Tobacco Product Use Among Youths With and Without Lifetime Asthma — Florida, 2016

The increasing availability of diverse tobacco products has led to complex tobacco product use patterns among youths (1). Use by youths of products containing nicotine in any form is unsafe (2); among young persons with asthma, use of combustible tobacco products, particularly cigarettes, is associated with worsening symptoms, poor asthma control, and an increased need for medical management (3,4). Studies suggest that youths with asthma adopt health risk behaviors, including tobacco product use, at rates similar to or higher than those of youths without asthma (3–7); however, these studies are often limited to a partial list of tobacco product types among high school students. To assess current use (≥1 days during the past 30 days) of one or more of five tobacco product types (cigarettes, electronic cigarettes [defined as e-cigarettes, e-cigars, vape pipes, vaping pens, e-hookah, and hookah pens], hookah, smokeless tobacco, or cigars) among Florida middle school (grades 6–8) and high school (grades 9–12) students with or without a previous medical diagnosis of asthma, the Florida Department of Health analyzed data from the 2016 Florida Youth Tobacco Survey (FYTS). In 2016, 11.1% of middle school and 27.9% of high school students with asthma, and 7.9% of middle school and 24.2% of high school students without asthma, reported any current tobacco product use. Current use of each tobacco product type was considerably higher among students with asthma than among those without asthma. E-cigarettes were the most commonly used tobacco product type reported by middle and high school students with asthma (7.9% and 19.6%, respectively) and without asthma (5.8% and 17.2%, respectively). Statewide tobacco prevention strategies could help reduce all forms of tobacco product use among youths, particularly among those with asthma.

FYTS is a cross-sectional, school-based, pencil-and-paper questionnaire administered to Florida public middle school and high school students.* The consent process for the FYTS is dependent upon the school district administering the survey. Several districts use an active permission form; however, most districts obtain parental consent through passive permission forms that instruct parents to sign the form only if they wish to opt their child out of participation. Student participation is voluntary. Information is collected on indicators of tobacco product use, perceptions of harm, and exposure to secondhand smoke to monitor and guide tobacco prevention and control policies and strategies in Florida. A two-stage cluster probability sampling procedure was used to generate a statewide representative sample of Florida students attending public schools in grades 6–12. Data were self-reported, and no identifying information was collected from participating students. In 2016, a total of 36,082 middle and 33,558 high school students participated in the surveys; combined student and school response rates were 78.0% and 71.0%, respectively (8).

Lifetime asthma status was assessed with the question “Has a doctor or nurse ever told you that you have asthma?” Response options were “yes,” “no,” and “not sure.” Students who responded “yes” were categorized as having asthma; all other responses were categorized as not having asthma. Students who did not answer the question (9.8%) were excluded from analyses. Current use of tobacco products, defined as use on ≥1 days during the past 30 days, was measured for cigarettes, e-cigarettes,^† hookah (water pipes),^§ smokeless tobacco products (chewing tobacco, snuff, or dip), and cigars (cigars, cigarillos, or little cigars).^¶ “Any tobacco product use” was defined as current use of ≥1 tobacco products, and “multiple tobacco product use” was defined as current use of ≥2 products.

Data were statistically weighted to yield representative estimates of Florida middle and high school students attending public schools. Prevalence estimates and corresponding population counts were calculated for current tobacco product use overall and by school level (middle or high) among students with or without asthma. Rao-Scott modified chi-square tests were performed to assess statistically significant differences between students with or without asthma; p values of <0.05 were considered statistically significant.

In 2016, 19.5% of middle and 20.6% of high school students in Florida reported lifetime asthma (Table 1). Approximately 190,000 middle and high school students in Florida (8.5% and 24.9%, respectively) reported current use of any tobacco product in 2016, with approximately 86,000 (3.1% and 9.0%, respectively) reporting multiple tobacco product use.

Current use of each tobacco product type was higher among middle and high school students with asthma than among those without asthma (p<0.05) (Table 2). Among students with asthma, 11.1% of middle (approximately 10,000) and 27.9% of high school (34,000) students reported current use of any tobacco product. Conversely, 7.9% of middle (30,000) and 24.2% of high school (116,000) students without asthma reported current use of any tobacco product. Among current users with asthma, 4.2% of middle (4,400) and 10.9% of high school (17,000) students reported multiple tobacco product use, compared with 2.8% of middle (12,000) and 8.6% of high school (52,000) students without asthma. During 2016, e-cigarettes were the most commonly used tobacco product type among middle (7.9%) and high school (19.6%) students with asthma, followed by hookah (3.8% and 9.7%), cigars (2.3% and 7.3%), cigarettes (2.2% and 5.7%), and smokeless tobacco (2.1% and 4.3%).

Acknowledgments

Richard Vogt, Colorado School of Public Health, Denver, Colorado.

Corresponding author: Keshia M. Reid, Keshia.Reid@flhealth.gov, 850-245-4917.

¹Florida Department of Health.

References

1. Lee YO, Hebert CJ, Nonnemaker JM, Kim AE. Youth tobacco product use in the United States. Pediatrics 2015;135:409–15. CrossRefexternal icon PubMedexternal icon
2. CDC, National Center for Chronic Disease Prevention and Health Promotion. E-cigarette use among youth and young adults: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion; 2016. https://e-cigarettes.surgeongeneral.gov/documents/2016_SGR_Full_Report_non-508.pdfpdf iconexternal icon
3. Dowdell EB, Posner MA, Hutchinson MK. Cigarette smoking and alcohol use among adolescents and young adults with asthma. Nurs Res Pract 2011;2011:1–7. CrossRefexternal icon PubMedexternal icon
4. Kit BK, Simon AE, Brody DJ, Akinbami LJ. US prevalence and trends in tobacco smoke exposure among children and adolescents with asthma. Pediatrics 2013;131:407–14. CrossRefexternal icon PubMedexternal icon
5. Choi K, Bernat D. E-cigarette use among Florida youth with and without asthma. Am J Prev Med 2016;51:446–53. CrossRefexternal icon PubMedexternal icon
6. 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;26:865–9. CrossRefexternal icon PubMedexternal icon
7. Martinasek MP, Gibson-Young L, Forrest J. Hookah smoking and harm perception among asthmatic adolescents: findings from the Florida youth tobacco survey. J Sch Health 2014;84:334–41. CrossRefexternal icon PubMedexternal icon
8. ICD International. Florida Youth Tobacco Survey: sampling, weighting, survey retrieval and response rate report. Fairfax, VA: ICD International; 2016.
9. Semic-Jusufagic A, Custovic A. Active smoking among asthmatic youth—how concerned we need to be. Int J Chron Obstruct Pulmon Dis 2007;2:3–4. CrossRefexternal icon PubMedexternal icon
10. Tyc VL, Throckmorton-Belzer L. Smoking rates and the state of smoking interventions for children and adolescents with chronic illness. Pediatrics 2006;118:e471–87. CrossRefexternal icon PubMedexternal icon

Abbreviation: CI = confidence interval.
* Asthma was defined as a “yes” response to the question “Has a doctor or nurse ever told you that you have asthma?”
^† Weighted to yield representative estimates of Florida middle and high school students attending public schools.

Abbreviation: CI = confidence interval.
* Current cigarette use was defined as having smoked cigarettes on ≥1 days during the past 30 days; current electronic cigarette use was defined as having used an electronic cigarette on ≥1 days during the past 30 days; current hookah use was defined as having smoked tobacco from a hookah or water pipe on ≥1 days during the past 30 days; current smokeless tobacco use was defined as having used chewing tobacco, snuff, or dip on ≥1 days during the past 30 days; current cigar use was defined as having smoked cigars, cigarillos, or little cigars on ≥1 days during the past 30 days.
^† Having asthma was defined as a “yes” response to the question “Has a doctor or nurse ever told you that you have asthma?”
^§ Use of each tobacco product type significantly differed by asthma status: Rao-Scott chi-square test; p value <0.05.
^¶ Weighted to yield representative estimates of Florida middle and high school students attending public schools.
** Any tobacco product use was defined as having used cigarettes, electronic cigarettes, hookah, smokeless tobacco, or cigars on ≥1 days during the past 30 days.
^†† ≥2 tobacco product use was defined as having used two or more tobacco products (cigarettes, electronic cigarettes, hookah, smokeless tobacco, or cigars) on ≥1 days during the past 30 days.