Cuyahoga County High School Students Smoking at the Same Rate as Adults

Cuyahoga County high school students are smoking tobacco products at the same rate as adults in the county, according to new data from the Prevention Research Center for Healthy Neighborhoods (PRCHN) at Case Western Reserve University. In 2013, more than 22 percent, or one in five high school students, report use of any tobacco product within the prior 30 days.

Equally surprising is that ninth- through twelfth- graders are smoking cigars and hookahs, or water pipes, more than cigarettes – matching a national trend. More students report cigar use at 15.1 percent than any other tobacco product. The second most common choice is hookah at 10.6 percent, which exceeds 10.4 percent cigarette – a first since the researchers began surveying county youth more than 10 years ago. And, more often than not, kids are using multiple tobacco products, smoking both cigarettes and cigars.

"When we think about smoking, we mostly think about cigarettes because that is what most adults use,” said Erika Trapl, PhD, lead research investigator, assistant professor of epidemiology & biostatistics, and associate director of the PRCHN at Case Western Reserve. “But our data show that it’s other tobacco products, like flavored little cigars, that are luring kids into a potential lifetime of tobacco addiction. The rates are high across the county and it is a serious concern.”

Administered since 2000 by the PRCHN, the Cuyahoga County Youth Risk Behavior Survey, based on a national survey developed by the Centers for Disease Control and Prevention, tracks adolescent risk behaviors over time. Almost 17,000 students from 43 of the 54 public school districts in the county participated in the voluntary, parent-approved survey in 2013.

At first glance, the county’s overall cigarette smoking rate is well below the 16 percent threshold set by the federal government in the Healthy People 2020 initiative. Closer examination of smoking data shows that while cigarettes are the product of choice for adults, adolescent tobacco usage is different and came as a surprise to the researchers and local health officials.  

The survey data show cigars aren’t an urban problem. Across the county, use is higher in east side suburbs at 22 percent and 17 percent in western suburbs – significantly more than cigarette and hookah use. The inner ring suburbs on the east side of the county showed higher cigar use and the inner ring suburbs on the west side were the opposite, with higher cigarette and hookah use. 

In addition to increased cigar use, the surveys show the emergence of hookah use, a water pipe, often smoked with flavored tobacco. Hookah smoking increased three-fold in the city of Cleveland, and of the tobacco products surveyed, it saw the largest increase in usage from 2011 to 2013.

"From the perspective of the Cuyahoga County Board of Health, steps in the right direction to address the youth access obstacle would be raising the price on non-cigarette tobacco products, restricting products’ common self-serve placement next to candy and gum, implementing mandatory vendor education for compliance check violators, and renewing funding for coordinated compliance checks with both law enforcement and public health officials to send a stronger message and result in greater compliance,” said Nichelle Shaw, MPH, chronic disease prevention supervisor at the Cuyahoga County Department of Health.

The Youth Risk Behavior Survey research is primary supported by funding from the Cuyahoga County Board of Health through the Ohio Department of Health’s Bureau of Child and Family Health, and serves as a community health assessment tool for the county. Both groups use the de-identified data to measure health indicators across the county in a variety of areas including Health Improvement Partnership-Cuyahoga, a community engagement initiative to address issues that affect the health of those living in the northeast Ohio. This Youth Risk Behavior Survey is the only such data that exists for the county; the state survey only samples seven high schools in the county.  

“Youth access is one of the most significant problems identified by the Cuyahoga County Youth Risk Behavior Survey data – children are still using, possessing and purchasing tobacco products, which is against the law for anyone under the age of 18,” Shaw added. “Contributions to the access problem include dramatically lower prices of cigar and hookah products, adult purchasing products on behalf of minors and tobacco retailers selling products to the minors.”

The Cuyahoga County Board of Health conducts tobacco vendor compliance checks of retail stores to determine if minors can purchase products. During the last round of checks, the board visited 55 Cuyahoga County retail locations; 30 percent of vendors sold tobacco to 14-17 year-olds and did not ask for any identification. In 2007, funding supported the accompaniment of plain-clothes law enforcement on the compliance checks, who subsequently issue citations to vendors after an illegal sale. In the year following this partnership, the Cuyahoga County Board of Health saw a dramatic decrease in illegal sales.

"A possible contributing factor to the rise in non-cigarette smoking may be the exclusion of cigar and hookah products from the Food & Drug Administration’s Center for Tobacco Products, added Trapl “Unlike cigarettes, the products don’t require ingredient reporting; the nicotine levels, carcinogens and chemical additive levels are unknown.”

The FDA recently proposed a new rule to extend their regulatory authority to cover alternative tobacco products, including e-cigarettes, cigars, pipe tobacco, and hookah tobacco. If enacted, FDA would establish standards for these tobacco products, establish limits on the sale and distribution of these products, and require premarket review for new products. Additionally, this new rule would allow the FDA to consider additional rules that would equalize the playing field of cigar products and hookah with cigarettes, such as requiring minimum pack sizes, introducing flavoring restrictions and implementing greater stringencies on packing colors and fonts, along with stronger warnings.

A data brief outlining the PRCHN’s research can be found at

Founded in 1843, Case Western Reserve University School of Medicine is the largest medical research institution in Ohio and is among the nation's top medical schools for research funding from the National Institutes of Health. The School of Medicine is recognized throughout the international medical community for outstanding achievements in teaching. The School's innovative and pioneering Western Reserve2 curriculum interweaves four themes--research and scholarship, clinical mastery, leadership, and civic professionalism--to prepare students for the practice of evidence-based medicine in the rapidly changing health care environment of the 21st century. Nine Nobel Laureates have been affiliated with the School of Medicine.

Annually, the School of Medicine trains more than 800 MD and MD/PhD students and ranks in the top 25 among U.S. research-oriented medical schools as designated by U.S. News & World Report's "Guide to Graduate Education."

The School of Medicine is affiliated with University Hospitals Cleveland Medical Center, MetroHealth Medical Center, the Louis Stokes Cleveland Department of Veterans Affairs Medical Center, and the Cleveland Clinic, with which it established the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University in 2002.

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Jessica Studeny