Youth smoking rates in the United States have plummeted to historic lows—an unprecedented victory in tobacco control. Yet, public health seems oddly silent. Why is this monumental achievement not being celebrated?
Featuring:
DR. KENNETH WARNER
Dean Emeritus, Prof. Emeritus
School of Public Health, University of Michigan
sph.umich.edu
Transcription:
00:10
Brent Stafford: Hi, I'm Brent Stafford and welcome to another edition of RegWatch on GFN.tv. Something incredible has been happening with teen smoking in the United States and yet no one seems to be paying attention. Over the past few decades, youth smoking has declined so dramatically and so rapidly that it has nearly disappeared. So why then are public health agencies, tobacco control organizations and the media not celebrating this news? Joining us today to help unpack this question is Dr. Kenneth Warner, Dean Emeritus and Professor Emeritus with the School of Public Health at the University of Michigan. Dr. Warner, it's great to have you back on the show.
00:52
Kenneth Warner: Well, thank you. It's great to be back.
00:55
Brent Stafford: Dr. Warner, in your article published in the American Journal of Public Health, titled, Kids No Longer Smoke Cigarettes, Why Aren't We Celebrating?, you state, by any measure, youth smoking has nearly ceased to exist. Is this really the case?
01:13
Kenneth Warner: Absolutely. If you look at the data from both Monitoring the Future, which is a survey of drug use dating back to the mid-1970s, and the National Youth Tobacco Survey, a federal survey of kids' use of tobacco products, you see that it has plummeted. Smoking peaked in the mid-1990s. and has declined pretty steadily since then. And we're now down to a point where the numbers are simply vanishingly small.
01:46
Brent Stafford: Now, is it fair to say that today those smoking rates are so small that they're statistically irrelevant?
01:54
Kenneth Warner: Well, I'm pretty careful about throwing around the words statistically and irrelevant in the same voice. They statistically show up in the sense that we're looking at 1.4% of all middle and high school students in the United States having smoked in the past 30 days. And by the way, that doesn't mean that they're smoking all the time. That means that they've had at least a puff on one cigarette in the last 30 days. So that's 1.4%. That's a pretty trivial number. It's not trivial for the kids who are doing it. For them, it's a very serious issue. But when you look at problems that afflict our children, smoking, cigarette smoking is not one of them.
02:41
Brent Stafford: So what was the height in the 1990s?
02:45
Kenneth Warner: Well, if we take a look at some of the MTF data, the Monitoring the Future, it's really quite fascinating. If we look at past 30-day smoking, seniors in high school, so these are 18-year-olds, peaked in 1997 at a little over 36% of them having smoked in the past month. And in fact, over 20% of eighth graders, these are 14-year-olds, had smoked in the last 30 days. so those numbers have now come down to you know around one or two percent obviously 1.4 percent for the average across all grades uh so it's just dropped precipitously there's something that i like to look at that i think is maybe more important and that's daily smoking because that's an indication of people who are clearly dependent on cigarettes And when I say dependent, I'm not saying they're all physiologically addicted, but if they're doing this every single day, this is a big part of who they are. Let's take a little look at those numbers. High school seniors in 1997, 25% of them were smoking every single day. In 2023, the number is 0.7%. Now, let me put that in some perspective. Go back to 1997. We're looking at every four high school seniors was a smoker. Today, it's one out of every 143.
04:18
Brent Stafford: Dr. Warner, before we dive any further into our conversation, please take a moment to share with us a bit about your background and work in tobacco control research.
04:27
Kenneth Warner: Well, I was trained as an economist and I have been working on tobacco policy research since 1976. So my first publication on the subject was a year later, 1977. So I've been around for a few years working on tobacco control. And that's what I focused on most of my research for the last, What is that? Almost 50 years now. I have served in a variety of capacities in the field. I was the senior scientific editor of the 25th Anniversary Surgeon General's Report. I was the World Bank's representative to four of its six negotiating sessions on what became the Framework Convention on Tobacco Control. I just finished a term on the FDA's Tobacco Scientific, I'm sorry, Tobacco Control Scientific Advisory Committee. And I've been president of the International Society for Research on Nicotine and Tobacco.
05:29
Brent Stafford: Back to teen smoking, I guess I should mention I use teen a lot when I know that technically it should be youth, but youth also can include those over 21 to 25 or so. Maybe you might have a thought on that.
05:43
Kenneth Warner: Well, actually, the word I like is adolescent. which I think covers the age group pretty well because we are looking at something ranging from age 12 up through 18 typically. And certainly in Canada, where I believe your minimum age for purchase is 18, here it's now 21. 18 is a good logical cutting off point in part because it's the end of high school and the beginning of whatever follows at college or whatever the individual does thereafter. So I kind of like the word adolescent, but I use them reasonably interchangeably. I don't use teen because we are talking about some preteens and we're not talking about 19 year olds, for example.
06:26
Brent Stafford: Right. So the drop that we've been talking about here does, you know, go across the cohorts from middle school through to high school.
06:34
Kenneth Warner: Correct.
06:36
Brent Stafford: So let me ask you about the difference between past 30-day and daily. You mentioned it, and it's a bugaboo of mine because it's always seemed that you can get a really large number with the past 30-day, and that seems to be a weapon in this war of statistics.
06:53
Kenneth Warner: Well, the fact is that today you can't get a large number with past 30-day when you're looking at cigarette smoking. I might add, by the way, we've also seen cigar smoking plummeting. Those numbers are a little lower than cigarette smoking. And if you look at the kids' past 30-day use of any combustible tobacco product, I think that's 2.8%, if I recall, in 2024 from the most recent National Youth Tobacco Survey. The numbers are just, as I say, getting to be vanishingly small at this stage, even with past 30-day.
07:29
Brent Stafford: Dr. Warner, one of the areas you are widely known for is evaluating tobacco control interventions. Can you point to a specific intervention or interventions that are responsible for this collapse in adolescent smoking in the U.S.? ?
07:45
Kenneth Warner: Well, I think we have to give credit to all of the evidence-based tobacco control measures. The one that I'm perhaps most fond of, because I started working on it back in the early 80s, is cigarette price and tax. We know that kids are typically more price responsive than are adults. And in fact, young adults are more price responsive than older adults. So, as we have seen the price of cigarettes rising, and it has been rising faster than normal inflation, that certainly has been a deterrent for kids to smoke. But we've also seen clean indoor air laws, which a couple of decades ago or a few decades ago didn't exist and now are pretty pervasive. They've helped to establish a tone about what's acceptable. We've seen restrictions on marketing to kids. We have seen counter advertising in some instances by federal government agencies, CDC and the FDA, that probably have been effective on their own as well. I think it's fair to say all of these measures have contributed. As I said, we've been watching youth smoking drop steadily since the 1990s, the middle of the 1990s. It seems to have sped up of late, but it has been dropping pretty consistently all the way through. I think the bottom line is that this has led to social norm changes. And whereas in the 90s it was kind of cool to be a smoker, today it's considered just antisocial behavior. And you don't tend to see anybody doing it as a consequence. It's interesting, I won't get into the same detail, but it's interesting to think about the interaction between policies and social norm change. So as policies are adopted, they undoubtedly change norms. But as norms change, they change legislators' receptivity to adopting more policies. And we've seen these two things interacting and going back and forth over time.
09:52
Brent Stafford: I'm curious about that last bit. Can you expand on that?
09:57
Kenneth Warner: About how they interact?
09:58
Brent Stafford: Yeah, about how they interact. I mean, is it equally the interaction or are the legislators more or less likely to move as social norms move?
10:10
Kenneth Warner: I don't know that I can say which is more important than the other, but we certainly know that both are in effect. If you look, for example, at taxation, It is much lower in the major tobacco states in the Southeast than it is throughout the rest of the country. And the norms in the Southeast about smoking are very different than they are in the rest of the country. There was research probably going back four or five decades now that demonstrated that you tended to see higher taxes in states in which there were fewer smokers, proportionally fewer smokers. So while taxation reduces smoking, a reduced population of smokers increases taxes in effect. It gets the legislators more predisposed to use them.
10:59
Brent Stafford: So these changes to the landscape could certainly be seen as a win then for tobacco control, could they not?
11:06
Kenneth Warner: Absolutely.
11:07
Brent Stafford: So why then are they not patting themselves on the back and making sure that all Americans know about the win? I mean, the collapse in teen smoking is incredible news. I would imagine the CDC, FDA, and the Campaign for Tobacco-Free Kids, they must have organized a parade. When is it?
11:25
Kenneth Warner: Well, I don't know. I haven't received the invitation yet. To me, this is really fascinating and disturbing, frankly, because this is such a major development. I think, without a question of a doubt, this is one of the greatest public health achievements in the United States in the present century. And I would go so far as to say it may be one of the most important achievements in tobacco control in history, all of history. So yeah, we ought to be talking about it. We should be celebrating it, and we're not seeing that. The major organizations, like the Campaign for Tobacco-Free Kids, mentions it in passing when they mention it, if at all. The media can have covered the numbers when the numbers are released, but I have yet to see any major stories on this remarkable accomplishment. If you look at the government, we haven't heard much of anything from the federal government or the states, for that matter, about this triumph in public health. I was delighted to see earlier this week that the director of the Center for Tobacco Products, Brian King, issued in his blog a bit of a celebratory comment on the reduction in youth smoking. I would love to take credit for it. It did follow very soon after the publication of my paper in American Journal of Public Health, but I'm sure he gets other sources besides that as well. But I was pleased to see him mention it. That's the first mention that i've seen by a major governmental authority that is saying this is a major accomplishment now he went on to talk about remaining problems for example if you look at the last 30-day use of any tobacco product by kids a little over eight percent of kids have used a tobacco product over the last month now five years ago that number was something like 23%. So we've made enormous progress with all tobacco products in that sense. But that's still one out of 12 kids. And it's a reason that, you know, particularly if you think that all tobacco products are the same in terms of their dangers, which by the way, most Americans do believe. They believe that smokeless tobacco and e-cigarettes are as dangerous as or more dangerous than cigarette smoking. So if you have that belief, then the end of cigarette smoking is simply a step in the right direction. It's not by any means a solution. And I feel that I'm worried that many people, because they hold that belief, do see this as simply a step. And the other thing is, frankly, if you admit that this is a success and an enormous success, to some extent, you're kind of reducing the importance of what you're doing overall.
14:25
Brent Stafford: Why does this good news about teen smoking seem to be bad news for tobacco control?
14:31
Kenneth Warner: Well, in part, again, it has to do with the notion that all tobacco products are bad for kids and they're still around. A second reason is that nicotine has kind of become the villain of the piece now. And by the way, when we look at the data, once again, a majority of Americans believe that nicotine is the substance that's responsible for the smoking-produced diseases, the lung cancer, heart disease, chronic obstructive pulmonary disease. And when I say majority of Americans, I'm not referring simply to high school grads and the like. You can also say the same about doctors. There was a study published fairly recently that I found truly shocking when I saw it in response to the following question. The answers were most of the doctors thought that nicotine was a cause of these diseases. And the question was, do you believe that nicotine in and of itself or directly, I don't remember the wording, but it was qualified, is the cause of lung cancer, heart disease, chronic obstructive pulmonary disease? And a majority, and even a sizable majority, said yes. So doctors don't understand it. Nicotine is a substance that addicts people. It is not the substance that causes the disease. That comes from the other 7,000 chemicals in cigarettes or the much smaller numbers of chemicals in other tobacco products.
16:05
Brent Stafford: It's been four years since we first had you on the show, and you've been on a couple of times since then, but not for about two years, I'd say. We haven't spoken with you. Have you gotten more frustrated with this lack of understanding, say, amongst doctors and action on behalf of the federal agencies on correcting the misperceptions?
16:34
Kenneth Warner: I wouldn't say I've gotten more frustrated because two years ago I was plenty frustrated. I don't think this is something new. And actually, it's interesting. At one level, I'm less frustrated because we do see the progress that we've seen with youth use of tobacco products. We see substantial progress with regard to younger adults. with regard to combustible tobacco products. So as fast as smoking has been dropping among kids, it's been dropping precipitously among young adults as well. That's the group, of course, that has taken up vaping more than any other adult group. I would love to see some focus by the federal government on what essentially is the truth, and that is educating people about nicotine being an addictive substance but not the cause of these diseases, and in turn talking about things like e-cigarettes as possible solutions for a significant number of middle-aged and older adult smokers who thus far have not taken up these alternative products in large numbers. And we know, by the way, that e-cigarettes are For people who are smoking, e-cigarettes are the most commonly chosen method of trying to quit, and they are, by their self-reports, the most successful. So this is something we'd like to see for the more inveterate middle-aged and older smokers. Give them a try. Have them try it. And we're not seeing that.
18:12
Brent Stafford: Dr. Warner, is there a correlation between the rise in e-cigarette use with the collapse in teen smoking?
18:19
Kenneth Warner: There's a correlation. Is there causation? I don't think we have definitive proof of that. But let's go back to those numbers we were talking about earlier. If you take a look at either 30-day, past 30-day, or daily smoking, and look at the decline that we've observed since the mid-1990s, specifically if you take a look at the period of the first decade of the 2000s you'll see that that decline was ongoing but it was slowing up somewhat and then when we get into the decade of the 2010s looking at about say 2012 2013 which is when kids are first seriously you know getting exposed to e-cigarettes and getting interested in them we see an acceleration of the rate of decline It is, in fact, the case that smoking among kids dropped at its fastest rate ever precisely during the period of e-cigarettes' greatest popularity with kids. Now, is that causation? Could be. It could very well be that many of the kids who were smoking are vaping instead to get off of smoking. It could be that kids who would have smoked are vaping instead. We don't know that definitively. What we do know is that when vaping first came around, one of the three great concerns was expressed about it was it was going to renormalize smoking. And in fact, it's exactly the opposite. If anything, it has denormalized it further. But again, I am not, as a scientist, I'm not prepared to say that there's definitive proof. I can say there's very significant correlation, and I find that meaningful, and it leads me to a conclusion that vaping is likely contributing to the decrease in youth smoking.
20:11
Brent Stafford: Dr. Warner, you state in your paper that, quote, anyone concerned about youth tobacco product use may consider the demise of smoking per se only a step in the right direction. This is especially true for the many people, including public health professionals, who believe that smokeless tobacco products are as dangerous as smoking. You mentioned that earlier in the interview. Do you have more to say on that?
20:38
Kenneth Warner: Well, I mean, this is a long standing problem and it comes in part from the government. The government on its websites and its advertising and so on, when there were bigger problems with smokeless tobacco products, was saying smokeless tobacco is not a safe alternative to cigarettes. Now, that's probably true. Anything you put in your mouth and keep there for a while, other than food and even some foods, is probably hazardous to health. But it's nothing like what you experience when you're inhaling combusted tobacco. But the message implicitly was saying this is as bad as smoking. And people interpreted it that way. So there's a lot of corrective advertising that should be done here. You know, it's interesting. There was a major lawsuit against the cigarette manufacturers years ago that led to so-called corrective, it wasn't advertising, but corrective messages coming from them. The government should consider suing itself and have some corrective measures coming out too.
21:48
Brent Stafford: Dr. Warner, we've had you on the show previously talking about the need to find common ground amongst tobacco control and public health. Cliff Douglas has been on the show and talked about that too as well. Do these statistics, this huge drop, this dramatic and rapid decline in teen smoking, do they help build some bridges to create a better landscape for common ground?
22:12
Kenneth Warner: One would hope so. There have been some attempts recently to get people on both sides of the aisle to sit down and talk with each other. Not many. And I can't say that I've seen them lead to a lot of useful output. But I think in the future there is some potential for that. One of the major players in this is the Food and Drug Administration. Because the Center for Tobacco Products has recently given marketing-granted orders to a few brands of menthol e-cigarettes. And that means that they now have, I use the term loosely, but that they now have given some authority to a flavored form of e-cigarette. Previously, they had only approved a handful of tobacco-flavored e-cigarettes. So they're kind of in the position right now where they have acknowledged that some e-cigarettes are appropriate for the protection of the public health. Now, if that's true of some of them, it should probably be true of many of them, not all, because we know a lot of them coming over from China, for example, we have no idea what's in them. There's probably no concern about what's in them. Whereas many of the bigger, more notable domestic brands of e-cigarettes, people do pay attention to what's in them. So I think that FDA is now in a position where they're going to have to think seriously about how they want to pursue the issue of e-cigarettes. And they can shape opinion in the general public health community. Mind you, they take grief from both sides of the argument all the time. So they're in a tough position. And they're in a very bureaucratic position and a very political position. So it makes it difficult. But I think they now have kind of positioned themselves at a point where we'd like to see some constructive, collaborative discussion.
24:15
Brent Stafford: Going back to the comment around the misperceptions and the lack of kind of embrace around these numbers, Is there a tobacco control industrial complex that's trying to hold on to its rationalization for existence?
24:35
Kenneth Warner: Well, there is something of a tobacco control industry. All of us are to some extent a member of that, I guess. But we do know that there are organizations that are very dependent on former Mayor Bloomberg's largesse. And he himself has made some rather outlandish comments about e-cigarettes. uh the famous most famous one i suspect was on cbs uh this morning when he said would you like your daughter to lose 10 to 15 iq points because she vaped and matt myers was also on the show and the uh announcer was kind of dumbfounded by the statement and said matt is this true and matt who is ever the diplomatic attorney managed to sort of get around the question uh but uh Mr. Bloomberg is very fixed in his ways. A number of us have approached him and his team and asked him to sit down and have some conversations and to look at some of the data with us. They have refused to do so. So it's kind of anti-scientific and very distressing. How much... People like those who work at the Campaign for Tobacco-Free Kids are part of the tobacco industrial complex. I don't know what's fair. I don't want to besmirch their motivation. I think that they're all very well motivated. I think they've been misled in many ways. And this is like so many other issues. People are believing what they want to believe. And everybody can find published papers that will support the positions that they hold. I think I want to be real careful about saying anybody's doing this for money per se.
26:26
Brent Stafford: Is there anything wrong then with a 24-year-old who's never smoked who decides that they want to use nicotine for the benefits in which nicotine can provide without any of the dangers around combustible? I know that us, on our side of this issue, we have to start doing better work going, well, is recreational nicotine not what should be advocated for? Because that's really it. Otherwise, no new nicotine users can ever be acquired into the marketplace without it being a problem.
27:01
Kenneth Warner: Well, if you're going to look at the new nicotine products, the one that's most interesting in this regard is nicotine pouches. because they're almost certainly minimally dangerous in any way, shape or form. And they're delivering nicotine that I understand can be pretty good delivery system. It's not as fast as vaping or using a heated tobacco product because you're not inhaling it, but it can get nicotine levels up pretty high. The problem with the 24-year-old who's vaping and who's never smoked and had no interest in doing it is that he or she is exposing themselves to some level of risk. And it's an unknown level. We know that people in Great Britain were saying that it was 5% the risk of smoking. There are others whom I respect who say it might be 30%. uh my suspicion from my having queried many of my colleagues is if it's well below that but it might be 15 so in that sense that's probably not a good thing and i would not want to see a 24 year old doing that there are other ways of getting nicotine or other products that might help them with whatever whatever reason they need or want that would be less harmful. And again, nicotine pouchers are at the top of that. I was talking to a colleague recently who uses a nicotine spray, you know, one of the Nicorette products, who has never smoked and never had a desire to smoke, but has suffered from ADHD and found that it was helping her with her ADHD. So if there are benefits of that sort for something that's primarily just nicotine, so be it. When it comes to the idea of recreational nicotine, I know a lot of people are talking about this now. I'll be very candid with you as a public health professional. I don't care about that a whole lot. In the same sense that you know, I understand a lot of people love to ski, and they are subjecting themselves to some risks. But I don't care about I don't want to encourage skiing because it's fun. I don't want to discourage it. It's just not something that's of particular interest to me as a public health professional.
29:21
Brent Stafford: Let me ask you, Dr. Warner, are public health agencies recommending e-cigarettes to the millions of current smokers in the US? And if not, why not?
29:31
Kenneth Warner: Well, the moment you added US, I have to change my answer from yes to not really. We do know that, again, in the UK, that the public health authorities there are recommending them, and apparently with a decent degree of success. It's true in the UK, as it is in the United States, that more people who smoke use e-cigarettes in quit attempts and with greater success, self-reported success. So we have the same data, same kind of qualitative conclusions in both countries. I'm not aware of many people in the United States who fall into the category of governmental authorities or even major health organizations that are recommending that. I do know a significant number of people whom I consider to be experts in the field. You mentioned Dr. Rigotti, Dr. Benowitz, who are quite prepared to recommend that to their patients. And a lot of them are working with the major healthcare voluntaries to try to get them to see that that makes some sense.
30:38
Brent Stafford: So, Dr. Warner, as someone who spent decades fighting the battle against smoking, how does it make you feel to see the demise of youth smoking being overlooked?
30:51
Kenneth Warner: Well, as I say, it's disappointing to see it be overlooked. I have to say, as someone who has spent decades working in this area, I'm quite thrilled. I didn't know that I was gonna live long enough to reach this point. And I'm not that old yet, but I did not expect that. I don't think anybody expected to see youth smoking disappear as it has. If you look at the Healthy People 2020 and Healthy People 2030 reports, where they set what they believe to be ambitious goals for kids and adults, the goals for kids were so much higher than where we are. We've blown by them. And as I say, we've reached kind of almost an endpoint when it comes to combustible tobacco use among kids. And it's not the endpoint that we talk about with adult smoking, where we country several of them, maybe 10 or 11 now, they have a tobacco endgame goal, which is 5% prevalence of smoking. And we're getting close to that in countries like the US and the UK, Australia, many other countries now are down in the range of 10 to 14% of smoking. We are below 11% in the United States. That's both daily and non-daily smoking. At the rate that we're watching this decline, by the end of the decade, I would expect that number to be down probably in the range of 7% or so. So we're actually approaching what people have referred to as the end game goal. It's not a good end game goal and we're going to have to rethink it because what it's ignoring is the fact that when we look at our 10 or 11% adult smoking prevalence in the United States, There are multiple groups of people, marginalized groups of society, American Indians, people who have mental health problems, people from low socioeconomic backgrounds, military veterans. You can list a good eight, nine, ten of these groups for whom the smoking prevalence is at least twice that of people who don't belong to these groups. So we have to recognize that 10% or 11% represents a range from almost zero up to 20 or 30% for different groups. So we got a long way to go with that, but we're actually well beyond what I would have expected two decades ago. So I feel good about that. I would like more acknowledgement of it, but the numbers don't lie.
33:32
Brent Stafford: Final question, Dr. Warner, the 12th edition of the Global Forum on Nicotine, the annual conference on safer nicotine products takes place again this year in Warsaw, Poland from June 19 to 21. The conference theme is challenging perceptions. In your mind, what are some solutions to addressing the misunderstandings, misconceptions and mischaracterizations that are holding back progress for safer nicotine products?
34:00
Kenneth Warner: I wish that I had good answers for that. I think the simple and probably correct answer is that we need authoritative bodies not only to speak the truth, but to speak it loudly. So it would be very helpful if CDC, FDA, and the other major agencies in the United States would talk about the difference between nicotine as a cause of disease and nicotine as a cause of addiction. It would be very useful if they would talk about the continuum of risk and the fact that cigarettes are way up at the top, way ahead of any other tobacco product. And down at the bottom, we've got things like the Nicorette gum and the pouch. And then close to that, presumably, are e-cigarettes and maybe a bit above that, maybe heated tobacco products. And then you start moving quite a ways up when you get to cigars and other combustibles. So simply getting people to understand that there's a gigantic difference between combusted and non-combusted tobacco. would be very valuable. And it's got to come from the people who have a visible presence and a voice. And that's who we're talking about here.