Youth Nicotine Use

        This vital sign measures the percentage of Tennessee high school students currently using cigarettes and e-cigarettes. Nearly 9 out of 10 current smokers try their first cigarette before they turn 18. Since youth who smoke face an elevated risk of chronic lifetime smoking and the associated smoking-related diseases, this Vital Sign is an important indicator of the future personal and societal costs posed by tobacco-related diseases. 

        Youth Nicotine Use is broken into two measures—high school student cigarette use and high school student electronic nicotine delivery systems (ENDS) use, including e-cigarettes. The first indicator measures the percentage of high school students who smoked cigarettes on at least one day during the thirty days before the survey (9.4%). The second indicator measures the percentage of high school students who used ENDS (e-cigarettes, e-cigars, e-pipes, vape pipes, vaping pens, e-hookahs, and hookah pens) on at least one day during the 30 days before the survey (11.5%). E-cigarettes, while often marketed as the safe alternative to cigarettes, are addictive since they contain liquid nicotine and other potentially harmful chemicals. Even though e-cigarettes do not actually emit smoke, there is also a link between e-cigarette use and tobacco cigarette use in youth. Additionally, ENDS have been linked to lung illnesses and even occasional deaths-- this condition has been termed "e-cigarette or vaping product use-associated lung injury" or EVALI by the CDC.   

        Rates of chewing tobacco and cigar use are not captured by these measures, though they are both forms of nicotine use and can elevate the risk of serious health outcomes. Both of these metrics were developed using data collected in the 2017 Youth Risk Behavior Survey. 

        Tobacco is the most preventable cause of premature mortality and morbidity in Tennessee and in the U.S.A. Every year in the U.S., cigarette smoking is linked to more than 278,000 deaths among men and more than 201,000 deaths among women, and more than 40,000 deaths from second-hand smoke. The short-term and long-term health consequences of tobacco use can include cancer, heart disease, chronic obstructive pulmonary disease (COPD), stroke, and diabetes. Preventing tobacco initiation among youth is critical to preventing future morbidity and mortality in Tennessee. If cigarette smoking continues at the current rate among youth in this country, 5.6 million of today’s Americans younger than 18 years of age will die early from a smoking-related illness. In addition to health consequences for the smoker, tobacco use during pregnancy is a well-known risk factor for infant mortality and certain birth defects. 

        In 2017, the rate of cigarette use among Tennessee high school students was 9.4% and falling. However, the rate of e-cigarette use among Tennessee high school students was 11.5% and rising. Reducing the rate of youth nicotine use in communities across Tennessee is crucial for the long-term health of today’s youth and for future generations, as having a parent who smokes is a significant risk factor for youth nicotine use. 

        Nationally, male students are more likely to smoke both cigarettes and e-cigarettes than female students. Tobacco use is higher nationally among White and Hispanic students than it is among Black students. However, it is important to note that Black Americans are more likely to begin smoking as adults than White or Hispanic Americans. Despite initiating smoking later in life, Black Americans are more likely to die from smoking-related diseases than White or Hispanic Americans.  

        Youth nicotine use remains higher among low-income youth and youth whose parents have low levels of education. Venues selling tobacco products are found at a higher density in low-income neighborhoods than in higher income neighborhoods. Additionally, low-income families and those with less than a high school degree have a higher incidence of lung cancer, so they are more likely to suffer the negative effects of smoking than higher income and higher educated populations.  

        People living in rural areas have higher rates of smoking than people living in urban areas, and this applies to high school students as well as adults. In addition, smokers living in rural areas are more likely to smoke 15 or more cigarettes daily and are less likely to have access to programs that will help them quit. Furthermore, Tennessee’s rural populations often have challenges in accessing healthcare and are more likely to suffer from negative health outcomes due to smoking, as illustrated by the fact that rural populations have 18–20% higher rates of lung cancer than urban populations.  

        Students with mental health problems or who have experienced trauma or Adverse Childhood Experiences (ACEs) are more likely to use nicotine than the general population. The LGBTQ population is also considered especially vulnerable due to high rates of substance abuse, depression, HIV infection, and social and employment discrimination, all of which are associated with higher smoking prevalence. 

        The tobacco industry has historically targeted many of these populations with advertisements tailored to that specific population’s lifestyle, dynamic societal expectations, or preferences. For example, youth were intentionally targeted in the development and advertising of flavored tobacco products. The tobacco industry has similarly targeted people with mental health problems by making financial contributions to organizations that work with mentally ill patients.  

Vital Sign Actions Guide

The following are lists of intervention strategies that you, your health council, and other local stakeholders could use to address youth nicotine use in your community.  


1. BABY & ME Tobacco Free 

BABY & ME Tobacco Free is an evidence-based program based in Tennessee’s County Health Departments that helps pregnant women stop using tobacco during pregnancy and continue to remain tobacco-free post-partum. The program involves prenatal counseling sessions with trained healthcare providers, carbon monoxide monitoring and incentives for testing tobacco-free. Women who quit using tobacco may earn vouchers for diapers and baby wipes during the third and fourth pre-natal visit and once a month through twelve months postpartum. Promotion of this program at primary care facilities and businesses that serve pregnant women can help increase the number of women who enroll and quit using tobacco. 


2. CATCH My Breath (School Curriculum) 

CATCH My Breath is an electronic cigarette prevention program tailored for middle- and high-school students. This curriculum was created at the University Of Texas School Of Public Health and is supported by the CVS Health Foundation. This free curriculum consists of four lessons, each lasting 30-40 minutes.


3. Community Anti-Drug Coalition 

Community coalitions organize a group of stakeholders and organizations with the common goal of reducing substance use disorders, including nicotine dependence, and their long-term health consequences. Youth who become addicted to nicotine at a young age may become addicted to other substances more easily in the future, due to chemical changes in the brain. The Tennessee Department of Mental Health and Substance Abuse Services offers resources and recommendations on creating an effective coalition in your county or community. Additionally, partnering with existing Anti-Drug Coalitions in programming and educational campaigns is a great way to increase community outreach. 


4. Good Behavior Game 

The Good Behavior game is an intervention that can be implemented in the classroom to improve behavior and academics. This program is recommended by the Substances Abuse and Mental Health Service Administration (SAMHSA). Evaluation shows that Good Behavior Game participants show decreased tobacco and alcohol use, decreased illicit drug use, and reduced use of services for drug abuse. 


5. LifeSkills Training 

LifeSkills Training is a school-based prevention program targeting middle school adolescents. This 3-year program trains students in self-management skills, social skills, and drug awareness and resistance skills, including tobacco. LifeSkills Training is rated by Blueprints Programs as a Model Plus program and rated 3.9-4.0 by SAMHSA.


6. Voluntary No Smoking Areas/Young Lungs At Plays Signs 

Evidence shows that policies restricting tobacco use (smoking) in public places, both indoor and outdoor, decreases exposure to secondhand smoke and the prevalence of tobacco use. Due to Tennessee’s preemption laws, smoking is currently allowed in outdoor public spaces. Signage that promotes voluntary no-smoking areas has potential to increase support to tobacco bans and decrease exposure to secondhand smoke. One example of this signage is the “young lungs at play” campaign that reminds the public that secondhand smoke is harmful to children.


1. BlueCross BlueShield Grants

Purpose: BlueCross BlueShield of Tennessee awards funding for programs that help to create active, healthy spaces across the state. BCBS manages two funding opportunities—BlueCross Healthy Place and Community Trust grants. See the source below for specific funding criteria and exclusions. 

Duration: Varies 

Amount: Varies 


2. Community Foundations

Purpose: Community Foundations offer small grants that focus on community-driven change in Tennessee. The Community Foundations in Tennessee include Appalachian Community Fund, The Community Foundation of Greater Chattanooga, Community Foundation of Greater Memphis, Community Foundation of Middle Tennessee, Knox County Community Foundation, and East Tennessee Foundation. Most of these foundations consider healthy youth development as a focus area of grant funding. Counties can search for other local community foundations in addition to those listed here. 

Duration: Varies 

Amount: Varies 


3. Environmental Justice Small Grants Programs 

Purpose: The U.S. Environmental Protection Agency (EPA) funds the Environmental Justice Small Grants Program to support local initiatives that educate and engage communities on environmental and public health issues. Tobacco use is related to environmental protection in a number of ways—second hand smoke detracts from the air quality, and can cause asthma in non-smokers, while cigarette butts are harmful to the physical environment. Counties may consider adding tobacco cessation and prevention to their environmental justice initiatives. 

Duration: One year 

Amount: Up to $30,000 


4. Robert Wood Johnson Foundation

Purpose: These grants are focused on health systems, “healthy children, healthy weight”, healthy communities and healthy leadership. The Robert Wood Johnson Foundation focuses on tobacco control through research and campaign support.

Duration: One to three years

Amount: $50,000-$300,000 (average)


5. The HCA Foundation 

Purpose: The HCA Foundation promotes health and wellbeing, childhood and youth development, and the arts in middle Tennessee communities through grant funding administration. Organizations must be 501(c)3 nonprofits in the Middle Tennessee area (see the website for eligible counties) to apply.

Duration: Varies 

Amount: Varies


6. Tobacco-Free Generation Campus Initiative Grant Program 

Purpose: The Tobacco-Free Generation Campus Initiative Grant Program is administered by the American Cancer Society, with support from the CVS Health Foundation. The goal of this program is to increase the number of 100% smoke- and tobacco-free college and university campuses across the United States. 

Duration: One year 

Amount: $8,000-$20,000


7. W.K. Kellogg Foundation 

Purpose: Funding from the Kellogg Foundation is focused on educated kids, healthy kids, secure families, community and civic engagement, and racial equity. This foundation funds programs that fight youth tobacco use including educational campaigns and school-based programming.

Duration: 6 months to 5 years

Amount: $10,000 to $5 million 


1. Great American Smokeout 

The American Cancer Society promotes November 15 as the Great American Smokeout, an event that encourages current tobacco users to make the choice to quit. The campaign website provides cessations tools for tobacco users, resources for employers to help their employees quit using tobacco, and downloadable bilingual campaign resources.


2. Kick Butts Day 

The Campaign for Tobacco-Free Kids promotes Kick Butts Day on March 20 across the United States. The goals of this campaign are to raise awareness about the harmful effects of tobacco, to educate local leaders, and to prevent youth tobacco use. For a map of events and a campaign toolkit, visit the website Kick Butts Day website.


3. Promote the TN Quitline and Smokefree TXT

The TN Quitline is a resource for Tennesseans who wish to quit using tobacco products. The Quitline provides counseling to smokers as young as age 13 through a toll-free phone line, and online resources such as tips and a smoking calculator.


4. Smokefree Teen provides tips, information, and resources for current tobacco users, while providing extra support for teens, veterans, women, Spanish language speakers, and seniors over 60. Promoting the Smokefree Teen website to teens that currently use any form of tobacco can help them to access resources such as a texting cessation program, online chat with an expert, and social media accounts to connect with peers. 


5. Tennessee Quit Week

Tennessee Quit Week is held each year in February and is supported by the Tennessee Department of Health. This campaign aims to encourage current tobacco users to quit using tobacco products. Click on the link for materials and resources. 


6. The Real Cost 

The FDA launched “The Real Cost” campaign as a way to combat youth cigarette smoking, smokeless tobacco use, and e-cigarette use. This campaign seeks to educate middle and high school students about the dangers associated with tobacco use in all of its forms. Click on the link for video ads, digital and social media resources, and other materials. 


7. Through With Chew Week 

Through With Chew week encourages individuals to “break up with tobacco” the week of Valentine’s Day. The objective of this campaign is to educate people about the dangers of smokeless tobacco. 


8. Tips From Former Smokers (CDC)

Tips From Former Smokers is an ad campaign that shows the adverse health outcomes of using tobacco. Videos show how cancer, heart disease, stroke, buerger’s disease, gum disease, and other long-term health effects can change the lives of both smokers and those who suffer exposure to secondhand smoke. The goals of this campaign are to inform the public of the risks of tobacco and to encourage current users to quit using tobacco. Click on the link for campaign materials and social media resources. 



TNSTRONG (Tennessee Stop Tobacco and Revolutionize Our New Generation) is an anti-tobacco campaign targeting youth in Tennessee that is supported by the Tennessee Department of Health. This campaign involves youth ambassadors that help spread messaging, a three day youth summit each summer, and additional messaging such as the “Strike Out Tobacco” campaign that targets youth baseball teams. 


10. Truth Initiative Texting Program 

The Truth Initiative offers a texting program that teens can enroll in to help quit using e-cigarettes. Teens can text "QUIT" to (202)804-9884 to enroll in the program for tips and encouraging texts to help them quit. Teens can also utilize the This Is Quitting mobile app and the BecomeAnEX digital plan through the Truth Initiative. 


11. World No Tobacco Day 

World No Tobacco Day is held on May 31st each uear and is sponsored by the World Health Organizations. This campaign serves as a call to action, advocating for tobacco reduction policies and programming. 


12. Youth Education Campaign 

The Stanford School of Medicine offers free resources for educational lessons that can be taught to youth in various settings, including school, after-school programs, faith-based programs, etc. The Tobacco Prevention Toolkit includes lessons on general tobacco use, e-cig use, smokeless tobacco, the dangers of nicotine addiction, and positive youth development skills. Additionally, the CDC provides free campaign materials and ads through the Media Campaign Resource Center.


1. Advocate for Price Increase on Tobacco Products 

The most effective way to decrease the number of youth who begin smoking tobacco is through price increases of tobacco products. In Tennessee, state tobacco taxes preempt local taxes. However, community members can lobby their local legislators for increases in the state tobacco tax.


2. Advocate for Tobacco 21 Policies and Enforcements 

More than 95% of adult smokers start using tobacco before they turn 21. Over 450 cities and counties in 26 states have already raised the minimum age to purchase tobacco to 21. While Tennessee’s state preemption laws currently don’t allow counties to raise the minimum age to purchase tobacco, community members can lobby their legislature in support of tobacco 21 laws. Advocating for tobacco age increases should include advocating for enforcement measures.


3. Gold Sneaker Policies 

The Gold Sneaker initiative is a voluntary certification program that provides policy and programming recommendations to licensed child care facilities in Tennessee. These policies aim to set standards regarding daily physical activity, nutrition requirements, screen time limits, and other health-promoting behaviors such as tobacco policies in schools and child care facilities. Gold Sneaker is managed and funded through the Department of Health.


4. Preemption Lobbying 

Preemption is often cited as one of the greatest limitations to local regulations on tobacco. When state laws precede the authority of local laws, preemption takes place. State laws ban smoking inside certain establishments, including most workplaces and restaurants (with several exceptions) but allow smoking in most public outdoor areas, including parks and public playgrounds. Thus, Tennessee’s state laws preempt any local laws that would prohibit smoking in outdoor areas. State laws also preempt youth access (tobacco age limits) and tobacco pricing laws. Community members can lobby Tennessee legislators to change preemption laws, following the example of many other states.


5. Smoke-Free Policies in Private Multi-Unit Housing

Individuals and families living in Multi-Unit Housing (MUH) may suffer from secondhand smoke when tenants in neighboring units are permitted by the rental organization or landlord to smoke tobacco. There are several benefits to both the rental agencies and the tenants when smoking tobacco is prohibited, including protection from secondhand smoke, rental appeal, reduced risk of fire, etc. See the sources below for more information on the benefits of tobacco-free policies in MUH and how to best implement these policies


6. Tobacco-Free College Campuses 

Policies on college campuses should be updated to prohibit use of all forms of tobacco. While policies related to public colleges and universities in Tennessee are limited due to preemption laws, campus policies can still reflect a “voluntary” tobacco ban in an effort to change a system-wide culture. See the source below for evidence and resources, including tobacco policies at Belmont University and UT Martin as examples of how Tennessee colleges are regulating tobacco on campus.


7. Tobacco-Free School Policies

Individual schools and local school boards can update their policies to include Electronic Nicotine Delivery Systems in the tobacco section. Electronic cigarettes are easily concealed and often look like pens or USB drives, making it easy for students to use them at school. Policies should address the use and possession of tobacco products in all forms. See the source below for a sample school policy. 


1. Screening for Tobacco Use/5 A's or 2 A's and R 

The American Academy of Pediatrics recommends that care providers screen adolescents, as well as their care takers, for tobacco use including electronic forms of tobacco. Policies should ensure that care providers follow the “5 A’s” approach to assessing tobacco use and promoting cessation. Additionally, patients’ caretakers that use tobacco should also be referred to cessation counseling. The CDC also recommends an abbreviated version of the 5A’s—the 2A’s and R screening methods. 


*State employees are prohibited from engaging in
political activity not directly a part of that person’s employment during any
period when the person should be conducting business of the state (Tenn. Code
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This document is not a Department endorsement of legislative policy.