p,a,vn ting Tobacco Use Among Young People

USDHHS 1989b). Since the recalled age at initiation is
often 10 or more years younger than the age of the
respondent at the time of the survey, recall bias may
affect the reliability of these estimates.

  In the 1991 NHSDA, 69 percent of respondents
aged 30 through 39 years reported trying a cigarette by
age 18. Of all persons who had ever tried a cigarette, 88
percent had tried their first cigarette by age 18. The mean
age of first trying a cigarette was 14.5 years. Thirty-five
percent of the respondents had become daily smokers by
age 18. Of those who had ever sinoked daily, 71 percent
had smoked daily by age 18. The mean age of becoming
a daily smoker was 17.7 years.

  Surveys conducted in 1991 among school-aged stu-
dents, while lacking information on postadolescent ini-
tiation, provide information of more recent initiation
patterns (i.e., during the 1980s and early 1990s). Among
12th~grade students surveyed in 1991,22 percent of TAPS
respondents, 40 percent of NHSDA respondents, 40 per-
cent of MTFI' respondents, and 37 percent of YRBS re-
spondents first tried a cigarette by age 14 (Table 8).
About 60 percent of the respondents in the NHSDA, the
MTFP, and the YRBS and about 50 percent of the TAPS
respondents had smoked by their senior year. Daily
cigarette use began by age 16 (or the 10th grade) for 18 to
23 percent of respondents to the NHSDA, the MTFP, and
the YRBS (Table 9). By their senior year, 22 to 29 percent
of these respondents had become daily smokers.

Other Patterns of Smoking
  Two of the surveys gathered further information
about smoking patterns-the number of days per month

an adolescent smoked and the number of cigarettes the
adolescent smoked per day. In the 1991 YRBS, responses
indicated that in general, the greater number of days
students reported smoking during the 30 days preceding
the survey, the greater the number of cigarettes they
smoked per day (Table 10). For example, 49 percent of
students who smoked cigarettes on only one or two days
during the preceding 30 days smoked fewer than one
cigarette per day; among students who smoked ciga-
rettes on all 30 days, 47 percent smoked 11 or more per
day.

  Smoking patterns were also reported recently by
Moss et al. (1992), using 1989 TAPS data (Table 11).
About 41 percent of teenage smokers-whether male or
female-smoked every day, and about one in four
smoked on fewer than five of the preceding 30 days. The
percentage of smokers who smoked every day increased
with increasing age; 48 percent of 16- through l&year-
old smokers smoked every day. About twice as many
white as black teenagers smoked every day (42 vs. 22
percent), and blacks were more likely than whites to
have smoked on fewer than five days. Non-Hispanics
were more likely than Hispanics to smoke every day.

  Sixteen percent of 12- through l&year-old TAPS
respondents who smoked during the week preceding
the survey smoked 20 or more cigarettes daily. Males
smoked more cigarettes daily than females. Older stu-
dents smoked more cigarettes daily than younger stu-
dents; 47 percent of 16- through l&year-old smokers
and 11 percent of 12- and 13-year-old smokers reported
smoking 10 or more cigarettes daily. Whites smoked
more cigarettes daily than blacks, and non-Hispanics

Table 10.  Percent distribution of the number of cigarettes smoked per day, by the number of days on
    which cigarettes were smoked during the 30 days preceding the survey, Youth Risk Behavior
     Survey, United States, 1991

Number of days
cigarettes were smoked

<l

  Cigarettes smoked per day

1       2-s     6-10    11-20    >20   Total     N

1-2                49.2      29.2      18.0     1.7     1.0     0.2    100 756
3-5                25.3      29.2      41.5     3.6      0.4     0.0    100 452
6-9                7.0      32.5      54.4     5.8      0.4      0.0    100 273

lo-19               7.4     13.0     66.5     10.8     1.8     0.4    100 326
20-29               0.7      4.6      61.4     27.9     5.4     0.0    100 294
30                 0.1      0.3      26.5     26.0     36.6     10.8    100 803
Average             14.8      15.0      37.2     14.8     14.1     4.0    100 2,904
Source: Centers for Disease Control and Prevention, Division of Adolescent and School Health (unpublished data).

Epidemiology  51


Surgeon General's Report

Table 11.  Percentage of current smokers by the number of days smoked during the past month and the
    average number of cigarettes smoked daily, by gender, age, and race/Hispanic origin, Teenage
     Attitudes and Practices Survey, United States, 1989
               Number of days              Number of cigarettes
              smoked during past month*            smoked daily+

                         Every
Category            <5     5-9    10-29   day         <5      5-9    l&19    220

Overall            24.1     8.7    26.4     40.8         37.9    20.4   25.7    16.0

Gender
Male            23.9    8.5    26.6     41.0         33.9    19.3   27.6    19.2
Female           24.3    8.9    26.2     40.6         42.7    21.6   ' 23.5    12.1

Age (years)
12-13             51.9    8.3*    23.3     16.5t        64.3    24.6*   11.0*     0.0

14-15            28.4     9.8    34.5     27.3         55.5    17.2   23.0     4.3*

16-18            20.0     8.4    24.1     47.5         31.6    21.1    27.2    20.1

Race
White            23.4     8.4    26.2     42.0         36.6    20.1    26.5    16.8

Black            37.0    15.0*    26.5     21.6         60.3    20.5t   16.3t    2.9*

Hispanic origin
Hispanic          30.7    11.2*    31.9     26.3         59.2    22.5   11.6s    6.6%
Non-Hispanic       23.5     8.5    26.0     42.0         36.3    20.2   26.9    16.7

Source: Moss et al. (1992).
*Excludes unknown number of days smoked.
`Excludes unknown number of cigarettes smoked daily and none smoked during the past week.
SEstimate does not meet standards of reliability or precision (< 30 percent relative standard error).

were heavier smokers than Hispanics. Thus, not only
were black and Hispanic adolescents less likely to smoke
than whites, but those who did smoke, smoked fewer
cigarettes each day than their white adolescent counter-
parts.

  On average, persons 12 through 18 years old who
smoked the week before the survey (N = 1,099) smoked 9
cigarettes each day. Males smoked IO cigarettes daily
and females smoked 8. Whites averaged 9 cigarettes per
day and blacks averaged 6 (1989 TAPS, CDC, Office on
Smoking and Health [OSHI, unpublished data). The
overall average for adult smokers is 19 cigarettes a day
(CDC 1992aI.

Initiation Continuum of Smoking

  The 1989 Surgeon General's report on smoking
and health described the continuum of smoking be-
havior as one that occurs in four stages: initiation,

experimentation, regular smoking, and dependence
or addiction (USDHHS 1989b). The report also ac-
knowledged a preparatory stage that occurred before
any initial smoking (Flay et al. 1983). These five stages
are examined in detail in Chapter 4 (see "Develop-
mental Stages of Smoking").

   Data from the 1989 TAPS were used to create an
initiation continuum similar to the smoking continuum
for adults that was described in the 1989 Surgeon
General's report (Pierceand Hatziandreu 199O;USDHHS
1989b). This initiation continuum incorporates mea-
sures of smoking behavior and measures of the possibil-
ity that a respondent will smoke in the future. In 1989,
54.5 percent of persons 12 through 18 years old reported
that they had never smoked a cigarette, not even a few
puffs (TabIe 12). These respondents were asked to report
(1) whether they thought they would try a cigarette soon
("yes, " "no," and "don't know"), (2) whether they would

52 Epidemiology


Prewnting Tobacco Use Among Young People

Table 12. Percent distribution of an initiation continuum for cigarette smoking among persons aged 12-18
    yeas, by age, gender, and race/Hispanic origin, Teenage Attitudes and Practices Survey, United
      States, 1989

Uptake continuum category

   Age (years)         Gender

Overall lZ-14 15-16 17-18       Male Female

Race/Hispanic origin

White/ Black/
non-   non-
His-   His-
panic  panic Hispanic

1.

Never tried smoking,
not susceptible

44.3

2.

Never tried smoking,
susceptible

10.2

3.

Tried smoking, not a whole
cigarette, not susceptible

7.9

4.

Tried smoking, not a whole
cigarette, susceptible

3.3

5.   Smoked l-99 cigarettes,       13.5

but none in the f&t 30 days,
and not intending to smoke
in a year

6.

Smoked l-99 cigarettes, but none
in the last 30 days, and might
smoke in a year

7.

Smoked 2 100 cigarettes, but
none in the last 30 days, and not
intending to smoke in a year

8.

Smoked 2 100 cigarettes, but
none in the last 30 days, and
might smoke in a year

9.

10.

11.

Smoked l-99 cigarettes,
at least some in the
past 30 days

Smoked 2 100 cigarettes and
smoked on l-19 days during
the past 30 days

Smoked at least 100 cigarettes
and smoked on at least 20
days during the past 30 days

4.1

0.9

0.4

5.9

2.2

7.3

55.5  40.1  32.9      42.0  46.8    42.3  54.0 40.3

15.8   8.4   4.3      10.1  10.3     9.4  10.5 15.9

6:6

4.3

7.5

4.2

0.2

0.2

3.7

0.7

1.3

8.3   9.5       8.6   7.2     7.1  12.7 8.0

3.2   2.1       3.8   2.7     2.6   5.2 5.4

16.6  18.8      13.6  13.4    14.6   9.6 12.6

4.8   3.1       4.2   3.9     4.4   1.9 5.4

1.0   1.9       1.2   0.7     1.2   0.0 0.8

0.4

0.7

0.4

0.4

0.5

0.3 0.5

7.3   7.4       5.8   5.9     6.3   4.1 5.6

2.6   3.8       2.3   2.0     2.6   0.6 1.7

7.5  15.5       7.8   6.7     9.1   1.2 4.0

Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data).

Epidemiology 53


Surgeon General's Report

smoke a cigarette if one of their best friends were to offer
them one ("definitely yes," "probably yes," "probably
not," "definitelynot," and "don't know"), and (3) whether
they thought they would be smoking cigarettes in one
year ("definitely yes," "probably yes," "probably not,"
"definitely not," and "don't know"). Never smokers who
answered "no" to the first question, "definitely not" to the
second question, and "definitelynot" to the third question
were categorized as "not susceptible" to smoking. Those
who answered these three questions in any other way
were considered susceptible to smoking in the future
(Pierce et al. 1993). According to these criteria, 44 percent
of all TAPS respondents had never tried a cigarette and
were not considered susceptible to smoking, and
10 percent had never tried smoking but were con-
sidered susceptible.

  Adolescents who had tried smoking but had not
smoked a whole cigarette accounted for 11 percent of
TAPS respondents; 8 percent were judged to be not
susceptible to smoking in the future, and 3 percent were
judged susceptible. Those who had smoked at least one
cigarette were only asked question 3, above, concerning
whether or not they thought they would be smoking in a
year. A large category (14 percent of all respondents)
was composed of those who had smoked at least 1 but
fewer than 100 cigarettes, who had not smoked in the
preceding 30 days, and who definitely did not intend to
smoke in a year. Another 4 percent had smoked from
1 to 99 cigarettes, had not smoked in the preceding
30 days, and were not definite in their resolve to not be
smoking in a year. Slightly more than 1 percent of TAPS
respondents had smoked at least 100 cigarettes but had
not smoked in the preceding 30 days; these respondents
are considered to be former smokers (USDHHS 1989b,
199Ob).

  Finally, among the 15 percent of respondents who
smoked in the preceding 30 days, about 45 percent
(6 percent of all respondents) had smoked fewer than
100 cigarettes in their lifetime. Although current smok-
ers, these persons were still at a relatively early stage in
the process of smoking initiation. Among those who
had smoked at least 100 cigarettes and had smoked in
the preceding month, more than three-fourths (7 percent
of all respondents) had smoked on 20 or more of those
30 days.

   The distribution of this continuum was similar for
males and females. White adolescents were more likely
to be further along the continuum than were Hispanic
and black adolescents.

Cigarette Brand Preference
  Knowing what brands of cigarettes are preferred
by young smokers may aid the development of

smoking prevention programs and may provide insight
into the influence that cigarette advertising may have on
YOU% people.

  ln 19781980, the NHE assessed the brands of ciga-
rettes most often used by current smokers (CDC, OSH,
unpublished data). Among 707 respondents who were 18
or 19 years old, the most commonly used brands were
Marlboro (37 percent), Kool (14 percent), Salem (10 per-
cent), Winston (9 percent), Newport (8 percent), Virginia
Slims (5 percent), Merit (4 percent), Benson & Hedges
(3 percent), and Camel (2 percent). Ten percent of females
and no males used Virginia Slims. Among whites,
Marlboro (42 percent), Kool (10 percent), Winston
(10 percent), Salem (8 percent), Virginia Slims (6 percent),
and Newport (6 percent) were the most commonly used
brands. Among blacks, Kool (46 percent), Newport
(25 percent), Salem (20 percent), and Benson & Hedges
(6 percent) were the most commonly smoked brands.

  In the 1989 TAPS, adolescent respondents who
generally bought their own cigarettes were asked what
brand they usually purchased. More than two-thirds of
these smokers usually purchased Marlboro (Table 13).
Preference for Marlboro did not differ appreciably by
gender, Hispanic origin, age, or region of the country.
White adolescent smokers were much more likely to
smoke Marlboro cigarettes than were black adolescent
smokers (71 vs. 9 percent).

  The next most popular brands, Newport and Camel,
each accounted for only 8 percent of the overall
population's preference. Black smokers, however, were
much more likely to smoke Newport cigarettes than
were white smokers (61 vs. 6 percent), although sample
sizes of blacks were small. Smokers who resided in the
Northeast and the Midwest were more likely to smoke
Newport cigarettes than were smokers in the South and
the West. Among white adolescents, Newport was more
popular in the Northeast (14 percent) and the Midwest
(7 percent) than in the South (1 percent) and the West
(1 percent) (CDC 1992b). The Camel brand was more
popular among male (11 percent) than female smokers
(5 percent), among white (8 percent) than black smokers
(3 percent), and among smokers residing in the West
(18 percent) than among those residing in the other three
regions (from 4 to 7 percent).

   Several nonnational studies conducted since the
1989 TAPS suggest that Camel cigarettes may be gaining
in popularity among young smokers In a 1990 survey of
ninth-grade students in 10 U.S. communities included in
the Community Intervention Trial for Smoking Cessa-
tion (COMMIT) evaluation, 43 percent of smokers who
usually bought their own cigarettes bought Marlboro,
30 percent bought Camel, and 20 percent bought New-
port (CDC 1992b). As TAPS data also indicated, adoles-
cent smokers residing in communities in the western

54 Epidemiology


prL~wting Tobacco Use Among Young People

Table 13.  Percent distribution of cigarette brands that 12-18-year-old current smokers* reported usually
    buying, by gender, race/Hispanic origin,' age, and region, Teenage Attitudes and Practices Survey,
     United States, 1989

Category

                                  Benson
                                   &
Number Marlboro  Newport Camel Winston Hedges Salem Kool Merit Vantage Other

OverallS      865

Gender
Male       477

FemaIe      388

Race

White      807

Black        41

Hispanic origin
Hispanic     46
Non-Hispanic 817

Age (years)
12-15       195

16-18       670

Region
Northeast 184

Midwest     247

south      281

West       153

Overall market
share, 1989

68.7      8.2    8.1    3.2    1.5     1.4    1.0   0.5    0.1    7.3

68.9      7.3    10.9    3.6    0.5    0.2    1.9   0.7    0.2    6.0

68.4      9.4     4.6    2.6    2.9    2.9    0.0   0.3    0.0    8.9

71.4      5.6    8.4    3.4    1.0    1.3    0.6   0.5    0.1    7.6

8.7     61.3    3.1    0.0    9.7    3.3   10.9   0.0    0.0    2.9

60.9     12.8    7.6    0.0    2.8    3.7    5.8   0.0    0.0    6.5

69.1      8.0     8.1    3.3    1.5    1.3    0.8   0.5    0.1    7.3

74.8      6.1     8.7    2.5    0.9    0.4

67.0      8.8    7.9    3.3    1.7    1.6

1.1

1.0

0.0

1.1

2.1

0.0

5.9

0.0    0.0    6.5

0.6    0.1    7.8

68.4     16.2    4:l    0.0    2.3    0.0

70.2     10.0    7.3    3.4    2.2    0.0

67.2    5.b    6.1    6.2    1.1    2.9

69.6      2.0    18.1    0.7    0.6    2.3

0.6    0.5    7.9

0.5    0.0    5.3

0.4    0.0    9.1

0.6    0.0    6.2

26.3      4.7    3.9    9.1    6.2    3.9

3.8    2.5   33.7

Sources: Centers for Disease Control (1992b); Maxwell (1992).
*Persons who reported smoking on one or more of the 30 days preceding the survey.
`Excludes the racial category "other" (N = 17). Ethnicity for two persons was unknown.
`Data were weighted to provide national estimates.

United States showed more preference for Camel ciga-
rettes than did smokers from other regions of the nation.
Other studies conducted after TAPS report rates of Camel
preference among adolescent smokers that are consis-
tent with the COMMIT survey results (DiFranza et al.
1991; Pierce, Gilpin, et al. 1991).

  In June and July 1992, the George H. Gallup Inter-
national Institute 0992) conducted a telephone survey of
a nationwide sample of 1,125 youths 12 through 17 years
old. Smokers (those who reported having smoked at

least one cigarette during the 30 days preceding the
interview) were disproportionately oversampled, and
the data were weighted to represent the adolescent
population. Smokers were asked, `Thinking now about
the last time you bought cigarettes for yourself, what
brand did you happen to buy on that occasion?"
Marlboro was the brand bought by 53 percent of these
teenage smokers, Camel by 16 percent, and Newport
by 8 percent. The most popular brand among blacks in
this survey was Newport (54 percent preference).

Epidemiology 55


Surgeon Generul's Reporf

Trends in Cigarette Smoking            Current Smoking

Ever Smoking

  Data from the NTIS, the NHSDA, and the MTFP
suggest that the prevalence of ever smoking among ado-
lescents has declined since the 1970s (Table 14). In the
NHSDA, the prevalence of smoking among youths 17
through 19 years old declined from 78 percent in 1979 to
64 percent in 1991, an average decline of 1.2 percentage
points per year. In the MTFP, the prevalence among 17-
and 18-year-olds decreased from 76 percent in 1977 to 62
percent in 1992, an average decline of 0.9 percentage
points per year. In the NHIS, the percentage of 18- and
19-year-olds who had smoked at least 100 cigarettes
dropped from 41 percent in 1974 to 25 percent in 1991, an
average decline of 1 .O percentage points each year.

   NHIS data have been used to examine historical
trends in smoking by reconstructing the prevalence of
cigarette smoking for the decades in this century before
systematic surveillance of cigarette smoking was con-
ducted WSDHHS 1980,1985,1991b; Harris 1983). Us-
ing information on a respondent's date of birth, age
at initiation of fairly regular smoking, and duration
of abstinence (for former smokers), the smoking status
of the respondent can be assessed for any given year.
For this report, the reconstructed prevalence of smoking
among those aged 10 through 19 years is reported for the
years 1920 through 1980.       ,.
  Except for 1980, smoking during this 60-year pe-

riod was more common among white and black ado-
Iescent males than among white and black adolescent
females (Figure I). The prevalence of cigarette smoking

Figure 1.  Trends in the reconstructed prevalence* of cigarette smoking among IO-19-year-olds, by
     gender and race, United States, 1920 -1980

25 1

m White males

IIII~II Black males

                                                                           -  White females

                                                                           - -  Black females
0             I           I           I           I           I         1
1920        1930        1940        1950        1960        1970        1980
                              Year

Source: U.S. Department of Health and Human Services (1991b). Data sources are the 1970,1978,1979,1980, and 1987
National Health Interview Surveys.
The smoking prevalence for each of the years indicated was calculated for people who would have been 10-19 years old in
each of those years by using the survey respondents' date of birth, age when they first began smoking regularly, and age
when they quit smoking (see Appendix 2).

56 Epidemiology


Pmwrlting TO~UCCO Use Among Young People

Table 14. Trends in the prevalence (%I of ever smoking among young people, National Teenage Tobacco
    Surveys (NTIS), National Household Surveys on Drug Abuse (NHSDA),Monitoring the Future
   Projeci (MTFP), National Health Interview Surveys (NHIS), United States, 1968-1992

Year        NITS'            NHSDA'          MTFPt           NHIS_

1968

1970

1972

1974

1976

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

36.1

40.8

39.2

41.3               69.5

                 64.1

                 67.8

34.0               78.1

72.6

63.2

66.2

61.4

63.6

41.1

75.4

75.8

75.3              36.7

74.0              39.3

71.0              34.1

71 .o

70.1

70.6               34.5

69.7

68.8              29.8

67.6

67.2              26.2

66.4              27.7

65.7

64.4               27.6

63.1              25.3

61.8

Sources: NTTS: U.S. Department of Health, Education, and Welfare (USDHEW) (1972,1976,1979b); NHSDA: Centers for
Disease Control and Prevention (CDC), Office on Smoking and Health (OSH) (unpublished data on 1974-1991 surveys);
MTFP: Johnston, O'Malley, Bachman (in press); NHIS: CDC, OSH (unpublished data on 1974-1991 surveys).
`NTTS, aged 17-18 years. Published reports (USDHEW 1972,1976,1979b) merge never smokers and experimenters (those
who tried or experimented with smoking, but who had not yet smoked 100 cigarettes) into one category. By definition,
therefore, the NTIS will underestimate the percentage of ever smokers. The trends, however, use the same definition.
`NHSDA, aged 17-19 years. Those who reported in 1974,1976, and 1977 that they were current smokers and those who were
not current smokers but who responded "yes" to the question, "Have you ever smoked cigarettes?" were classified as ever
smokers for those years. For the years 1979 through 1991, ever smoking status was determined by response to the question,
"About how old were you when you first tried a cigarette?" The prevalence of ever smoking is the complement of the
response "Never tried a cigarette."
tMTFP high school seniors, aged 17-18 years. Based on response to the question, "Have you ever smoked cigarettes?"
`NHIS, aged 18-19 years. Based on response to the question, "Have you smoked at least 100 cigarettes in your entire life?"
Those who had smoked at least 100 cigarettes by the time of the survey were classified as ever smokers.
`Available information from published sources (USDHEW 1972,1976,1979b) do not permit exact comparisons with the 1989
TAPS data.

Epidemiology 57


Surgeon General's Report

remained higher among white adolescent males than
among black adolescent males. Smoking prevalence
gradually increased among white males during the six
decades covered by the data. Among black males, preva-
lence declined between 1950 and 1980.

  Among female adolescents, the reconstructed
prevalence of current smoking increased steadily from
1920 through 1980; in 1980, the prevalence among fe-
males surpassed that among males for the first time
during the six-decade study period. Prevalence among
white females has been higher than among black females
since 1950. The data indicate a sharp increase in female
smoking prevalence between 1970 and 1980.

  Trends in current smoking prevalence over the past
two decades indicate that for both males and females,
past-month smoking declined sharply in the late 1970s or,
early 1980s (Table 15). Progress then slowed consider-
ably, especially for males. In the MTFP surveys, the past-
month smoking prevalence among males actually
increased from 27 percent in 1981 to 29 percent in 1992; in
the NHSDA and the THIS, male smoking prevalence was
about the same in 1985 and in 1991. The prevalence among
adolescent females in the MTFP and NHIS surveys was
only slightly lower in 1991 and 1992 than in 1985; in the
1991 NHSDA, female smoking prevalence was about the
same as in 1985. By the early 198Os, smoking was gener-
ally more common among females than among males.
By 1991, however, adolescent females and males had
almost equivalent smoking prevalence.

  In all three surveys with information on race, the
prevalence of current smoking declined during the late
1970s or early 1980s for both black and white older
adolescents (Table 16). In the middle 197Os, current
smoking was almost equally common among blacks and
whites. At the end of that decade, black adolescents
were less likely to be current smokers than white adoles-
cents; this trend continued during the 1980s. Among
white high school seniors in the MTF'P, current smoking
was more prevalent in 1992 (32 percent) than in 1981(30
percent). In all three surveys, prevalence among older
white adolescents was slightly higher in 1991 and 1992
than it was in 1985.

  Wallace and Bachman (1991) reported that white
high school seniors were more than twice as likely as black
high school seniors to report smoking in the past month,
even after statistical control was made for factors such as
parental education, number of parents living at home,
urban or rural location, educational plans, academic per-
formance, and religious attitudes and practices.

  MTJ!P trend data are available for daily smoking
among racial and ethnic subgroups (Bachmanet al. 1991).
In general, for Asian, black, white, Hispanic, and Ameri-
can Indian male and female high school seniors, the
prevalence of daily smoking declined from 1976-1984. The

decline continued at a reduced rate during the late 1980s for
most groups and ceased altogether among white males.

  Overall, the prevalence of daily smoking among
high school seniors was 29 percent in 1976,21 percent in
1980, and 17 percent in 1992. Among males, the preva-
lence was 28 percent in 1976,19 percent in 1980, and 17
percent in 1992; among females, 29 percent smoked daily
in 1976, 24 percent in 1980, and 17 percent in 1992.
Among whites, the prevalence of daily smoking de-
clined from 29 percent in 1976 to 22 percent in 1980; the
prevalence was 20 percent in 1992. Among blacks, the
prevalence of daily smoking declined from 27 percent in
1976 to 16 percent in 1980 and continued to decline to 4
percent in 1992 (Bachman, Johnston, O'Malley 198Oa,
1981; ISR, University of Michigan, unpublished data).

  Data on smoking among the nation's high school
seniors have also been reported as a function of parental
education (NCHS 1993). Interestingly, the prevalence of
past-month smoking decreased slightly from 1980
through 1991 among those seniors whose parents had
completed fewer years of formal education and increased
slightly during that period among those seniors whose
parents had relatively more years of formal education.
For example, among those seniors whose parents, on
average, did not graduate from high school, the preva-
lence of past-month smoking decreased from 33 percent
in 1980 to 31 percent in 1991; among seniors whose
parents graduated from high school, prevalence of smok-
ing was 34 percent in 1980 and 29 percent in 1991. Among
seniors whose parents had some postgraduate educa-
tion, the prevalence of smoking was 24 percent in 1980
and 27 percent in 1991.

Age or Grade When Smoking Begins

  The age at which people become regular cigarette
smokers has been measured in national surveys con-
ducted in 1955,1966, 1970,1978,1979,1980,1987, and
1988 (Haenszel, Shimkin, Miller 1955; NCHS 1970;
USDHHS 1980, 1989b, 1991b; CDC 1991b). Data from
the 1955 Current Population Survey (Haenszel, Shimkin,
Miller 1955) suggest that during the first half of the
century, people became regular smokers at progressively
younger ages. The data for males are limited, however,
because before 1974 many of the reports for men were
provided by proxy respondents.

  To reduce proxy responses, Ahmed and Gleeson
(NCHS 1970) limited their analysis of data from the 1966
Current Population Survey to females. These investiga-
tors concluded that between 1955 and 1966, U. S. women
began smoking at an earlier age.

  For the present report, the likelihood of having
become a regular cigarette smoker by age 18 was deter-
mined for females surveyed in the 1970,1978-1980, and

58 Epidemiology


preventing TO~UCCO Use Among Young People

Table 15.  Trends in the prevalence (o/o) of current smoking* among young people, by gender, National
    Teenage Tobacco Surveys WITSl, National Household Surveys on Drug Abuse (NHSDA),
     Monitoring the Future Project (MTFP), National Health Interview Surveys (NHIS), United States,
       1968-1992

Year

   N-l-l-S            NHSDA            MTFP             NHIS

Males   Females     Males Females      Males   Females      Males Females
(aged 17-18 years)    (aged 17-19 years)    (aged 17-18 years)    (aged 18 -19 years)

1968      34.0

1970      37.8

1972      31.2

1974      32.6

1976
1977
1978

1979      19.6

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

21.0

24.1
26.0
26.4       47.8

        35.1

        39.0

38.7

52.0

47.2.

27.0       41.7t    41.7t

35.6    37.3

27.8    26.7

28.3.    32.9

28.9    20.2

27.0    27.0

37.7

36.7
34.5

31.2

26.8

26.5

26.8

28.0

25.9

28.2

27.9

27.0

28.0

27.7

29.1

29.0

29.2

39.1

39.7
38.1

37.1

33.4

31.6

32.6

31.6

31.9

31.4

30.6

31.4

28.9

29.0

29.2

27.5

26.1

36.9    30.8

30.6     33.5

29.5     34.2

24.9     27.8

23.3     31.4

20.1     24.5

21.6     20.9

19.6     23.1

21.7     18.0

22.0    20.6

Sources: N'ITS: U.S. Department of Health, Education, and Welfare (USDHEW) (1972,1976,1979b); NHSDA: Centers for
Disease Control and Prevention (CDC), Office on Smoking and Health (OSH) (unpublished data on 1974-1991 surveys);
MTFP: Bachman, Johnston, O'Malley (1980a, b, 1981,1984,1985,1987,1991); Johnston, Bachman, O'Malley (1980a, b, 1982,
1984,1986,1991,1992); Johnston, O'Malley, Bachman (1991a, in press); Institute for Social Research, University of
Michigan (unpublished data); NHIS: CDC, OSH (unpublished data in 1974-1991 surveys).
*For the NTTS, current smokers are those who state that they smoke less than one cigarette per week, one or more cigarettes
per week, or one or more cigarettes a day (USDHEW 1979b). For the NHSDA and the MTFP, current smoking is defined as
any cigarette smoking during the 30 days preceding the survey. For the NHIS, current smokers are those who report that
they have smoked at least 100 cigarettes and who respond "yes" to the question, "DO you smoke now?"
`The 1979 NHSDA determined current smoking status only for those respondents who had smoked at least 100 cigarettes
(lifetime). The National Institute on Drug Abuse later published adjusted 1979 estimates using data from the 1982 NHSDA
(Miller et al. 1983). The adjusted 1979 estimates used the ratio of the 1982 prevalence estimate, based on the 1979 definition,
to the prevalence estimate based on the definition used in other years (i.e., any smoking in the last 30 days, regardless of
whether the respondent had ever smoked 100 lifetime cigarettes). This table reports estimates based on the same adjust-
ment procedure.
rAvailable information from published sources (USDHEW 1972,1976,1979b) does not permit exact comparisons with the
1989 TAPS data.

Epidemiology 59


Surgeon General's Report

Table 16.  Trends in the prevalence (X) of current smoking* among white and black young people, National
     Household Surveys on Drug Abuse (NHSDAI, Monitoring the Future Project (MTFP), National
     Health Interview Surveys (NHISI, United States, 1974-1992

NHSDA+             MTPP

NHIS

Year

White    Black
(aged 17-19 years)

White    Black
(aged 17-18 years)

White    Black
(aged 18-19 years)

1974
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992

41.9     47.4
43.0     47.2
42.9     44.3

44.4$    37.7$

39.2     20.9

28.6     20.8

33.0     17.6

28.3      7.2
30.5     11.4

38.3     39.7
38.4     34.4
37.0     31.5
34.9     28.7
31.0     25.2
30.1     22.3
31.3     21.2
31.3     21.2
31.0     17.6
31.7     18.7
32.0     14.6
32.2     13.9
32.3     12.8
32.1     12.4
32.5     12.0
31.8      9.4
31.8      8.2

33.6     33.7

33.3     26.3
32.6    30.8
26.1      29.0

28.6      18.5

23.4      18.4

23.4      15.3
23.7      9.4

22.2      10.3
24.9      7.6

Sources: NTTS: U.S. Department of Health, Education, and.Welfare (1972,1976,1979b); NHSDA: Centers for Disease
Control and Prevention (CDC), Office on Smoking and Health (OSHI (unpublished data on 1974-1991 surveys); MTFP:
Bachman, Johnston, O'Malley (1980a, b, 1981, 1984,.1985,1987,1991); Johnston, Bachman, O'Malley (1980a, b, 1982,19&k
1986,1991,1992); Johnston, O'MaIIey, Bachman (1992a); Institute for Social Research, University of Michigan (unpublished
data); NHIS: CDC, DSH (unpublished data on 1974-1991 surveys).
*For the NHSDA and the MTFP, current smoking is defined as any cigarette smoking during the 30 days preceding the
survey. For the NHIS, current smokers are those who report that they have smoked at least 100 cigarettes and who
respond "yes" to the question, "Do you smoke now?"
`In the NHSDA, "white" and "black" include respondents of Hispanic origin, except for 1985.
tithe 1979 NHSDA determined current smoking status only for those respondents who had smoked at least 100 cigarettes
(lifetime). The National Institute on Drug Abuse later published adjusted 1979 estimates using data from the 1982 NHSDA
(Miller et al. 1983). The adjusted 1979 estimates used the ratio of the 1982 prevalence estimate, based on the 1979 definition,
to the prevalence estimate based on the definition used in other years (i.e., any smoking in the last 30 days, regardless of
whether the respondent had ever smoked 100 Iifetime cigarettes). This table reports estimates based on the same adjust-
ment procedure.

1987-1988 NHE (Figure 2). The data confirm that women
in the United States have started to smoke at increasingly
younger ages. The largest differences exist for women
who were at least 45 years old at the time of the survey.
The initiation curve for 18 through 24year-old females
surveyed in 1987 and 1988 is, by age 18, lower than that
for 18 through 24year-old females surveyed in 1978
through 1980, which is consistent with the notion that the
prevalence of cigarette smoking has declined recently
among young females (Table 15).

  Johnston, (YMalley, and Bachman (1992a) used
retrospective reports from h4TFP high school seniors to
describe trends in the initiation of daily smoking among
seniors. Their data show that the likelihood of becoming
a daily smoker at an earlier grade level increased sharply
during the early to middle 1970s for the 1976 through
1978 senior classes. From 1975 through 1977, this likeli-
hood decreased, and the grade of initiation declined or
leveled for the 1979-1986 and 1988 classes. The lifetime

60 Epidemiology


praenting Tobacco Use Among Young People

Figure 2. Cumulative percentage of females becoming regular cigarette smokers by age 18, by age at time of
    survey, United States, 1970,1978-1980, and 1987-1988

25
z
g 20
L
15

Age at time of survey:
-  18-24 years

3    5    7    9    11.   13    15    17
Age when respondent began smoking regularly (years)

     -
30-
   Age at time of survey:
25-  35-44years

20-

2
2
& 15-

c

lo-

  3    5    7    9 11    13    15    17
Age when respondent began smoking regularly (years)

25 1  Age at time of survey:

20-  55-64 years

2 15-
8
5
f lo-

3    5    7    9   11   13   15   17
Age when respondent began smoking regularly (years)

40-
  Age at time of survey:

Age at time of survey:
25-34 years

30-
30-

25-
25-
2 2
8 20-
8
% % 20-
a 15-
a
15-

  10-
  10-

  5-
  5-

   3 3    5 7
        5 7    9 9    11
                     11    13
                          13    15
                              15    17
                                  17
  Age when respondent began smoking regularly (years)
  Age when respondent began smoking regularly (years)
  30
  30-

  25 1 Age at time
   Age at time of survey:
            of survey:
  25 -  45-54 years
   45-54 years

  20-
  20-
F F
8 15-
8
ti ti 15-

f,
f,

  lo-
  lo-

  5-
  5-

  0 0
    3    5 7    9    11    13    15    17
  Age when respondent began smoking regularly (years)

  12-
  12- Age at time of survey:
   Age at time of survey:

  lo-
  lo- 2 65 years
   2 65 years

  8-
  8-
5 5
2 2  6-
  6-
k k

  4-
  4-

   2-
   2-

  0 0
   3 3 5 7 9 11 13 15 17
      5 7    9    11   13   15   17
  Age when respondent began smoking regularly (years)

3    5    7    9    11    13    15    17
Age when respondent began smoking regularly (years)

Age when respondent began smoking regularly (years)

Source: National Health Interview Surveys 1970,1978,1979,1980,1987,1988,
Centers for Disease Control and Prevention, Office on Smoking and Health
(unpublished data).

- 1987-1988 Surveys

- 1978-1980 Surveys

- - 1970 Survey

Epidemiology 61


Surgeon Germal's Report

prevalence of daily cigarette smoking at aII grade levels
increased among the classes of 1989,1990, and 1991.

Number of Cigarettes Smoked Each Day

  Trends in the intensity of smoking among MTFI'
high school seniors indicate that since 1976, the propor-
tion of heavy smokers (2 one-haIf pack per day) has
decreased and the proportion of never smokers has in-
creased (Figure 3). For example, in 1976,25 percent of
high school seniors had never smoked, and 19 percent
were heavy smokers; by 1992, 38 percent had never
smoked, and 10 percent were heavy smokers (Bachman,
Johnston, 0'MaIIey 1980a; ISR, University of Michigan,
unpublished data).

Attempts to Quit Smoking
  Cessation attempts are common among young
smokers. In the 1989 TAPS, 74 percent of 12- through

l&year-old smokers reported that they had seriously
thought about quitting, 64 percent reported that they
had tried to quit smoking, and 49 percent reported that
they had tried to quit during the previous six months
(AIIen et al. 1993).

  Nearly half of aII smokers among high school se-
niors surveyed by the MTFP between 1976 and 1984
reported that they wanted to stop smoking (Table 17).
Interest in quitting declined slightly thereafter. About 30
percent of current smokers reported that at one time in
their lives they had tried but failed to stop smoking.
About 40 percent of daily smokers reported that they
had tried at least once to stop smoking but had faiied.
The percentage of seniors who at some time had smoked
regularly but had not smoked during the 30 days pre-
ceding the survey (former smokers) increased sharply
for males from 1977 through 1980 and for females from
1977 through 1981 (Figure 4). This measure declined
sharply after 1980 for males and after 1981 for females.

Table 17. Trends in high school senior smokers' interest in quitting smoking and attempts to quit
   smoking, by frequency of smoking during the past 30 days, Monitoring the Future Project, United
     States, 1976-1989

Respondents answering "Yes"

Survey Question

Do you want to stop smoking now?
Among those who smoked
at all during the last
30 days

1976 -1979       1980-1984          1985-1989
N (weighted) %    N (weighted) %     N (weighted) %

3,872   46.1       3,805   47.1       3,418   42.5

Among those who smoked
2 1 cigarette/day during
the last 30 days

3,396   46.1       3,262   47.6       2,761   43.9

Have you ever tried to stop smoking
and found that you could not?
Among those who smoked
at all during the last
30 days

4,740   31.5       4,942   31.4       4,534   27.8

Among those who smoked         3,604   38.5       3,464   41.6
2 1 cigarette/day during
the last 30 days
Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data).

2,953   39.4

62 Epidemiology


pmwnting Tobacco Use Among Young People

Figure 3.  Trends in the intensity of smoking among high school seniors, Monitoring the Future Project,
      United States, 1976-1992

45 1

40-

35-

30-

2 25-
8

Never smoked

Have smoked but not
in the past 30 days

. . . . . . . . . . . . . . . .

< 1 cigarette/day in
the past 30 days

----    l-5 cigarettes/day in
       the past 30 days

II-   . . 2 one-half pack/day in
       the past 30 days

1984
Year

1986    1988    1990   1992

Sources: Bachman, Johnston, O'Malley (1980a, b, 1981,1984,1985,1987,1991); Johnston, Bachman, O'Malley (1980a, b, 1982,
1984,1986,1991,1992); Institute for Social Research, University of Michigan (unpublished data).

Figure 4.  Trends in the percentage of former smdkers among ever smokers,* by gender, high school seniors,
    Monitoring the Future Project, United States, 1976-1989

                                        . . . . . . .  Male

Z?-                                      - Female

16-

        14      I    1    I    I    I    I    I     I    I    I    I    I    I
          1976      1978      1980      1982      1984      1986      1988
                                   Year
Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data).
*Percentage of those who had ever smoked regularly who had not smoked during the previous 30 days.

Epidemiology 63

161-235 95-3


The trend of cessation is similar to the trend for current
smoking prevaIence. Substantial progress occurred in
the late 197Os, but this progress slowed considerably in
the 1980s.

Trends in Knowledge and Attitudes About
Smoking

Trends in Perceived Health Risks of Smoking

  Data from the M'TFP allow comparisons of trends
in beliefs about the risks associated with cigarette smok-
ing and in actual smoking behavior. The decline in the
prevalence of ever smoking has been associated with an
increase in the percentage of high school seniors who
believe that smoking one or more packs of cigarettes
each day is a serious health risk (Figure 5). This associa-
tion has been observed for both genders and for whites
and blacks (Bachman, Johnston, 0'MalIey 198Oa, b, 1981,
1984, 1985, 1987, 1991; Johnston, Bachman, O'Malley
198Oa, b, 1982,1984,1986,1991; ISR, University of Michi-
gan, unpublished data). For example, during the early
1980s the percentage of black high school seniors who
felt that there is great risk associated with smoking a
pack or more per day increased substantially. At the
same time, the percentage of black youth who had smoked

Surgeon General's Report

at all and who had smoked daily declined rapidly. In
1989, over 50 percent of smokers and 74 percent of non-
smokers reported that they believed that smoking a pack
or more per day is a serious health risk 0989 MTFP,
CDC, OSH, unpublished data).

  The percentage of seniors who believed that smok-
ing entails a great risk to health increased from 56 per-
cent in 1976 to 69 percent in 1991, and the percentage
who believed that the health effects of smoking had been
exaggerated decreased from 16 percent in 1981 to 14
percent in 1991 (Table 18). Nonetheless, 3 out of 10
seniors in 1991 still did not believe that heavy smoking
poses a serious threat to health.

  Among 12- through l&year-olds in the 1989 TAPS,
32 percent believed that there is no harm in having an
occasional cigarette; 57 percent of smokers in the survey
endorsed that statement (Allen et al. 1993). Twenty-one
percent of smokers and 3 percent of never smokers be-
lieved that it is safe to smoke for only a year or two.

Trends in Perceptions About Smoking

  The percentage of high school seniors surveyed by
the MTFP who considered smoking a "dirty habit" in-
creased between 198lf66 percent) and 1991 (72 percent)
(Table 18). About 73 percent of white and 74 percent of
black adolescents now feel this way, compared with only

Figure 5. Trends in the percentage of high school seniors who believe that smoking is a serious health
    risk and in the percentage who have ever smoked, Monitoring the Future Project, United
      States, 1976-1991

- Ever smoked

--/ 1 / , , , , , , t , ( ( / , 1
  1976     1978     1980     1982     1984     1986     1988     1990
                           Year

Sources: Bachman, Johnston, O'MaIley (1980a. b, 1981,1984,1985,1987,1991); Johnston, Bachman, O'MalIey (1980a, b, 1982,
1984,1986,1991,1992); Institute for Social Research, University of Michigan (unpublished data).

64 Epidemiology


Preoenting Tobacco Use Among Young People

69 percent of whites and 54 percent of blacks surveyed in
1981 (Johnston, Bachman, 0'Malley 1982; ISR, Univer-
sity of Michigan, unpublished data). The perception that
smoking is a dirty habit has increased among males,
females, smokers, and nonsmokers. Fii percent of
smokers and 81 percent of nonsmokers classified smok-
ing as a dirty habit in 1989 (Johnston, Bachman, O'Malley
1982,1984,1986,1991,1992;Bachman, Johnston,CYMalley
1984,1985,1991; 1981-1989 MTFI', CDC, OSH, unpub-
lished data).

  Between 1977 and 1981, the percentage of seniors
who felt that their close friends would not, or did not,
approve of their smoking increased substantially (Table
18). The percentages reported for 1981 and 1991, however,
were essentially identical. The percentage of senior who
believed that adults should be prohibited by law from
smoking in certain public places increased from 42 percent
in 1977 to 45 percent in 1986 and remained about the same
in 1991.

  TARS data on 12- through Wyear-olds provide
further information on beliefs about smoking. In 1989,
smokers were from two to five times more likely than
never smokers to report that they believed that cigarette
smoking helps people relax, reduce stress, feel more
comfortable in social situations, reduce boredom, and
keep their weight down (Allen et al. 1993). Smokers may
also deny the addictive properties of cigarettes (LJSDI-IHS

1988b). TAPS data indicated that 39 percent of smok-
ers-but only 11 percent of never smokers-believed
that they would be able to quit smoking anytime they
wanted.

Trends in Perceptions About Smokers

  The overwhelming majority of high school seniors
surveyed by the MTFP did not believe that cigarette
smoking makes smokers their age look mature, in con-
trol, or independent (Table 18). About half believed that
smoking makes smokers look insecure, and more than
60 percent perceived cigarette smoking as something
smokers use to try to look mature. between 1981 and
1991, smoking among seniors became less of the behav-
ioral norm; fewer than 20 percent of seniors in 1991
reported feeling that smoking is an attempt to conform
to such a norm.

  Responses to the MTFP indicate that the majority
of high school seniors prefer to date nonsmokers and
that this is becoming a trend. Since 1981, the propor-
tion of respondents who prefer to date nonsmokers has
increased by over 10 percent, to about 74 percent. The
most substantial change occurred among black high
school seniors (Figure 6). The percentage of white
seniors who preferred to date nonsmokers increased
only slightly. Over 85 percent of nonsmokers and

Figure 6. Trends in the percentage of high school seniors who prefer to date nonsmokers, by race,
    Monitoring the Future Project, United States, 1981-1991

55       1      I      I      I      I      I      I      1      I      1
1981    1982    1983   1984   1985    1986    1987   1988    1989    1990    1991
                         Year

Sources: Bachman, Johnston, O'Malley (1981,1984,1985,1987,19911; Johnston, Bachman, O'Malley (1982,1984,1986,1991,
1992); Institute for Social Research, University of Michigan (unpublished data).

Epidemiology 65


surgeon General's Report

Table 18. Trends in high school seniors' beliefs and attitudes about smoking and smokers, Monitoring the
    Future Project, United States, 1976,1981,1986,1991

Beliefs and attitudes                  1976          1981         1986        1991

About smoking

How much do you think people
risk harming themselves if
they smoke one or tiore packs of
cigarettes per day?* (percentage
who say great risk)
The harmful effects of cigarettes have
been exaggerated.+ (percentage who agree)
Smoking is a dirty habit.
(percentage who agree)
How do you think your close
friends feel (or would feel) about your
smoking one or more packs of cigarettes
per day?* (percentage who disapprove)
Do you think that people (who are 18
or older) should be prohibited by law
from smoking tobacco in certain
specified public places? (percentage
who say yes)
About smokers

56.4         63.3         66.0        69.4

           15.5         16.2        13.8

          65.5         68.6        71.6

6&Y         73.9         76.2        74.3

42.P         43.0         45.1        44.9

In my opinion, when a guy my age
is smoking a cigarette, it makes him
look (percentage who agree)

. . . like he's trying to appear mature and
sophisticated

61.4         62.7        60.8

. . . insecure                                 42.0         43.6        47.9

. . . conforming                               25.4         21.3        16.5

. . . rugged, tough, independent                       8.6          9.9         9.8

. . . mature, sophisticated                          5.3          4.6         5.0

. . . cool, calm, in control                          6.2          5.5         5.3

Sources: Bachman, Johnston, O'MaUey (198Oa, 1987); Johnston, Bachman, O'Malley (198Oa, 1982); Institute for Social
Research, University of Michigan (unpublished data).
*Possible responses included "no risk," "slight risk," "moderate risk," "great risk," "can't say-drug unfamiliar."
Percentages include those who say "great risk."
`Possible responses included "disagree," "mostly disagree," "neither," "mostly agree," "agree." Percentages include
those who "agree" or "mostly agree."
Qossibie responses included "not disapprove," "disapprove," "strongly disapprove." Percentages include those who
"disapprove" or "strongly disapprove."
51977 data.

&i Epidemiology


prtwzting Tobacco Use Among Young People

Table 18. Continued

Beliefs and attitudes                 1976          1981         1986        1991

About smokers

In my opinion, when a girl my age is
smoking a cigarette, it makes her look
(percentage who agree)

. . like she's trying to appear mature and
sophisticated

. . . insecure

. . conforming

. . . independent and liberated

. . mature, sophisticated
. , . cool, calm, in control

I prefer to date people who don't
smoke. (percentage who agree)

Smokers know how to enjoy life more
than nonsmokers. (percentage who agree)

I think that becoming a smoker reflects
poor judgment. (percentage who agree)

I strongly dislike being near people who
are smoking. (percentage who agree)

I personally don't mind being around
people who are smoking. (percentage
who agree)

Do you disapprove of people (2 age 18)
who smoke one or more packs
of cigarettes per day?
(percentage who disapprove)

64.6         65.0        64.1

47.4         49.5        52.0

26.5         21.7        19.5

11.2       9.5         9.6

6.9          5.4         4.5

5.5          4.5         4.1

66.5

71.0

74.0

2.8          2.4         3.6

57.0         59.3        61.0

38.2         36.9        33.1

65.9          70.0         75.4         71.4

45.4

48.9

about one-third of smokers preferred to date nonsmok-
ers in 1989 (1989 MTF'P, CDC, OSH, unpublished data).

  Findings from the 1989 TAPS also suggest that few
adolescents consider smoking a norm for their age group.
Twothirds of 12- through Wyear-old respondents agreed
with the statement, "Seeing someone smoking turns me
off," and 86 percent (94 percent of never smokers and 51
percent of current smokers> preferred to date nonsmok-
ers (Allen et al. 1993).

  Adolescents seem to be more concerned about
people smoking around them. In the MTFP, the percent-
age of high school seniors who strongly disliked being
near smokers increased between 1986 (45 percent) and
1991(49 percent), and the percentage who reported that
they did not mind being around smokers declined (from
38 percent in 198i to 33 percent in 1991) (Table 18). Males
were consistently more likely than females to mind being
around smokers (Johnston, Bachman, O'Malley 1982,

Epidemiology 67


1984,1986,1991,1992; Bachman, Johnston, O'MalIey 1984,
1985, 1991; ISR, University of Michigan, unpublished
data). The percentage of female seniors who.did not
mind being around smokers changed little over time.
From 1981 through 1991, the proportion of high school
seniors who did not mind being around people who
were smoking decreased by about 50 percent among
blacks and by only 5 percent among whites (Figure 7).
Smokers' acceptance of being around other smokers re-
mained constant, at approximately 70 percent, from 1981
through 1989, whereas the percentage of nonsmokers
who did not mind being around smokers decreased
from 25 to 21 percent (1981-1989 MTFF surveys, CDC,
OSH, unpublished data).

Adult Implications of Adolescent Smoking

  Some notable findings regarding young peopIe's
expectations to smoke, or to abstain from smoking,
have emerged from the MTFP (see Johnston, O'Malley,
Bachman 1992b). In their senior year, respondents who
answered one of five questionnaire forms were asked,
"Do you think you wiII be smoking cigamttes five years
from now?" Overall, about 1 percent said they "definitely'
would be smoking in five years, 14 percent said they "prob-
ably" would, 27 percent said they probably would not, and
58 percent said they definitely would not flable 19). About
55 percent of past-month smokers and about 45 percent of
daily smokers stated that they probably would not or defi-
nitely would not be smoking in five years.

  Of the seniors in the fuII panel, 68 percent indicated
that they had not smoked in the 30 days preceding the
senior-year survey; 9 percent had smoked less than one

Surgeon General's Report

cigarette per day; 8 percent had smoked one to five ciga-
rettes per day; 7 percent had smoked about one-half pack
per day; and 8 percent had smoked a pack or more per day
(Table 20). Five years after graduation, the same total
proportion (32 percent) were past-month smokers. Some-
what more (26 vs. 23 percent), however, were daily
smokers. Further, for each smoking group defined by
senior-year smoking level, those who continued to smoke
increased their frequency of smoking (Tables 20-21).

  Of the respondents who were nonsmokers at the
end of their senior year, 86 percent remained nonsmok-
ers five to six years later, whereas only 13 percent of
those who smoked one pack each day in their senior
year became nonsmokers (Table 20). Those students
who smoked one-half pack per day in their senior year
were nearly as likely to continue use as were those
students who smoked one pack daily; 81 percent of half-
pack-a-day smokers &II smoked, and the majority of
them increased their rate of smoking (Table 21). Seventy
percent of respondents who in their senior year smoked
one to five cigarettes per day continued to smoke five
years later; most of these continuing smokers increased
their rate of use. Even among the seniors who smoked
the least &ass than one cigarette per day), 42 percent
continued to smoke five to six years later, and two-thirds
of these had increased their rate of smoking.

When earlier smoking behavior is controlled, se-
niors' expectations to smoke had very limited power to
predict subsequent smoking behavior (Table 22). Many
seniors who smoked one pack per day had expectations
of discontinuing use. These expectations showed no
relationship to the actual rate of smoking five to six years
later. The same is true for those seniors who smoked

Table 19. High school seniors predicting whether they will be smoking in five years, by smoking status in
   senior year, Monitoring the Future Project, United States, 1976-1986 senior classes
                Predicted likelihood of smoking in five years (o/o)*

Senior year
smoking status       Definitely    Probably     Probably
(use in past 30 days)        will         will        will not

None                  0.4          1.3          21.0
< 1 cigarette/day           0.5         14.7          56.5
l-5 cigarettes/day          1.8         37.6          44.1
About % pack/day          0.6         57.7          30.3
2 1 pack/day             5.1          62.9          26.7

Total                0.9         14.2         27.0

Source: Institute for Social Research, University of Michigan (unpublished data).
o Entnes are row percentages.

Definitely    Number
will not   (weighted)

77.3      1,926
28.3       248
16.5       211
11.3        197
  5.2        228

58.0     2,810

68 Epidemiology


prevating Tobaca, Use Among Young People

Figure 7. Trends in the percentage of high school seniors who do not mind being around people who
    are smoking, by race, Monitoring the Future Project, United States, 1981-1991

5
5
5
  5
  5 5        .' ,.`"S `,
    5
    ?? o ?? ,.**    `0..
    ??? ???       ??       ,.*h

      ?        ???? ???? ???? ???
                 ????      ???
                              ? ??? ??? ??

0         I       I        I       I       I       I       I       I       I       I
1981   1982   1983   1984   1985   1986   1987   1988   1989   1990   1991
                        Year

Sources: Bachman, Johnston, O'Malley (1981,19&Q, 1985,1987,1991); Johnston, Bachman, O'Malley (1982,1984,1986,1988,
1991,1992); Institute for sodal Research, University of Michigan (unpublished data).

Table 20. Intensity of smoking (%) in senior year of high school, by intensity of smoking 5- 6 years
    later, Monitoring the Future Project, United States, 1976-1986

Smoking intensity (past 30 days) 5-6 years later (%)*

Senior-year            < 1 ciga-   l-5 ciga-
smoking intensity              r&e      rettes                 Number   Column
(use in past 30 days)     None   i&Y    l&Y   M pack   r 1 pack (weighted) percentage

None              85.6      4.9       2.6       2.7       4.1    9,238      67.6
< 1 cigarette/day      57.8     14.4      9.6      7.8     10.4    1,268      9.3
l- 5 cigaretes day
        per       29.6      8.8      17.2      20.5      23.9    1,058       7.7
About ?4 pack/ day      18.8      4.9       8.7      21.7      46.0    Lo(Jo       7.3
2 1 pack/day         13.4      2.7      4.1      10.1      69.7    1,100       8.1

Total            68.0      5.9      5.0      6.6

Source: Institute for Social Research, University of Michigan (unpublished data).
*Entries are row percentages.

14.6   13,665     100.0

Epidemiology 69


Surgeon General's Report

Table 21.  Direction of change in smoking behavior (%) between senior year of high school and 5 - 6 years
     later, Monitoring the Future Project, United States, 1976-1986 senior classes

Senior-year
smoking status
(use in past 30 days)

Quit

   Smoking status 5-6 years later"

                             Number
Less use      Same level      More use  (weighted)

None                                        85.6          14.4     9,238
< 1 cigarette/day          57.8                      14.4         27.8      1,268
l-5 cigarettes/day          29.6           8.8          17.2          44.4      1,058
About `/z pack/day         18.8          13.6          21.7          46.0      1,000
2 1 pack/day            13.2          17.7          40.2         29.0       869

Source: Institute for Social Research, University of Michigan (unpublished data).
*Entries are row percentages.

Table 22. Smoking intensity 5-6 years after high school, by senior-year smoking status and expectation to
    smoke in 5 years, Monitoring the Future Project, United States, 1976-1986 senior classes

Senior-year
smoking intensity
(use in past 30
days) and predicted
likelihood of
smoking in 5 years

None

        Smoking intensity
         (past 30 days)
        5-6 years later*

< 1 cigarette  l-5 cigarettes          2 1 pack   Number
/day      /day    112 pa&day    /day   (weighted)

None
Will smoke
Will not smoke
  Total
< 1 cigarette/day
Will smoke
Will not smoke
  Total
l-5 cigarettes/day
Will smoke
Will not smoke
  Total
About l/z pack/day
Will smoke
Will not smoke
  Total
2 1 pack/day
Will smoke
Will not smoke
  Total

55.3        10.6         19.8        8.3         5.9      30
84.7         5.6         2.9        2.5         4.3    1,829
84.2        5.7         3.2        2.6         4.3    1,859

41.7        18.4        19.5        14.0         6.4       36
58.4        14.7         9.7        9.7         7.5      208

55.9        15.2         11.1        10.4         7.3      244

32.3         3.0        15.5        23.0        26.2      83
31.8        5.8        15.9       23.0        23.5      125
32.0         4.7        15.7       23.0        24.6      208

15.5         4.9         6.5        21.0        52.1      115
17.6         2.5         6.5        21.1        52.3       81

16.4         3.9         6.5        21.1        52.2      196

13.3         2.2         3.2        9.6        71.8      153
13.2        1.6        5.3       6.3       73.6     72
13.3        2.0         3.8        8.5        72.4      225

Grand Total        67.0         6.0         5.2         6.6        15.2    2,731

Source: Institute for Social Research, University of Michigan (unpublished data).
*Entries are row percentages.

70 Epidemiology


Preventing Tobacco Use Among Young People

one-half pack-or even as little as one to five cigarettes-
per day in high school. Expectations were predictive
only for those smokers who smoked less than one ciga-
rette per day; 58 percent of those who thought they
probably or definitely would be smoking in the future
did, in fact, continue to smoke, whereas only 42 percent
of those who did not expect to smoke in the future did
smoke. Among seniors who had never smoked, less
than 2 percent thought they would be smoking in five
years (Table 19). This small group did, in fact, have a
higher rate of subsequent smoking (45 percent) than
never smokers who did not expect to be smoking in five
years (15 percent) (Table 22).

  Thus, the expectation to avoid smoking seemed to
make some difference among nonsmokers and very light
smokers in high school, although very few seniors in these
groups reportecl an expectation to smoke. On the other
hand, among light, moderate, and heavy daily smokers, the
expectation to abstain from smoking in the future seemed
overwhelmed by the strong forces that tend to maintain or
advance smoking behavior once it is established. One
implication of these results is that young people should be
made aware of the strongly addictive nature of nicotine and
its ability to overwhelm future good expectations. Clearly,
prevention is the major goal, but immediate cessation is of
aitical importance for adolescents, even for those who
smoke very little in high schooL

Smoking and Other Drug Use

  In Chapter 2, tobacco use is discussed as a possible
predictor of other drug use (see "Smoking as a Risk
Factor for Other Drug Use" and "Smokeless Tobacco
Use as a Risk Factor for Other Drug Use"). The present
chapter presents detailed information on high school
seniors' usage patterns for cigarettes, alcohol, marijuana,
cocaine, inhalants, and smokeless tobacco. Both preva-
lence of past-month use and comparisons of the self-
reported age at first use of each will be presented.

Prevalence of Smoking and Other Drug Use

  Among high school seniors in the MTFP studies,
the majority of alcohol users (60 percent) and smokeless
tobacco users (57 percent) did not smoke (Table 23). The
majority of marijuana (62 percent), cocaine (68 percent),
and inhalant (56 percent) users smoked cigarettes. Ciga-
rette smoking prevalence was from 1.9 to 3.9 times higher
among users of these drugs than among nonusers.

  Although most drinkers (60 percent) did not
smoke, almost all smokers (88 percent) were drink-
ers. Almost one-half (45 percent) of cigarette smok-
ers were also marijuana smokers, 11 percent were
cocaine users, 5 percent used inhalants, and 33 per-
cent used smokeless tobacco (which will be discussed
separately later in this chapter). The prevalence of

Table 23.  Prevalence (%) of cigarette smoking among users of other drugs and prevalence of other drug
     use among smokers, + high school seniors, Monitoring the Future Project, United States,
       1985-1989

               Prevalence of      Prevalence of
           smoking among   smoking among      Prevalence of    Prevalence of
               users of other      nonusers of      drug use among  drug use among
Other substances      drugs       other drugs          smokers      nonsmokers

Alcohol                40.0            10.3               87.6          54.8
Marijuana              62.1           20.3               44.9          11.2

Cocaine+             68.1          27.2             10.9          2.1

Inhalantst             56.1           28.5               4.8          1.5
Smokeless tobacco5        43.0           22.4              32.5          15.6

Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data).
*Any use of cigarettes or other drugs during the past month.
`Includes "coke," "crack," and "rock."
%lue, aerosols, laughing gas, etc.
SMales only, 1986-1989 senior classes only.

Epidemiology 71


Surgeon General's Report

other drug use was from 1.6 to 5.2 times more preva-
lent among cigarette smokers than nonsmokers.

Grade When Smoking and Other Drug Use Begins

  MTFP data from 1986 through 1989 were merged
to observe the grade at which seniors reported trying
cigarettes, smokeless tobacco, alcohol, marijuana, and
cocaine (Figure 8). Among ever smokers, 31 percent
hieci their first cigarette by the sixth grade, and 61 per-
cent first smoked by the eighth grade. Among those who
had used smokeless tobacco, 23 percent had first done so
by the sixth grade, and 53 percent by the eighth grade.
Proportionately fewer users of alcohol, marijuana, and
cocaine initiated use as early as respondents initiated use
of cigarettes and smokeless tobacco. Thirty-four percent
of alcohol users, 26 percent of marijuana users, and 6
percent of cocaine users first tried these drugs by the
eighth grade.

  By the 12th grade, only 8 percent of MTFP respon-
dents had not tried cigarettes or alcohol; 68 percent had

tried both, and 24 percent had tried alcohol but not
cigarettes (Table 24). Of those students who had tried
both cigarettes and alcohol by 12th grade, almost half (49
percent) had tried cigarettes before trying alcohol; 33
percent had tried both at about the same time.

  About 30 percent of all students had not tried ciga-
rettes or marijuana by the 12th grade (Table 25); 44 percent
had tried both, and 22 percent had tried cigarettes but not
marijuana. Of those-who had tried both by 12th grade,
most students (65 percent) had tried cigarettes before mari-
juana; 23 percent had tried both at about the same time.

  About one-third of seniors (34 percent) had not
tried cigarettes or cocaine; 12 percent had tried both, and
over half (53 percent) had tried cigarettes but not cocaine
(Table 26). Of those who had tried both by 12th grade, 90
percent had tried cigarettes before trying cocaine, and 9
percent had tried both at about the same time.

  These data support the contention that tobacco use
falls early in the sequence of drug use for young adoles-
cents and therefore may be considered a "gateway' drug.

Figure 8. Grade when respondents (high school seniors) first tried cigarettes, smokeless tobacco, alcohol,
   marijuana, and cocaine, among respondents who had ever used these substances by grade 12,
    Monitoring the Future Project, United States, 1986-1989

100

I-

  60
2
8
k
L
  40

Grade 12

    Cigarettes  Smokeless tobacco   Alcohol    Marijuana     Cocaine
Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data).

72 Epidemiology

Grade 11

Grade 10

Grade 9

Grades 7-8

Grade 16


pr~wnting Tobacco Use Among Young People

Table 24. Percent distribution of high school seniors (N [weighted] = 19,831), by grade in which they first
    (if ever) used cigarettes and alcohol, Monitoring the Future Project, United States, 1986-1989

           Grade when respondent first tried alcohol
Grade when
respondent
first tried                                                     Never     Row
cigarettes    S6       7-a        9        10        11        12      used     total

$6        4.2       7.2       4.9       2.5       1.5       0.6       0.3      21.2

7-8        1.3       8.0       6.4       3.1       1.3       0.5       0.2      20.8

9       0.4       2.0       4.9       2.4       1.0       0.4       0.1       11.1

10       0.3        1.1        1.9       2.8       1.0       0.3          *        7.4

11       0.2       0.5        1.2       1.6       1.6       0.3       0.1       5.5

12       0.1       0.3       0.5       0.6       0.6       0.6       0.1       2.7

Never used   2.0        3.8       5.3       5.3       4.7       2.8       7.5      31.4

Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data).
* < 0.05.

Note: Totals may not equal the sum of individual percentages because of rounding.

Table 25.  Percent distribution of high school seniors (N [weighted] = 20,657), by grade in which they first
    (if ever) tried cigarettes and marijuana, Monitoring the Future Project, United States, 1986-1989

Grade when
respondent
first tried
cigarettes 5 6

Grade when respondent first tried marijuana

7-8        9        10        11

12

Never     Row
used     total

56       2.0       4.5       3.3       2.2       1.4       0.8       6.2      20.3

7-8       0.3        4.1       4.4       2.9       1.5       0.8       5.8      19.8

  9       0.1       0.5       2.5       2.3       1.2       0.6       3.5      10.7

10       0.1       0.2       0.5       1.7        1.4       0.5       2.6       6.9

11           *        0.1       0.3       0.4       1.3       0.6       2.5       5.2

12          *           *        0.1       0.2       0.2       0.5       1.5       2.6

Never used   0.2       0.5       0.9       0.9       0.9       0.6      30.5      34.5

Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data).
*< 0.05.
Note: Totals may not equal the sum of individual percentages because of rounding.

Epidemiology 73


Surgeon General's Report

Table 26. Percent distribution of high school seniors (N [weighted] = 21,007), by grade in which they first
    (if ever) used cigarettes and cocaine, Monitoring the Future Project, United States, 1986-1989

            Grade when respondent first tried cocaine
Grade when
respondent
first tried                                                    Never    Row
cigarettes    56       7-8        9        10        11       12      used     total

16        0.1       0.4       0.9       1.2       1.4       0.9       15.4     20.3
7-8           *       0.2       0.6       1.1       1.3       0.9       15.6      19.7

9           *           *       0.2       0.5       0.6       0.3       9.0      10.7
10           *           *           *       0.2       0.4       0.2       6.1       7.0

11           o           ?           o           ?        0.2       0.2       4.8      5.2
12           o           ?           ?           ?           ?        0.1       .2.5       2.6
Never used    *           o        0.1       0.2       0.2       0.3       33.8      34.5

Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data).
o 0.05.
<
Note: Totals may not equal the sum of individual percentages because of rounding.

Table 27.  Percentage of high school students who used tobacco, by behaviors that contribute Lo
     unintentional and intentional injuries, Youth Risk Behavior Survey, United States, 1991
                                              Current      Current
                     bY       Current    frequent     smokeless
Risk behavior        Number cigarette use*  cigarette use'  cigarette use'   tobacco us&

Seat belt used
Always
Most the time/sometimes
Rarely/ never
Physical fighting'
0 times
l-5 times
26times
Weapon carrying**
0 days
2 1 day
Attempted suicide'
0 times
11 time

2,908   60.2         17.8          6.8         13.5
5,651      70.1         26.3         11.4         17.6
3,548      80.6         40.3         21.8        26.5

6,864      63.9        20.3         8.1         13.9
4358      77.8         35.4         17.3         23.2
789      82.6         49.3        30.5         32.1

8,703     65.5         22.6         9.4        13.3
3,171     82.8         41.1         22.2         27.5

10,060      68.2         24.8         10.6         17.8
824     85.0         52.5         33.8        33.6

Sources: Centers for Disease Control and Prevention (CDC), Division of Adolescent and School Health (unpublished data);
CDC, Office on Smoking and Health (unpublished data).
*During the respondent's lifetime.
`Cigarette use on 2 1 day during the 30 days preceding the survey.
*Cigarette use on 2 20 days during the 30 days preceding the survey.
sDuring the 30 days preceding the survey; includes chewing tobacco or snuff; males only.
A When riding in a car driven by someone else.
`During the 12 months preceding the survey.
**During the 30 days preceding the survey; includes any weapon such as a gun, knife, or club.

74 Epidemiology


preuen ting Tobacco Use Among Young People

Cigarette use is most likely to precede use of other sub-
stances and to be prevalent among users of other drugs.

Cigarette Smoking and Other Health-Related
Behaviors

  Available data on the relationships between ciga-
rette smoking and other health-related behaviors are
derived from cross-sectional studies and thus suggest
that other behaviors may covary with adolescent smok-
kg. Even if the direction of influence is not established,
information on the extent of these relationships is useful
for intervention, since such data may suggest a syn-
drome of health-compromising behaviors that need to
be considered together.

  Data from the 1991 YRBS indicate that high school
students who reported practicing other selected health-.
risk behaviors were more likely to be past-month or
frequent smokers than were those who reported fewer
selected health-risk behaviors. For example, students in
the survey were more likely to be past-month or fre
quent smokers if they rarely or never wore seat belts, had
participated in a physical fight six or more times during
the preceding year, had carried weapons one or more

days during the preceding month, or had made one or
more suicide attempts during the preceding year (Table
27). Students were also more likely to be past-month or
frequent smokers if they had ever had sexual intercourse,
had had sexual intercourse with four or more partners
during their lifetime, or had not used a condom during
their most recent sexual intercourse (Table 28). These
relationships for sexual risk behaviors held for males
and females, regardless of age (CDC, OSH, unpublished
data). Lastly, students were more likely to be past-
month or frequent smokers if they had not participated
on any sponsored sports teams during the preceding
year or if they had used steroids without a doctor's
prescription (Table 29).

Cigarette Smoking and Health Status

Pregnancy and Smoking

  Data on maternal smoking status during pregnancy
are recorded on birth certificates in 43 states and the
District of Columbia (NCHS 1992b). ln these states, the
overall maternal smoking prevalence was 20 percent in
1989. Maternal smoking among adolescent women

Table 28. Percentage of high school students who used fobacco, by sexual risk behaviors, Youth Risk
     Behavior Survey, United States, 1991
                 , hY       Current      Current      Current
                    cigarette    cigarette    frequent     smokeless
Risk behavior          Number     use*         use'    cigarette usez   tobacco uses

Sexual intercoursed
No               5,011      55.1         13.8         3.1         12.9
Yes               6,508      82.6         38.8         20.7         23.9
Number of sexual partners*
l-3               4,048      81.0         33.8         15.4         23.2
24               2,443      85.4         47.9         30.3         24.9

Condom use1
No               2,494      86.4         46.2         27.5         23.8

Yes               2,091      79.3         36.0         18.5         26.6

Sources: Centers for Disease ControI and Prevention (CDC), Division of Adolescent and School Health (unpublished data);
CDC, Office on Smoking and Health (unpublished data).
* During the respondent's lifetime.
' Cigarette use on 11 day during the 30 days preceding the survey.
$ Cigarette use on 2 20 days during the 30 days preceding the survey.
5 Any smokeless tobacco use, including chewing tobacco or snuff, during the 30 days preceding the survey; males only.
* During the respondent's lifetime.
7 During last sexual intercourse, among students who had sexual intercourse during the 3 months preceding the survey.

Epidemiology 75