While cigarette smoking has declined significantly during the past 40 years, use of other tobacco products is increasing—particularly among young people.110 These include:
- Cigars: tobacco wrapped in leaf tobacco or another tobacco-containing substance instead of paper, which can be bought individually
- Cigarillos: small cigars that cost less and are also available for purchase individually
- Hookahs or waterpipes: pipes with a long, flexible tube for drawing smoke from lit, flavored tobacco through water contained in a bowl
- Smokeless tobacco: products like chewing tobacco and snuff that are placed in the mouth between the teeth and gums
- Powder tobacco: mixtures that are inhaled through the nose
In 2014, almost one-quarter of high school students reported past-month use of a tobacco product—with e-cigarettes (13.4 percent), hookahs (9.4 percent), cigarettes (9.2 percent), cigars (8.2 percent), smokeless tobacco (5.5 percent), and snus (moist powder tobacco) (1.9 percent) as the most popular.17
Cigars
In 2016, an estimated 12 million people aged 12 or older (4.6 percent of the adolescent and adult population) smoked cigars during the past month.7 The majority of adolescents and young adults who smoked cigars also smoke cigarettes.111
Cigarillos
Data from the Tobacco Use Supplement to the Current Population Survey and NSDUH suggest that younger and less economically advantaged males initiate tobacco use with cigarillos.111 From 2002 to 2011, past-month cigarette smoking declined for males and females of all age groups. However, during this same period, rates of cigarillo use among males aged 18 to 25 remained constant (at approximately 9 percent).111
Hookahs or waterpipes
Between 2011 and 2014, use of hookah increased among middle and high school students, despite decreased use of cigarettes and cigars, according to the NYTS.17 Research also suggests that rates of hookah use for tobacco smoking increase during the first month of college.112 Nationally representative data from college students indicate that daily cigarette or cigar smokers (as well as marijuana users) were more likely to be frequent waterpipe users.113
Hookah users may mistakenly believe that it is less addictive or dangerous than cigarettes; however, one session of hookah smoking exposed users to greater smoke volumes and higher levels of tobacco toxicants (e.g., tar) than a single cigarette.114 Additionally, hookah smoking is linked with nicotine dependence and its associated medical consequences115,116 (see "What are the physical health consequences of tobacco use?"). Reviews of the literature on waterpipe users suggest that like those who use other forms of tobacco, many have tried to quit but have been unsuccessful on their own.115 These findings indicate the need for tobacco control policies and prevention and treatment interventions for this form of nicotine delivery that are similar to those seen for cigarettes.
Smokeless tobacco
In 2016, 8.8 million people aged 12 or older (3.3 percent of this population) used smokeless tobacco during the past month.7 Overall, use of smokeless tobacco among adults decreased from 1992 to 2003 but has held constant since.117 Longitudinal data suggest that people are more likely to switch from smokeless tobacco use to cigarette smoking than vice versa.118 Although smokers may attempt to use smokeless products to cut down or quit, research suggests that this approach is not effective.116 However, some argue that using smokeless tobacco in lieu of cigarettes may help reduce the harms associated with smoking traditional cigarettes.119
Polytobacco Use
Some users of tobacco consume it in multiple forms (polytobacco use); this behavior is associated with greater nicotine dependence120 and the risk for other substance use disorder.72 Analyses of a decade of data from NSDUH found steady rates of polytobacco use from 2002 to 2011 (8.7 percent to 7.4 percent) among people age 12 and older. However, use of some product combinations—such as cigarettes and smokeless tobacco, cigars and smokeless tobacco, and use of more than two products—increased over that period.120
Among individuals younger than 26, rates of polytobacco use increased despite declines in overall tobacco use. Polytobacco use was associated with being male, having relatively low income and education, and engaging in risk-taking behaviors.120 In 2014, an estimated 2.2 million middle and high school students had used two or more types of tobacco products during the past month, according to the NYTS.121 Polytobacco use was common, even among students who used tobacco products 5 days or fewer during the past month.121 The 2012 NYTS had found that 4.3 percent of students used three or more types of tobacco. This study also observed that male gender, use of flavored products, nicotine dependence, receptivity to tobacco marketing, and perceived peer use were all associated with youth polytobacco use.122
Flavored Tobacco Use Among Adolescents and Young Adults
One specific concern about e-cigarettes and tobacco products like cigarillos and hookahs is the addition of flavorings, which may make them particularly appealing to youth.17,111 The Family Smoking Prevention and Tobacco Control Act of 2009 banned the sale of cigarettes with flavors other than menthol, but other flavored tobacco products (e.g., small cigars, cigarillos, and smokeless tobacco) can still be sold. Adding flavors to tobacco products or to the nicotine solution of e-cigarettes can make them more appealing to some users because they can mask the harsh taste.108,123 Although more research is needed on how flavors affect long-term use, health experts have expressed concerns that many of the flavorings used in tobacco products are also found in candies and beverages.124 Such flavors may make them more appealing to youth and may contribute to increased use of these products among young people.
Approximately 6.3 percent of middle and high school students reported using either flavored cigarettes or small cigars, according to the 2011 NYTS.125 Data from the 2014 NYTS indicate that of middle and high school students who currently used tobacco, about 70 percent—an estimated 3.26 million youths—had used at least one flavored tobacco product during the past month.126 Among past-month users, the most commonly used flavored products were e-cigarettes, hookah tobacco, and cigars.126 It seems that youth may not necessarily “grow out of” using flavored tobacco products. Among young adults aged 18 to 34, nearly one-fifth (18.5 percent) of those who use tobacco, consumed flavored (including menthol) products.127