INTRODUCTION

In 2015, we published an article in this journal highlighting changes in tobacco use among Mississippi youth following the 1997 Settlement of Mississippi’s Medicaid Lawsuit and subsequent tobacco prevention initiatives in this state.¹ With the increasing popularity of e-cigarettes, the landscape of tobacco use among our youth has changed in the eight years since our original article.

To briefly recap, a successful lawsuit against the tobacco industry requesting monetary compensation for Medicaid expenses caused by tobacco products led to a settlement in 1997. Some of the funds from this settlement were applied to support statewide tobacco control programs. From 1998 to 2007, the Partnership for a Healthy Mississippi coordinated the state’s comprehensive tobacco prevention programs, focusing primarily on youth from kindergarten through high school. The funds for the Partnership were appropriated by the Chancery Court. In June 2007, the Mississippi Supreme Court determined that only the Mississippi Legislature could appropriate funds to tobacco prevention programs, and state support for the Partnership’s tobacco control programs ceased. In FY2008, the Mississippi Legislature appropriated $8 million for the Mississippi State Department of Health (MSDH) to create a state tobacco prevention and cessation program within the Office of Tobacco Control.¹ Support for this office continues through the present.

To support surveillance and evaluation of the statewide tobacco control programs, the MSDH began administering the annual Mississippi Youth Tobacco Survey (YTS) to middle and high school students in 1998. The YTS is a school-based comprehensive tobacco survey administered annually to Mississippi public high school students. The Mississippi State University Social Science Research Center began collaborating with the MSDH to conduct this survey in 2002 and has led this project since 2003.

The Office of Tobacco Control, Mississippi State Department of Health

Mississippi has an active statewide tobacco prevention program. Created in 2008, the Office of Tobacco Control leads the statewide tobacco prevention programs and supports state and community interventions to encourage and promote tobacco-free lifestyles. Local tobacco-free coalitions sponsored by the Office of Tobacco Control work to prevent the initiation of tobacco use among youth, reduce exposure to secondhand smoke, promote tobacco cessation services, and eliminate tobacco-related disparities. Systems change programs support tobacco control initiatives across the state. The Office of Tobacco Control also directs youth programs to deter the initiation of tobacco use among school-age youth and sponsors cessation services, including the Mississippi Tobacco Quitline and the University of Mississippi Medical Center ACT Center for Tobacco Treatment, Education, and Research.

There are 34 Mississippi Tobacco-Free Coalitions (MTFCs) that cover the state’s 82 counties and implement tobacco control programs at the grassroots level. The MTFCs are community-based coalitions that work to educate municipalities and schools regarding smoke-free air, prevent the initiation of tobacco use among youth, reduce exposure to secondhand smoke, promote cessation services, and eliminate tobacco-related disparities.

System change partners include the Mississippi Academy of Family Physicians, the Community Health Center Association of Mississippi, and the Mississippi Public Health Institute. These groups support tobacco cessation and policy education to health care providers and other stakeholders across the state.

The Office of Tobacco Control implements youth tobacco prevention programs across the state to decrease the initiation of tobacco use among school-age and college youth. Both the Partnership for a Healthy Mississippi and Caffee, Caffee & Associates Public Health Foundation design and run these programs. These youth programs collaborate with community-based coalitions and organizations throughout the state and provide youth advocacy and empowerment opportunities for junior high, high school, and college students. The primary goal of the Partnership for a Healthy Mississippi is to use social media to prevent tobacco use initiation through youth empowerment, advocacy, and community engagement. The Caffee, Caffee & Associates program targets high-poverty, high-risk secondary schools across the state to reduce tobacco initiation among youth and eliminate tobacco-related disparities.

The Office of Tobacco Control funds two tobacco cessation programs. The Mississippi Tobacco Quitline is an evidence-based, tobacco cessation treatment program that provides services to Mississippi adults who are motivated to quit using tobacco products. The program is available by telephone and a web-based format to deliver counseling and nicotine replacement therapy at no cost to participants. In FY2022, the responder 30-Day quit rate was 37.2% among Quitline enrollees, exceeding the North American Quitline Consortium (NAQC) goal of 30%.^2,3 The ACT Center for Tobacco Treatment, Education, and Research delivers a cessation program via an in-person, group setting. Nicotine replacement therapy (NRT) and medications are also available at no cost to participants.

Smoke-Free Ordinances

Local ordinances and statewide laws prohibiting smoking in indoor public spaces protect nonsmokers from the harmful effects of secondhand smoke. These laws also reduce youth smoking.⁴ The impact of these laws comes from both disrupting opportunities for trial/experimentation and by changing social norms such that smoking is perceived as less acceptable. In recognition of these benefits, 28 states and the District of Columbia have passed smokefree laws that apply to indoor restaurants, non-hospitality workplaces, and bars, and 1,174 municipalities have implemented smokefree ordinances. As of July 2023, 62.6% of the U.S. population is protected by either a state law or local ordinance.⁵

In Mississippi, the Office of Tobacco Control and partners have successfully educated many municipalities about the health and economic benefits of passing comprehensive local smoke-free ordinances. These ordinances prohibit smoking inside of all restaurants, bars, and workplaces to protect the health of and reduce heart attacks among nonsmokers,^6–8 as well as reduce smoking initiation among youth.⁴ To date, there are now 185 Mississippi municipalities with smokefree ordinances, protecting 37% of Mississippians; 155 of these ordinances also include e-cigarettes.⁹

METHOD

The Mississippi Youth Tobacco Survey

The Mississippi Youth Tobacco Survey (YTS) is a comprehensive tobacco survey administered annually to Mississippi public high school students. The YTS measures students’ attitudes, knowledge, and behaviors concerning tobacco use. We added questions about e-cigarette use in 2010. Data from the YTS assist the state in designing, implementing, and evaluating their comprehensive tobacco control program. Cross-sectional data for the Mississippi YTS are available for 1998-2000, 2002-2004, 2006, and 2008-2019 and 2021-2022. The YTS was not conducted in 2001 and 2007 due to changes in management of tobacco prevention programs. Hurricane Katrina prevented administration of the survey in 2005, and COVID-related school closures prevented administration of the survey in 2020.

Procedure

The Institutional Review Board for the Protection of Human Subjects in Research at Mississippi State University approved these annual surveys. Public high school students in the state of Mississippi were selected for participation using a multi-stage sample design. Teachers used standardized procedures to group administer the anonymous, self-administered questionnaires during a normal class period. Our original paper provides more detail on our procedures.¹

Statistical analyses were conducted using SPSS 28.0 and complex sampling procedures. The use of complex sampling procedures was required because standard statistical analyses are based on the assumption that the data were obtained through simple random sampling. Statistical procedures completed with the assumption that the data was obtained with simple random sampling would have underestimated the error variance due to the homogeneity of students within the same school and the same classroom.

Measures

Respondents were asked about their use of cigarettes, cigars, smokeless tobacco, and e-cigarettes^[1] during the past 30 days. Those who reported using a product on at least one of the past 30 days were categorized as a current user of that product.

Statistical Analyses

We applied Chi-Squared tests to contrast the prevalence of past 30-day use for each tobacco product.

RESULTS

Overall response rates range from 59% to 78%. Sample characteristics for each year did not vary significantly across years. Sample characteristics for 2022 are provided in Table 1. The sample included similar numbers of black and white students. The distribution by sex was also balanced. Participation was higher among students in 9^th grade compared to 10^th, 11^th, and 12^th grades.

Prevalence of Past 30-Day Use of Tobacco Products, 1998-2022

Cross-sectional analyses indicate that past 30-day cigarette smoking, cigar use, and smokeless tobacco use have decreased both substantially and significantly since 1998 (see Table 2). From 1998 to 2022, past 30-day use of cigarettes declined from 30.3% to 2.3%, cigar use declined from 22.3% to 6.3%, and smokeless tobacco use declined from 9.4% to 2.0%. Each of these declines was statistically significant, p<.05. Demographic analyses found that past 30-day use decreased for all of these tobacco products across all grades, among males and females, and black and white students. Conversely, past 30-day e-cigarette use increased from 1.2% in 2010 to 21.6% in 2018, and then stabilized from 2018 through 2022 (see Figure 1). The prevalence of current e-cigarette use did not statistically change from 2018 through 2022. Past 30-day e-cigarette use increased from 2010 to 2022 across all grades, among males and females, and black and white students.

Figure 1.Self-Reported Past 30-Day Use

Stratified by sex, race, and grade, students experienced statistically significant reductions in past 30-day use of cigarettes and cigars across all categories. White students, males, and all grades experienced statistically significant reductions in past 30-day use of smokeless tobacco. Past 30-day use of this product was less than two percent among black students and females in 1998 and did not change in 2022. All categories of students experienced statistically significant and substantial increases in the prevalence of past 30-day e-cigarette use from 2010 to 2022.

Past 30-Day Use of Tobacco Products, 2022

In the most recent administration of the YTS, the prevalence of past 30-day e-cigarette use was much higher than that for cigarettes, cigars, and smokeless tobacco use (see Figure 2). E-cigarette use did not significantly differ across sex or race. Overall, cigarette use was low, but white students (3.5%) were more likely to report past 30-day smoking than black students (1.1%), p<.05. Conversely, black students (9.1%) were more likely to report past 30-day cigar use than white students (3.2%), p<.05. Males (3.4%) were more likely to report past 30-day smokeless tobacco use than females, (0.6%), p<.05.

Figure 2.2022 Past 30-Day Use of Tobacco Products

DISCUSSION

The social climate for tobacco control in Mississippi experienced several important changes over the past two and a half decades. Cross-sectional data from the Mississippi Youth Tobacco Survey demonstrates large and meaningful declines in the prevalence of cigarette smoking, cigar use, and smokeless tobacco use over the past 24 years among our high school students. These declines occurred as Mississippi implemented and sustained statewide tobacco control programs, increased the state cigarette tax from 18 cents to 68 cents in 2009, and passed 186 local comprehensive smoke-free ordinances. Reductions in youth tobacco use are associated with each of these activities.^10–13 Also, the minimum age to purchase tobacco products was increased from 18 to 21. The U.S. enacted this federal law in late 2019, and Mississippi implemented a minimum age of 21 to purchase tobacco products in July of 2021. Raising the minimum age for the sale of tobacco disrupts youths’ regular access to tobacco and nicotine by reducing their ability to buy these products from older high school students. The popularity of e-cigarettes, which are lightly regulated and untaxed, is a challenge to our state’s successful tobacco control efforts.

Cigarettes have historically been the most commonly used tobacco product by Mississippi youth. However, past 30-day e-cigarette use surpassed cigarette smoking in 2015. Currently, e-cigarette use among our youth is almost seven times greater than cigarette smoking. There were two points in time that experienced large increases in e-cigarette use. The prevalence of e-cigarette use tripled from 2013 to 2014 – most likely due to reductions in cost and improvements in product usability. From 2014 through 2017, current use did not change. However, current use almost doubled in 2018 as the JUUL e-cigarette gained popularity among teens and young adults. The JUUL and copycat products had several unique features; they delivered nicotine to the brain very efficiently, they were small and did not look like previous e-cigarettes, their aerosol was easy to conceal, and the teen-targeted marketing on social media was very effective.

Health Impacts of the Increased Prevalence of Youth E-Cigarette Use

Many of the chemicals and carcinogens found in combustible cigarettes are at substantially lower levels in e-cigarette aerosol, or simply not present.¹⁴ E-cigarettes may present less harms to health than cigarettes, but that does not mean that these products are safe – being less dangerous than the leading cause of death in the United States is a very low bar. Moreover, prospective research among adolescents indicates that e-cigarette use among never smokers is a risk factor for future combustible cigarette smoking, after controlling for psychosocial predictors of smoking.^15–19

Limitations

This study is subject to the limitations of cross-sectional and self-report surveys. Cross-sectional studies may be susceptible to sampling bias variation across years, and self-report data may not provide accurate e-cigarette data from all respondents. Another limitation concerns the lack of comparative Youth Tobacco Survey data from neighboring states. These states either do not conduct this survey, or they do not publicly release the results, so it is not possible to place our trends in the context of regional trends using this data set.

Potential Policies for Mississippi

At the local and state level, the use of e-cigarettes should be prohibited in places where smoking is not allowed. There is no objective evidence that e-cigarette aerosol is harmless to bystanders. Currently, 156 of Mississippi’s 186 municipalities with comprehensive smoke-free ordinances also include e-cigarette restrictions.⁹

Taxation is another strategy for making e-cigarettes less attractive to nonsmokers. The lack of a state tobacco tax on e-cigarettes represents a missed opportunity for reducing use among nonsmokers. Mississippi currently has one of the lowest state cigarette taxes. At 68 cents per pack, this tax is substantially lower than the national average of $1.93.²⁰ A change to the tax structure that increased the state cigarette tax to the national average and also taxed e-cigarettes would be one approach to decreasing cigarette smoking and making e-cigarettes less attractive to nonsmokers.

Conclusion

Mississippi has experienced substantial decreases in cigarette smoking, cigar use, and smokeless tobacco use over the past 24 years among our high school students. These declines occurred as Mississippi implemented and sustained statewide tobacco control programs, increased the state cigarette tax from 18 cents to 68 cents in 2009, passed 185 local comprehensive smoke-free ordinances, and raised the age of sale for tobacco products to 21. These improvements to the current and future health of Mississippians are threatened by the rapid growth in popularity of e-cigarette use among our youth. Local and state smoke-free policies prohibiting e-cigarette use in public indoor places and tobacco taxes on e-cigarettes, coupled with continued funding for statewide prevention and control efforts for the Mississippi State Department of Health’s Office of Tobacco Control to engage youth, are effective strategies available to Mississippi to reduce e-cigarette use among our youth.