3.4e5.3) 4.0 (3.2e5.1) 2 tobcco s Current use of only cigrettes,.5 (.2e1.0) d.2 (.1e.6) d.3 (.1e.7) d.3 (.1e.8) d.5 (.2e1.2) d.4 (.2e.8) d.6 (.4e1.1) cigrs, nd smokeless tobcco Current use of only cigrettes,.1 (0.0e.6) d 0.0 (.e.) d.1 (0.0e.5) d 0.0 (0.0e.3) d.5 (.2e1.8) d.1 (0.0e.3) d.2 (.1e.4) d smokeless tobcco, nd t lest 1 other tobcco Current use of only cigrettes, 2.3 (1.7e3.1) 2.0 (1.4e2.8) 2.6 (2.0e3.4) 1.6 (1.1e2.2) 1.4 (1.1e2.0) 2.1 (1.5e2.9) 1.4 (1.0e2.1) cigrs, nd t lest 1 other tobcco Current use of only cigrettes nd.2 (.1e.4) d.1 (0.0e.3) d.2 (.1e.5) d.3 (.1e.6) d.1 (0.0e.5) d.1 (0.0e.2) d.1 (0.0e.3) d t lest 2 other tobcco s Current use of cigrettes, smokeless.8 (.5e1.3).9 (.5e1.7) d 1.0 (.7e1.4) 1.6 (1.1e2.4) 1.5 (1.1e2.3) 1.6 (1.0e2.4) 1.7 (1.1e2.6) tobcco, cigrs, nd t lest 1 other tobcco No current use of cigrettes but.3 (.2e.5) d.2 (.1e.6) d.3 (.2e.7) d.3 (.1e.9) d.1 (.1e.3) d.2 (.1e.5) d.1 (0.0e.3) d t lest 3 tobcco s non-hispnic others (Asins, Americn Indins/Alsk Ntives, or Ntive Hwiin/Other Pcific Islnders) Smple size 1,438 out of 1, out of 1, out of out of 1, out of out of out of 909 Any current tobcco use 25.6 (22.4e29.0) 22.1 (17.5e27.5) 15.6 (12.6e19.1) 14.7 (11.6e18.6) 13.2 (9.2e18.5) 12.6 (9.3e16.9) 11.2 (8.0e15.6) Current use of only 1 tobcco 14.0 (11.8e16.6) 13.3 (9.3e18.8) 8.1 (6.1e10.6) 9.4 (7.2e12.1) 7.1 (5.0e9.9) 6.2 (4.0e9.6) 6.7 (4.5e10.0) Current use of only cigrettes 12.0 (10.0e14.3) 10.4 (6.8e15.5) 6.2 (4.6e8.4) 7.8 (5.8e10.4) 5.9 (4.0e8.5) 2.9 (1.6e5.4) d 3.8 (2.1e6.8) Current use of only smokeless tobcco.6 (.3e1.5) d.8 (.3e2.1) d.4 (.1e1.3) d.5 (.1e1.5) d.4 (0.0e2.6) d 1.0 (.3e2.9) d.6 (.3e1.3) d Current use of only cigrs.6 (.3e1.1) d 1.7 (.9e3.1) d 1.0 (.4e2.7) d 1.0 (.5e1.9) d.7 (.3e1.6) d 1.4 (.5e4.1) d 1.9 (1.2e3.2) Current use of only 1 other tobcco.8 (.4e1.4) d.4 (.2e1.1) d.5 (.1e1.6) d.2 (0.0e.6) d.2 (0.0e.7) d.9 (.2e4.2) d.4 (.1e1.3) d Current poly tobcco use 11.5 (9.3e14.3) 8.8 (6.4e11.9) 7.5 (5.6e10.0) 5.3 (3.7e7.6) 6.1 (3.8e9.6) 6.4 (4.2e9.7) 4.5 (2.9e6.8) Current use of only 2 tobcco s 6.0 (4.5e7.8) 5.0 (3.1e8.0) 4.3 (2.9e6.4) 3.4 (2.1e5.4) 2.6 (1.5e4.6) 4.1 (2.3e7.0) 2.4 (1.5e3.5) Current use of cigrettes nd 5.4 (4.1e7.0) 4.8 (2.8e7.8) 4.2 (2.7e6.3) 2.5 (1.3e4.6) d 2.2 (1.2e4.0) 3.4 (1.9e6.2) d 1.8 (1.1e3.0) 1 tobcco Current use of only cigrettes nd.5 (.2e1.1) d 1.6 (.6e3.9) d.4 (.1e2.2) d.5 (.1e1.7) d.2 (0.0e.9) d.8 (.3e2.2) d.5 (.2e1.1) d smokeless tobcco Current use of only cigrettes nd 3.3 (2.3e4.8) 2.9 (1.8e4.7) 3.4 (2.2e5.2) 1.9 (.9e4.1) d 1.7 (.9e3.5) d 1.5 (.7e3.1) d 1.1 (.6e1.9) cigrs Current use of only cigrettes nd 1.6 (1.0e2.5).3 (.1e1.2) d.3 (.1e1.0) d.1 (0.0e.5) d.3 (.1e.9) d 1.1 (.4e2.9) d.3 (.1e1.0) d only 1 other tobcco No current use of cigrettes but only.6 (.2e1.6) d.3 (.1e.8) d.2 (0.0e.6) d.9 (.4e2.1) d.4 (.1e1.2) d.7 (.2e1.9) d.5 (.2e1.3) d 2 tobcco s Current use of t lest 3 tobcco 5.6 (4.1e7.6) 3.8 (2.1e6.5) 3.1 (2.2e4.5) 2.0 (1.0e3.8) d 3.5 (2.0e6.0) 2.3 (1.2e4.4) d 2.1 (1.2e3.7) s Current use of cigrettes nd t lest 5.5 (4.0e7.5) 3.8 (2.1e6.5) 2.9 (2.0e4.3) 1.8 (.9e3.6) d 3.5 (2.0e6.0) 2.3 (1.2e4.4) d 2.1 (1.2e3.7) 2 tobcco s Current use of only cigrettes, cigrs, nd smokeless tobcco.2 (.1e.7) d.3 (.1e1.1) d.4 (.1e1.5) d.4 (.1e1.8) d.5 (.2e1.4) d.3 (.1e1.2) d.8 (.2e2.4) d (continued on next pge) R.A. Arrzol et l. / Journl of Adolescent Helth 54 (2014) 54e60 60.e5

13 Tble 3 continued Chrcteristics Survey yer 60.e6 Current use of only cigrettes, smokeless tobcco, nd t lest 1 other tobcco Current use of only cigrettes, cigrs, nd t lest 1 other tobcco Current use of only cigrettes nd t lest 2 other tobcco s Current use of cigrettes, smokeless tobcco, cigrs, nd t lest 1 other tobcco No current use of cigrettes but t lest 3 tobcco s CI ¼ confidence intervl. Liner trend. b Liner nd qudrtic trend. c Other Tobcco is defined s use of pipe, bidis, or kreteks on t lest 1 dy of the pst 30 dys. d Dt sttisticlly unstble (denomintor <50 nd/or reltive stndrd error >30%)..2 (.1e.7) d 0.0 (.e.) d.2 (0.0e1.1) d 0.0 (.e.) d.3 (.1e1.2) d.6 (.1e3.2) d.1 (0.0e.4) d 2.5 (1.6e3.9) 1.4 (.7e2.9) d 1.5 (.8e2.7) d.8 (.3e2.0) d 1.4 (.7e2.7) d.7 (.2e3.1) d.5 (.2e1.3) d.3 (.1e.8) d 0.0 (.e.) d 0.0 (.e.) d 0.0 (.e.) d 0.0 (.e.) d 0.0 (.e.) d 0.0 (.e.) d 2.2 (1.3e3.6) 2.1 (1.1e4.1) d.9 (.4e1.9) d.5 (.2e1.5) d 1.3 (.5e3.3) d.7 (.2e2.4) d.8 (.4e1.8) d.1 (0.0e.9) d 0.0 (.e.) d.2 (0.0e1.4) d.2 (0.0e1.5) d 0.0 (.e.) d 0.0 (.e.) d 0.0 (.e.) d R.A. Arrzol et l. / Journl of Adolescent Helth 54 (2014) 54e60

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