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Center for Substance Abuse Prevention (US). Reducing Tobacco Use Among Youth: Community Based Approaches (Reference Guide). Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1997. (Prevention Enhancement Protocols System (PEPS), No. 1.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Reducing Tobacco Use Among Youth: Community Based Approaches (Reference Guide).

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1The Problem of Tobacco Use Among Youth

Nicotine use begins at a very early age in the United States, even though it is illegal to sell tobacco products to minors and in some States the use of tobacco by youth is illegal (Ary and Biglan 1988; Collins et al. 1987; Conrad et al. 1992; Cummings et al. 1992; Hoppock and Houston 1990). National surveys indicate that nearly all smokers aged 35 years or younger began using cigarettes sometime in early adolescence, roughly between the ages of 11 and 15 years (Substance Abuse and Mental Health Services Administration 1996), and few people take up tobacco after the age of 18. Clearly, a key factor in reducing future numbers of tobacco users lies in our ability to stop adolescent experimentation with tobacco products.

These surveys regarding the early onset of nicotine use suggest that substance abuse prevention programs that target adolescents are insufficient in number, inconsistent, and of inadequate duration. Furthermore, while school-based intervention is an important component of an overall prevention strategy, it is insufficient when used alone. Although most youth have received consistent and credible messages about the dangers of cigarette smoking, evidently these prevention and education efforts have not been sufficiently strong to prevent experimentation with tobacco products at young ages.

Substantial numbers of youth are already dependent on nicotine by the time they are exposed to prevention efforts.

Such data also highlight an important difficulty that communities must confront as they attempt to reduce tobacco use among youth: substantial percentages of these youth are already dependent on nicotine from cigarettes, smokeless tobacco, or both (Slade 1993). Conventional primary prevention (e.g., "Don't ever start.") or conventional secondary prevention (psychology-based approaches to encourage people to stop) may not be sufficiently strong or comprehensive to break nicotine dependence (Reardon et al. 1989).

Effective prevention approaches must be based on a clear understanding of the epidemiology of tobacco use among youth as well as patterns and trends of use. Community-based approaches for preventing tobacco use among youth must be powerful, must cover allforms of tobacco use, and must consider the possibility and even likelihood of concurrent use (Altman et al. 1992; Bal et al. 1990; Choi et al. 1991; Erickson et al. 1990; Feighery et al. 1991; Flynn et al. 1992; Pentz et al. 1989a, 1989b, 1989c; Perry et al. 1992). To provide a meaningful context for such efforts, this chapter reviews the history of tobacco use and norms in the United States and presents data on the epidemiology of, risk and protective factors for, and short- and long-term health consequences of tobacco use among youth in the United States.

Historical Context

Tobacco use in America has roots older than the nation's founding. It became well established in colonial America but involved only a small segment of the population, whose use was limited to pipe smoking and dry snuff. In the early 1800s, however, tobacco chewing and cigar smoking became more common. Cigarette smoking did not become popular and widespread until after the Civil War, after the invention of machines to produce cigarettes in mass quantities.

Increased sales and consumption of cigarettes created a social and regulatory backlash. Since smoking was perceived as a dirty habit, by the end of the 19th century cigarette sales to minors were banned in all States. Fourteen States banned all sales of cigarettes, even to adults.

During World War I, cigarette smoking became common among U.S. soldiers and was soon identified in the public mind as part of the war effort. Indeed, in the summer of 1918, General H. L. Rogers added tobacco to soldiers' rations (Risch 1989). Effective lobbying by the tobacco industry promoted the social acceptability of cigarette smoking, even among women, and resulted in repeal of much of the regulation of the tobacco market (Austin 1978; Henningfield 1985). By 1930, in the midst of the Great Depression, all strict prohibition laws had been repealed. Even laws against tobacco sales to minors began to soften, and enforcement became virtually nonexistent (Austin 1978).

From the 1930s through the 1950s, smoking became not only acceptable but even desirable to large segments of the population. This phenomenon can be explained in part by the seemingly universal practice of smoking among U.S. troops during World War II, a practice that may have been encouraged by the inclusion of "nine `good commercial quality' cigarettes" in the accessory packet of the troops' daily C ration (Koehler 1958). American cigarettes came to be identified as the best in the world. Cigarette smoking became a symbol not only of American industrial superiority but of success, sexuality, and the American way of life as well. Smoking was glamorized in movies and magazines and later, on television. The tobacco industry became one of the largest advertisers, promoting the image of smoking as a sophisticated practice associated with youth, good looks, health, and success (Ray and Ksir 1987).

In the 1950s, concerns about the health risks of smoking began to surface as research increasingly demonstrated links between smoking and various illnesses and diseases. This evidence was the primary basis for the landmark 1964 Surgeon General's report on smoking and health (U.S. Department of Health and Human Services 1964), which was the catalyst for major changes in how society attempted to control tobacco products. The report inspired dissension between antitobacco activists and the tobacco industry. Almost immediately, the Federal Trade Commission (FTC) proposed requiring health warnings on cigarette packages indicating that cigarette smoking "is dangerous to health and may cause death from cancer and other diseases." On the other hand, in 1965, Congress passed the Federal Cigarette Labeling and Advertising Act, which required a weaker warning and prevented the FTC and the States from regulating tobacco advertising in any other way (Action on Smoking and Health 1994). In 1966, John F. Banzhaf III, an attorney in Washington, DC, filed a complaint with the Federal Communications Commission (FCC) demanding free time under the Fairness Doctrine for counteradvertising against cigarette use. The FCC determined that the Fairness Doctrine (Box 1-1) applied to cigarette commercials, requiring broadcasters to provide free broadcast time for antismoking messages (Action on Smoking and Health 1994). This ruling was upheld in the U.S. Court of Appeals in 1968 and by the U.S. Supreme Court in 1969.

BOX 1-1: The Fairness Doctrine and the Equal Time Rule

The Fairness Doctrine directed any broadcast station presenting one viewpoint on a controversial public issue to afford reasonable opportunity for the presentation of opposing viewpoints. It is distinct from the Equal Time Rule, mandated by the Communications Act of 1934, which reads: "[i]f any licensee shall permit any person who is a legally qualified candidate for any public office to use a broadcasting station, he shall afford equal opportunities to all such candidates for that office."

Although clearly different, both policies originate from recognition of the airwaves as a scarce public resource, and they are usually presented as if they were the same.

In 1987, the FCC ceased enforcement of the doctrine. Subsequent efforts by Congress to revive it have failed (Cronauer 1994).

From 1967 to 1970, voluntary health agencies were able to wage a counteradvertising campaign against cigarette smoking, but initially were given only a third of the air time allotted to cigarette advertising, and nonprime time at that (Slade 1992). In 1969, the FCC ruled that radio and television stations must present a good portion of counteradvertising during prime time. Application of the Fairness Doctrine to broadcast cigarette advertising marked the beginning of a significant decline in cigarette consumption, which was attributed to the antismoking messages. To halt this decline, the tobacco industry successfully lobbied Congress to ban all broadcast cigarette advertising, effectively nullifying the requirement for free counteradvertising (Slade 1992).

In 1970, Congress required that all cigarette packages carry the following specific warning: "The Surgeon General Has Determined That Cigarette Smoking Is Dangerous to Your Health." In 1972, an FTC consent order required that all print advertising carry the same health warnings that appeared on cigarette packaging (U.S. Department of Health and Human Services 1994).

To counter the adverse publicity generated by the health warnings, the tobacco industry launched a three-pronged campaign: the establishment of the Tobacco Institute in the mid-1950s, industry-supported research on the health effects associated with smoking, and the production and marketing of products "designed to appear safe" (Slade 1992). So-called "safe" products have included filter-tipped cigarettes, shown during the 1960s not to be safe; low-tar brands, whose low-nicotine delivery can be circumvented by smoking more or inhaling more deeply; and smokeless cigarettes, whose potential harm thus far is as great as or greater than that of regular cigarettes (Slade 1992). The American Medical Association and the Coalition on Smoking OR Health asked the Food and Drug Administration (FDA) to regulate Premier, the first of the smokeless cigarettes, as a drug delivery device. Premier was withdrawn from the market in 1989 (Slade 1992). In 1996, R.J. Reynolds introduced a new smokeless cigarette, Eclipse. It contains a carbon tip that heats but does not burn tobacco and does not produce smoke or ash. Designed to reduce side-stream and second-hand smoke, it was in a final test marketing phase during 1996.

In the 1980s and early 1990s, numerous government agencies imposed a variety of restrictions on smoking. Designated smoking and nonsmoking areas emerged in public transportation and certain other public facilities. As concern about environmental tobacco smoke has grown, smoking has been banned in public buildings, transportation, and workplaces through employer initiative or Federal, State, and local ordinances. In the 1980s, regulations on advertising and warning labels were further tightened. In 1984, the Comprehensive Smoking Education Act (Public Law 98-474) replaced the Surgeon General's health warning on cigarette packages and advertisements with a new set of four rotating health warnings. The 1986 Surgeon General's report dealt with the health dangers of passive or secondhand smoke. In the same year, the Surgeon General endorsed a report on the dangers and addictive potential of smokeless tobacco. Shortly after that, the Comprehensive Smokeless Tobacco Health Education Act (Public Law 99-252) required the rotation of three health warnings on smokeless tobacco packages and advertisements, prohibited advertising of smokeless tobacco on television and radio, and required a public information campaign on the health hazards of using smokeless tobacco (U.S. Department of Health and Human Services 1994; Warner et al. 1992; Wasserman et al. 1991).

In 1988, the Surgeon General's Report officially designated nicotine as an addictive drug in the same class as alcohol, marijuana, cocaine, and heroin. In 1989, Congress banned smoking on all domestic airplane flights in the United States. By 1990, virtually all States and hundreds of localities had placed restrictions on smoking (Akers 1992; Warner 1986, 1989; Warner and Murt 1983).

While most States have had laws restricting access to tobacco by minors, the laws have been poorly enforced. The Synar Amendment to the 1992 Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act provided the needed incentive for States to enforce the laws. It requires all States to document good-faith efforts to inhibit access by youth to tobacco products and report on their results each year. It requires that all States must have a law prohibiting any manufacturer, retailer, or distributor of tobacco products from selling or distributing such products to any individual under the age of 18. It requires States to conduct annual random, unannounced inspections of a random sample of outlets accessible to youth to ensure compliance with the law. The regulation requires States to submit to the Substance Abuse and Mental Health Services Administration an annual report detailing each State's efforts to enforce the law and its success in reducing successful tobacco purchases made by youth, describing how inspections were conducted and the methods used to target outlets, and plans for enforcing the law in the coming fiscal year. By 1994, 43 States had enacted laws prohibiting tobacco sales to minors; by 1995, all States had such a law on the books. In 1993, the Environmental Protection Agency officially labeled secondary smoke as a group-A carcinogen that kills an estimated 3,000 Americans each year (Action on Smoking and Health 1994).

However, because tobacco is a heavily advertised and promoted legal product that is easily accessible to youth, prevention of its use by children and adolescents remains a public health priority. This concern is reflected in the 1994 Surgeon General's Report, which focused on tobacco use among youth, and in the Institute of Medicine's release of the document Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youth (Institute of Medicine 1994). The Goals 2000: Pro-Children Act of 1994 (P.L. 103-227) established a nonsmoking policy at sites housing such children's services as health care, day care, education, or library services.

Epidemiology of Youth Tobacco Use

A number of studies in the United States have tracked the use of tobacco products and attitudes toward their use among youth. The two most often cited are the Monitoring the Future (MTF) study and the National Household Survey on Drug Abuse (NHSDA). These two studies serve as the foundation for the following discussion of the epidemiology of tobacco use among youth.

Monitoring the Future

The MTF study, which has been conducted annually since 1975, is a stratified, random probability sample (approximately 17,000 annually) of high school seniors attending public and private schools in the continental United States. In 1991, the study was expanded to include 8th and 10th grade students from independent samples of schools. The total sample size for the MTF study is now close to 50,000 a year.

National Household Survey on Drug Abuse

The NHSDA was conducted periodically from 1974 to 1990 and since then has been conducted annually. Unlike the MTF study, in which information is gathered via questionnaires from students in sampled schools, the NHSDA is a stratified, random probability sample of persons 12 to 17 years old in households in the entire United States. Another difference is that youth in the NHSDA are interviewed personally, whereas students in the MTF study complete anonymous questionnaires.

The following discussion presents data on the incidence (new users and age at onset) and prevalence (changes in the percentage of persons who are using tobacco to various degrees) of tobacco use, as well as on high-risk populations or groups (characteristics that differentiate between those who will and those who will not use or become heavy users of tobacco).

Incidence

In epidemiologic studies of drug use, incidence refers to age at first use of the drug under study (Centers for Disease Control and Prevention 1991a). Perhaps the best data on incidence come from the NHSDA, which contains representative samples of persons 12 through 17, 18 through 25, 26 through 34, and 35 years and older. (Determining the age of smoking initiation for preadolescents, although important, is problematic, as most surveys do not include persons under the age of 12 years.) All persons who report ever having used cigarettes are asked their age at first use. Table 1-1 shows findings of the 1994 NHSDA by age group on the average age at first cigarette use. The average age at first cigarette use has not changed much across all of the birth cohorts included in the NHSDA; it is in early adolescence.

TABLE 1-1: Average Age in Years at First Cigareete Use, by Age Group, 1994.

Table

TABLE 1-1: Average Age in Years at First Cigareete Use, by Age Group, 1994.

Table 1-2 presents NHSDA data showing that for people in every age group, nicotine is clearly the first drug used and that its use begins even earlier than does use of alcoholic beverages (Bailey 1992; Breslau et al. 1993; Centers for Disease Control and Prevention 1992b; Fleming et al. 1989; Henningfield et al. 1990).

TABLE 1-2: Average Age at First Use of Cigarettes, Alcohol, and Illicit Drugs, by Age Group, 1994.

Table

TABLE 1-2: Average Age at First Use of Cigarettes, Alcohol, and Illicit Drugs, by Age Group, 1994.

The fact that youths smoke does not necessarily mean that they violate State laws relating to the purchase of cigarettes. Some youths ask for cigarettes from friends or obtain them from parents. Of those who do purchase cigarettes, in only a few States are they violating the law, because most State laws restrict sales to minors but not purchases by minors. In one study (Forster et al. 1992), 77 percent of adolescents who smoked weekly reported that they had given tobacco to another minor, and even people who smoked weekly reported that family and friends are an important source of tobacco products for them. (Chapter 3 presents a more detailed discussion of youth access to tobacco.) Most States prohibit tobacco sales to minors, 29 States prohibit youth purchase, 18 prohibit youth possession, 12 prohibit youth use of tobacco, and 37 have one or more of these provisions.

Prevalence

In epidemiologic substance abuse studies, prevalence is defined as the number of users at a given time. Prevalence is usually reported for lifetime, past year, and past month or current use.

Although experimentation with cigarettes is not universal, it is statistically and developmentally normative - that is, it is seen in greater than 50 percent of adolescent populations surveyed (Centers for Disease Control and Prevention 1992a; Escobedo et al. 1993; Johnston 1991; Thomas and Larsen 1993). The MTF data (Figure 1-1) show that among high school seniors the highest lifetime prevalence (75.8 percent) was seen in 1977, whereas the lowest rate (61.8 percent) occurred in 1992. Any experience with cigarettes has dropped about 12 percentage points among high school seniors over the past 15 years (NIDA 1996). The highest lifetime rate (78.1 percent) in the NHSDA for 12- to 17-year-olds was seen in 1979 and the lowest rate (61.4 percent) in 1990, a reduction of 16.7 percentage points.

FIGURE 1-1: Rates of Cigarette Use Among High School Seniors.

Figure

FIGURE 1-1: Rates of Cigarette Use Among High School Seniors.

There are notable racial differences in the use of tobacco by high school students (Centers for Disease Control and Prevention 1991b, 1996a, 1996b). White students in grades 9 through 12 report the highest use, followed closely by Hispanics. However, rates for use of any tobacco and use of cigarettes by black students are far lower than these rates. In 1995, 38.3 percent of white and 34 percent of Hispanic high school students reported ever having used cigarettes while for blacks this percentage was only 19.2 percent (Centers for Disease Control and Prevention 1996a).

Several conclusions can be drawn from these data. Lifetime experience with cigarettes declined steadily between 1975 and 1990, but recent data indicate that this trend may be reversing (Institute of Medicine 1994; Johnston et al. 1994; Pierce et al. 1989). Furthermore, 6 out of 10 high school seniors and youth aged 12 to 17 years have tried cigarettes. Nearly half of 8th graders and slightly more than half of 10th graders have used cigarettes. In fact, the MTF study showed a 6.1 percent increase in lifetime experience with cigarettes among 10th graders between 1991 and 1996 (Figure 1-2) (NIDA 1996).

FIGURE 1-2: Cigarettes, Any Use by Grade, 1991-1996.

Figure

FIGURE 1-2: Cigarettes, Any Use by Grade, 1991-1996.

Recent Changes in Cigarette Use

The MTF study provides a window on cigarette use by youth that reveals patterns that are more dangerous than experimentation. There were statistically significant increases between 1991 and 1996 in any use of cigarettes and in daily use of cigarettes among 8th, 10th, and 12th graders in the preceding 30 days (Figures 1-3 and 1-4). Equally notable, if not more so, is the fact that 22.2 percent of 12th graders, 18.8 percent of 10th graders, and 10.4 percent of 8th graders reported having used cigarettes daily during the 30 days before they completed the MTF questionnaire in 1996 (NIDA 1996). In addition, there was a statistically significant increase between 1991 and 1996 in the percentage of 8th, 10th, and 12th graders who smoked one-half pack or more daily. Thirteen percent of the high school seniors smoked one-half pack or more a day in 1996 (Figure 1-5) (NIDA 1996).

FIGURE 1-3: Cigarettes, Any Use Past 30 Days, by Grade, 1991-1996.

Figure

FIGURE 1-3: Cigarettes, Any Use Past 30 Days, by Grade, 1991-1996.

FIGURE 1-4: Cigarettes, Daily Use Past 30 Days, by Grade, 1991-1996.

Figure

FIGURE 1-4: Cigarettes, Daily Use Past 30 Days, by Grade, 1991-1996.

FIGURE 1-5: Frequent Use of Cigarettes (1/2 pack or more per day), by Grade, 1991-1996.

Figure

FIGURE 1-5: Frequent Use of Cigarettes (1/2 pack or more per day), by Grade, 1991-1996.

To put these data into historical and comparative perspective, consider that in 1979 there was a wide public outcry when it was reported that 10.9 percent of high school seniors were smoking marijuana daily (Clayton and Walden 1994; Johnston 1991). In 1993, 10.9 percent of high school seniors - the same percentage who had been using marijuana in 1979 - reported using one-half pack or more of cigarettes daily. In 1996, 13 percent of high school seniors reported using one-half pack or more daily (NIDA 1996). Yet, despite the fact that cigarettes contain a drug known to be addictive (Benowitz 1992; U.S. Department of Health and Human Services 1988), have negative health effects, and are the largest preventable cause of death in the United States, the public outcry calling for the prevention of tobacco use among youth has been minimal.

Prevalence of Use of Smokeless Tobacco

The principal epidemiologic studies of drug use among youth have only recently included smokeless tobacco in their purview. In fact, the 12th grade version of the MTF questionnaires did not include questions about smokeless tobacco until 1992. The responses to those questions revealed that a substantial percentage of youth have tried smokeless tobacco at some point (see Figure 1-6) (NIDA 1996). In fact, more than 1 in 10 high school seniors, nearly all of them male, report having used smokeless tobacco within the past 30 days (Figures 1-7 and 1-8) (NIDA 1996; Ary et al. 1987; Botvin et al. 1989; Boyd and Glover 1989; Dent et al. 1987).

FIGURE 1-6: Smokeless Tobacco, Any Use.

Figure

FIGURE 1-6: Smokeless Tobacco, Any Use. NOTE: 1991 data for smokeless tobacco are unavailable for 12th graders.

FIGURE 1-7: Smokeless Tobacco, Any Use, Past 30 Days.

Figure

FIGURE 1-7: Smokeless Tobacco, Any Use, Past 30 Days. NOTE: 1991 data for smokeless tobacco are unavailable for 12th graders.

FIGURE 1-8: Smokeless Tobacco, Daily Use Past 30 Days.

Figure

FIGURE 1-8: Smokeless Tobacco, Daily Use Past 30 Days. NOTE: 1991 data for smokeless tobacco are unavailable for 12th graders.

Concomitant Use of Cigarettes and Smokeless Tobacco

The prevalence for use of cigarettes and that for smokeless tobacco are almost always presented separately. However, some youth engage in both forms of tobacco use. This is particularly true for boys, who may use smokeless tobacco in same-sex social situations but cigarettes when they are with the opposite sex. Males may also use smokeless tobacco during the school sports season because they believe it will not affect their aerobic endurance and during school hours because detection is less likely. The Centers for Disease Control and Prevention examined the concomitant use of these two forms of tobacco, using combined data from the MTF senior classes of 1985 through 1989. They found that 15.6 percent of seniors who did not smoke (i.e., those who had not smoked any cigarettes in the preceding month) and 32.5 percent of those who currently smoke reported having used smokeless tobacco within the past month. Nearly half of high school seniors in the 1985 through 1989 classes were current users of tobacco (Centers for Disease Control and Prevention 1991b).

Table 1-3 shows data from a survey conducted in a rural Kentucky county in 1994 as part of an evaluation of a Center for Substance Abuse Prevention Community Partnership grant (Clayton and Walden 1994). Examining concurrent use of cigarettes and smokeless tobacco during the preceding 30 days has a dramatic effect on one's understanding of the epidemiology of tobacco use among youth. In this rural county, more than one-fourth (28.6 percent) of 7th grade boys and 40 to 50 percent of all boys in each grade from 8 through 12 had used some form of tobacco in the preceding 30 days.

TABLE 1-3: Percentage of Youth Reporting Tobacco Use During the Past Month, by School Grade and Sex, Madison County, Kentucky, 1994.

Table

TABLE 1-3: Percentage of Youth Reporting Tobacco Use During the Past Month, by School Grade and Sex, Madison County, Kentucky, 1994.

In each grade except the 11th in the Kentucky study, the percentage of boys who reported concurrent use of both cigarettes and smokeless tobacco was larger than that of boys who reported using only cigarettes. This may reflect the fact that these students live in a rural county where tobacco is the major crop or merely that they are from a rural area, where use of smokeless tobacco tends to be higher than in nonrural areas. An equally plausible hypothesis is that boys are as likely or more likely to use smokeless tobacco as they are to smoke cigarettes. If this is the case, community-based approaches must pay close attention to the use of smokeless tobacco among boys. The past-month prevalence rates for girls, regardless of grade, are based almost entirely on cigarette use, and these rates are also high.

Consequences of Tobacco Use

Because most of the research on the consequences of tobacco use has focused on adults who have used cigarettes for many years, attention to the consequences of tobacco use by youth is a relatively new phenomenon. Some of the most likely consequences of tobacco use among youth are the risk of nicotine addiction, short-term health risks, a greater risk for use of alcohol or illicit drugs, and a tendency to engage in health risk behaviors.

Risk of Nicotine Addiction

One major consequence of cigarette and smokeless tobacco use by youth is the development of physical and psychological dependence on nicotine. The 1988 Surgeon General's Report, The Health Consequences of Smoking: Nicotine Addiction, lists the following key criteria for determining addiction to a substance:

  • Compulsive use, often despite knowing the substance is harmful
  • Psychoactive effect (i.e., direct chemical effect in the brain)
  • Reinforcing behavior that conditions continued use
  • Withdrawal symptoms

Three out of four adults who smoke say that they are addicted, and by some estimates as many as 74 to 90 percent of smokers are addicted (Kessler 1994). In the 1994 NHSDA, the following symptoms of dependence were reported by 12- to 17-year-olds who had smoked cigarettes in the past year:

  • 57.5 percent wanted to cut down
  • 28.2 percent had used more than intended
  • 30.5 percent reported that tolerance had developed
  • 12.8 percent reported that cigarettes had caused problems at home or work
Sixty-seven percent of those interviewed reported at least one of the above problems.

Nicotine dependence in young people who smoke begins much earlier than previously suspected. For example, in a 3-year study of 197 girls aged 11 to 14 years, from 1985 through 1987, cotinine (a metabolite of nicotine) concentrations were found to be substantial (McNeill 1991). Even at the beginning of the study, approximately one-half of the average cotinine concentration found in adults was found in 11- to 14-year-olds who smoked daily. Two years later, the same group had cotinine levels that were more than two-thirds of those levels usually found in adults, despite the fact that these young people were in school and thus were subject to considerable restrictions on their smoking behavior. These girls had been receiving substantial doses of nicotine from a very early stage in their smoking careers, suggesting that the pharmacological effects of nicotine were already important in perpetuating their smoking.

In the rural Kentucky study mentioned earlier, an attempt was made to determine how many males in grades 6 through 12 who had used tobacco in the past month were dependent as measured using nicotine dependence scales (Clayton and Walden 1994). The study revealed that:

  • 24.2 percent of those who had used only cigarettes in the past month were dependent
  • 22.2 percent of those who had used only smokeless tobacco in the past month were dependent
  • 55.0 percent of those who had used both cigarettes and smokeless tobacco in the past month were dependent
  • 34.4 percent of all those who had used any type of tobacco product were dependent

Use of Tobacco and Other Drugs

The relationship between the use of tobacco and other drugs (e.g., alcohol, marijuana, heroin, or cocaine) cannot be considered causal. That is, there is insufficient evidence to state that tobacco use results in the use of other drugs. However, there is evidence that tobacco use is associated with the experimentation and use of other drugs. Figure 1-9, which shows data on 12- to 17-year-olds in the 1994 NHSDA, shows the strength of this association (Substance Abuse and Mental Health Services Administration 1996). Four times as many of those who had used cigarettes in the past month as of those who had not used them reported use of alcohol within the same month. Further, 14 times as many had also used marijuana and 12 times as many had used cocaine. The most important aspect of this issue is that tobacco use is a risk factor for other substance use, including alcohol, marijuana, and cocaine (Bailey 1992).

FIGURE 1-9: Percentage of Youth Who Used Drugs in the Past Month, Smokers and Nonsmokers.

Figure

FIGURE 1-9: Percentage of Youth Who Used Drugs in the Past Month, Smokers and Nonsmokers. NOTE: Numbers are extrapolations for the percentages to all youths represented by the 12- to 17-year-olds in the study sample.
SOURCE: (more...)

Other Risky Behavior and Tobacco Use

The Centers for Disease Control and Prevention conducts the Youth Risk Behavior Surveillance System survey with responses from more than 10,000 high school students. Just as tobacco use correlates with the use of other drugs, involvement in various other health risk behaviors correlates with the use of tobacco.

Table 1-4 shows that youth who reported engaging in health risk behaviors were more likely to be current smokers; current, frequent smokers; or current users of smokeless tobacco than youth who avoided such behaviors. For example, of those who had been in six or more fights in the past year, 30.5 percent were current, frequent smokers, whereas of those who had not been in any fights in the past year, only 8 percent were current, frequent smokers. Although these data do not suggest any kind of causal relationship, they do show that problem behaviors in youth cluster in the same individuals (Clayton 1992; Jessor and Jessor 1977). This correlation may be especially relevant at the community level as approaches are constructed to deal with the problem of tobacco use by youth.

TABLE 1-4: Involvement in Health Risk Behavior.

Table

TABLE 1-4: Involvement in Health Risk Behavior.

Although this correlation between early use of tobacco and subsequent use of other drugs is of concern, tobacco use in and of itself is the primary focus of this document. Similarly, although the health risk behaviors associated with tobacco use are a public health concern, the use of tobacco by youth is emphasized in this document. The short-term and long-term health risks of tobacco use, as discussed below, magnify the need for public health resources to prevent tobacco use among youth.

Short- and Long-Term Health Risks

The short-term health risks for youth who smoke cigarettes or use smokeless tobacco are considerable. Smoking accelerates the heart rate and increases the number of red blood cells, and cyanide in cigarette smoke anesthetizes the cilia in the tracheobronchial tree. The cilia are designed to sweep the lungs and the pulmonary system of particulate matter. Thus, youth who smoke are more likely than youth who do not smoke to contract upper respiratory infections, and to have them longer.

Smokeless tobacco contains nitrosamines, which are carcinogenic and in excessive amounts cause substantial damage to the oral mucosa, even after relatively short-term use (Offenbacher and Weathers 1985; U.S. Department of Health and Human Services 1986). The long-term health consequences of chronic cigarette use are well known: an increased risk of cardiovascular disease, cancer, and stroke (U.S. Department of Health and Human Services 1979). In individuals who have chronically used smokeless tobacco, the most widely recognized health consequences are found in the oral mucosa in the form of leukoplakia, gingivitis, hairy tongue, and cancers of the lip, tongue, salivary glands, floor of the mouth, and other structures (Offenbacher and Weathers 1985; U.S. Department of Health and Human Services 1986).

Cigarette smoking during childhood and adolescence results in coughing and phlegm production, an increased number and severity of respiratory illnesses, decreased physical fitness, an unfavorable lipid profile, and potential retardation in the rate of lung growth and the level of maximum lung function. People who begin to smoke at an early age are more likely to develop severe levels of nicotine addiction than those who start at a later age. Tobacco use is associated with alcohol and illicit drug use and is generally the first drug used by young people who enter a sequence of drug use that can include tobacco, alcohol, marijuana, and other illicit drugs. Smokeless tobacco use by adolescents is associated with early indicators of periodontal degeneration and with lesions in the oral soft tissue.

Although physical reactions to tobacco use have both immediate and long-term health consequences, young people do not consider the risk for long-term negative consequences. They use tobacco for immediate reasons, such as peer pressure and in reaction to the more powerful influences of advertising and cigarette promotion (Evans et al. 1995). Youth, however, may be concerned with the overt physical indications of tobacco use, such as stained hands and teeth and an unpleasant odor in hair and clothes (U.S. Department of Health and Human Services 1994).

Risk and Protective Factors for Tobacco Use Among Youth

In studies of substance abuse, a risk factor has been defined as "an individual attribute, individual characteristic, situational condition, or environmental context that increases the probability of drug use or abuse or a transition in level of involvement with drugs" (Clayton 1992). A protective factor has been defined as an influence that "inhibits, reduces, or buffers the probability of drug use, abuse, or a transition in the level of involvement with drugs" (Clayton 1992). Risk and protective factors may be integrated into the genetic and biological makeup of an individual, may be acquired characteristics, or may exist within the various contexts in which an individual acts out his or her roles in life.

Following is a summary of the most widely used general taxonomy of risk and protective factors for substance abuse (Hawkins et al. 1992):

  • Federal, State, and local laws and norms (e.g., taxation; laws making drugs illegal; laws regulating how, when, where, and to whom legal drugs can be distributed)
  • Cultural norms (e.g., marketing images of tobacco and tobacco users, social pressure from peers to use tobacco)
  • Availability of tobacco products
  • Poverty and social disorganization (e.g., extreme economic deprivation, neighborhood disorganization)
  • Physiological factors (e.g., biochemical, genetic)
  • Family factors (e.g., family drug use, family management practices, family conflict, poor bonding with family)
  • School factors (e.g., academic failure, low intelligence, low commitment to school, rejection by peers in elementary school)
  • Early and persistent problem behaviors (early onset of drug use)
  • Peer factors, personality, attitudes (e.g., association with drug-using peers, alienation and rebellious-ness, attitudes favorable to drug use)
Unfortunately, research on specific risk and protective factors for tobacco use is relatively new (Bry et al. 1982; Newcomb et al. 1986). This knowledge base is further limited because most studies have focused on risk rather than protective factors and predictors of initiation rather than predictors of the other stages (Clayton 1992) of cigarette and smokeless tobacco use (e.g., continuation, progression, and addiction within the tobacco category and from tobacco to other illicit drugs, regression, cessation, and relapse prevention).

A number of risk factors have nevertheless been shown to be related to the initiation of tobacco use by youth (U.S. Department of Health and Human Services 1994). In the 1994 Surgeon General's Report, these are classified into sociodemographic, environmental, behavioral, and personal factors (Table 1-5). Following is a general overview of these factors, which can help provide a picture of the antecedents of tobacco use among youth. It should be borne in mind that much more needs to be discovered about these risk factors. A review of the literature on these risk factors can be found in the Surgeon General's report Preventing Tobacco Use Among Young People (U.S. Department of Health and Human Services 1994).

TABLE 1-5: Psychosocial Risk Factors in the Initiation of Tobacco Use Among Adolescents.

Table

TABLE 1-5: Psychosocial Risk Factors in the Initiation of Tobacco Use Among Adolescents.

Sociodemographic Factors

Sociodemographic factors that affect an adolescent's risk for initiating tobacco use have an indirect but powerful influence. An adolescent's social development may be hampered when there is a discrepancy between what he or she aspires to and what he or she is actually able to achieve, due to the limitations of the political, social, economic, and educational systems of society. Among the most notable of these risk factors are the following (U.S. Department of Health and Human Services 1994):

  • Low socioeconomic status
  • Low parental educational attainment
  • Single-parent household
  • Developmental challenges of adolescence:
    • - Physical and sexual maturation
    • - Cultural pressures to make the transition to adulthood
    • - Establishing self-identity and personal values
  • Male gender
  • Hispanic or black ethnic/cultural background

Environmental Factors

Environmental factors are those that are, or are perceived to be, external to an individual but that may nonetheless affect his or her behavior. A number of these factors are related to the individual's family of origin, while others have to do with social norms and expectations:

  • Acceptability and availability of tobacco products
  • Interpersonal factors:
    • - Parental tobacco use
    • - Sibling tobacco use
    • - Peer tobacco use
    • - Strong attachments to peers who use tobacco
    • - Participation in antisocial activities
  • Perceived environmental factors:
    • - Normative expectations of tobacco use
    • - Social support for tobacco use
    • - Parental acceptance or tolerance of tobacco use
    • - Adult discrepancy (i.e., between "adult" behaviors in which an adolescent wants to participate and what was actually done by his or her parents at the same age)

Another environmental risk/protective factor for cigarette use that deserves special mention is region of residence. In the MTF study of high school seniors from 1975 through 1993, those from the Northeast consistently had the highest prevalence of daily smoking, whereas those from the West had the lowest. Since 1975, the prevalence of daily smoking among high-school seniors from the South has been consistently lower than that among seniors from either the Northeast or the North Central States.

Behavioral Factors

Certain patterns of behavior predispose youth to begin using tobacco. Most prominent of these are behaviors that lead to the perception of tobacco use as functional or appropriate:

  • Low academic achievement
  • Use of alcohol or illicit drugs
  • Risk-taking, rebellious, and deviant behavior patterns
  • Strong attachment to peer groups and weak attachment to family
  • Lack of participation in athletics or other health-enhancing behaviors
  • Weak or absent resistance or refusal skills
  • Stress

Personal Factors

Personal factors are the cognitive processes, values, personality constructs, and sense of psychological well-being inherent to the individual and through which societal and environmental influences are filtered. To some extent, these factors explain differences in the behaviors of people exposed to the same outside influences. A number of personal risk factors have been shown to be related to the start of tobacco use by youth:

  • Denial or minimization of health consequences of tobacco use
  • Perception of tobacco use as serving a purpose (e.g., to seem mature, gain peer acceptance, cope with personal problems or boredom)
  • Positive subjective expected utility (i.e., the extent to which a behavior is expected to have positive or negative effects)
  • Low self-esteem (i.e., one's subjective evaluation of oneself)
  • Perceived negative self-image (i.e., one's perceived external image)
  • Low self-confidence
  • Deficiencies in self-control (e.g., impulsiveness and sensation-seeking tendencies)
  • Low psychological well-being
The variety and diversity of these personal risk factors suggests that researchers in this area have not yet identified a universally accepted, limited constellation of personal factors that explain why adolescents begin using tobacco.

Summary

More research needs to be conducted on the risk and protective factors for initiation as well as other stages of use of tobacco products (continuation, progression, addiction, regression, cessation, and relapse prevention) before definitive statements can be made. As the knowledge base expands, it will be possible to provide States and communities with much clearer advice concerning approaches for reducing youth tobacco use. In the meantime, a number of observations can be drawn from the information presented in this chapter:

  • Use of and attitudes toward tobacco use have changed over time. A largely negative view of tobacco use at the end of the 19th century changed to a more positive view, promulgated by lobbying and advertising by the tobacco industry in the early 20th century. In today's more health-conscious society that view is once again evolving to emphasize the negative aspects of tobacco use.
  • Current negative attitudes about tobacco use are reflected in the increase in restrictions on its use in public facilities and workplaces.
  • These same attitudes and restrictions, however, are not mirrored in the use of tobacco among youth, which seems to be on the rise.
  • The complexity of the reasons for and patterns of tobacco use among youth requires that epidemiological analyses include separate profiles of cigarettes only, smokeless tobacco only, and concomitant use of both.
  • A better understanding of the risk and protective factors for tobacco use among youth is needed to develop and institute prevention programs that are effective in reaching their intended audiences and delaying, if not preventing, the adverse consequences of this threat to the health of our nation's children.

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