&TOBACCO 

Preventing Tobacco Use 

Among Young People 

A Report 

of the 

Surgeon 

General 

Produced by the Department of Health & Human Sewices 

Reprinted by the U.S. Department of Education 
Foreword 

Smoking kills an estimated 434,000 Americans each year, most of whom began smoking during their 

adolescence. The key to reducing this enormous death toll and the health consequences that accompany 

tobacco use, according to public health officials, is preventing young people from starting to use tobacco. 

Very few people begin to use tobacco as adults; almost all first use has occurred by the time people graduate 

from high school. By the age of 18, one in three persons is using tobacco. 

The earlier young people begin using tobacco, the more heavily they are likey to use it as adults, and 

the longer potential time they have to be users. Both the duration and the amount of tobacco use are 

related to eventual chronic health problems. 

This publication is adapted from Preventing Tobacco Use Among Young People: A Report of the Surgeon General released by the U.S. Department of Health and Human Services in 1994. The excerpts presented here 

provide important information for educators’about the vulnerable ages of 10 through 18 when most users 

start smoking, chewing, or dipping and become addicted to tobacco. It underscores the seriousness of 

tobacco use and the relationship of tobacco use to other adolescent problem behaviors. 

We appreciate the cooperation of the Office of the Surgeon General in making this report available for 

distribution by the Department of Education. Copies of the complete document are available for sale by 

the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C., 20402, 

S/N 017-001-00491-0. 
CONTENTS 

Chapter 1: Introduction ............................... 5 

Chapter 2: Health Consequences of Tobacco Use by Young People ...... 11 

Chapter 3: -Epidemiology of Tobacco Use Among Young People in the 

United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 

Chapter 4: Psychosocial Risk Factors for Initiating Tobacco Use . . . . . . . . 89 

Chapter 5: Efforts to Prevent Tobacco Use Among Young People ....... 115 

References .......... .’ ............................. 183 
pwzlenting Tobacco Use Among Young People 

Chapter 1 

Introduction 

Previous Surgeon General’s reports on tobacco use 

and health have largely focused on the epidemiologic, 

clinical, biologic, and pharmacologic aspects of adult use 

of tobacco products. This report on Preventikg Tobacco 

use A?nong Young People provides a more detailed look at 

adolescence, the time of life when most tobacco users 

begin, develop, and establish their behavior. Because 

regular use soon results in addiction to nicotine, this 

behavior may persist through adulthood, significantly 

increasing, through the extended years of use, the risk of 

long-term, severe health consequences. 

Despite three decades of explicit health warnings, 

large numbers of young people continue to take up 

tobacco; currently, over three million adolescents smoke 

cigarettes, and over one million adolescent males currently use smokeless tobacco. Clearly, effective interventions are needed to prevent more young people from 

trying tobacco. TO achieve significant long-term reductions in tobacco use and tobacco-related deaths in the 

United States, we must examine the nature and scope of 

adolescent tobacco use, consider the social, psychological, and marketing factors that influence young people in 

their decision to use tobacco products, and evaluate current efforts to prevent young people from becoming 

users. This report addresses the crucial problems of 

adolescent tobacco use. 

Development of the Report 

This report of the Surgeon General was prepared 

by the Office on Smoking and Health, National Center 

for Chronic Disease Prevention and Health Promotion, 

Centers for Disease Control and Prevention, Public Health 

Service, U.S. Department of Health and Human Services, 

as part of the department’s responsibility, under Public 

Law 91-222 and Public Law 99-252, to report current 

information on the health effects of cigarette smoking 

and smokeless tobacco use to the United States Congress. 

This report is the first to focus on the problem of tobacco 

use among young people. Given the continuing onset of 

use in adolescence and the growing evidence of health 

consequences associated with early use, the report was 

seen as both needed and timely. 

The current report has been produced through the 

efforts of experts in the medical, pharmacologic, 

epidemiologic, developmental, economic, behavioral, 

legal, and public health aspects of smoking and smokeless tobacco use among young people. Initial manuscripts for the report were prepared by 28 scientists who 

were selected for their expertise in specific content areas. 

This material was consolidated into chapters, each of 

which underwent peer review. The entire document was 

reviewed by a number of experts in the field, as well as by 

institutes and agencies within the U.S. Public Health 

Service. The final draft of the report was reviewed by 

the Assistant Secretary for Health and by the Secretary, 

Department of Health and Human Services. 

Several concerns guided the development of this 

report. The first, which is addressed in Chapter 2, is 

whether tobacco use is associated with health conse 

quences during the period of adolescence (broadly defined as ages 10 through 18, although research cited in 

this report varies somewhat in the ages considered adolescent). The long-term health consequences-that is, 

those that emerge in adulthood-have been the subject 

of extensive review and are widely acknowledged in the 

scientific and public literature. The chapter thus focuses 

on the serious health consequences, as well as the increased risk factors for subsequent health consequences, 

that are evident early in life among young smokers and 

smokeless tobacco users. Chapter 3 examines the 

epidemiologic patterns of tobacco use among the young. 

National data on trends in adolescent use are analyzed to 

determine the extent of the current problem, as well as to 

note changes in patterns of initiation and use. The factors 

that influence adolescents in their decision to use tobacco 

are examined in Chapter 4, which considers psychosocial 

risk factors, and Chapter 5, which examines the influence 

of tobacco advertising and promotion. The final concern, 

the focus of Chapter 6, was to assess what has been 

don-from the individual level to the legislative levelto prevent tobacco use among young people. 

Major Conclusions 

1. Nearly all first use of tobacco occurs before high 

school graduation; this finding suggests that if adolescents can be kept tobacco-free, most will never 

start using tobacco. 

2. Most adolescent smokers are addicted to nicotine 

and report that they want to quit but are unable to do 

so; they experience relapse rates and withdrawal 

symptoms similar to those reported by adults. 

3. Tobacco is often the first drug used by those young 

people who use alcohol, marijuana, and other drugs. 

Introduction 5 
Surgeon General’s Rep01 

4. Adolescents with lower levels of school achievement, with fewer skills to resist pervasive influences 

to use tobacco, with friends who use tobacco, and 

with lower self-images are more likely than their 

peers to use tobacco. 

5. Cigarette advertising appears to increase young 

people’s risk of smoking by affecting their 

perceptions of the pervasiveness, image, and fur 

lion of smoking. 

6. Communitywide efforts that include tobacco tax i 

creases, enforcement of minors’ access laws, you1 

oriented mass media campaigns, and school-has 

tobacco-use prevention programs are successfu

reducing adolescent use of tobacco. 

Introduction 

The health effects of cigarette smoking have been 

the subject of intensive investigation since the !95Ck. Cigarette smoking is still considered the chief preventable 

cause of premature disease and death in the United 

States. As was documented extensively in previous Surgeon General’s reports, cigarette smoking has been causally linked to lung cancer and other fatal malignancies, 

atherosclerosis and coronary heart disease, chronic obstructive pulmonary disease, and other conditions that 

constitute a wide array of serious health consequences 

(USDHHS 1989). More recent studies have concluded 

that passive (or involuntary) smoking can cause disease, 

including lung cancer, in healthy nonsmokers. In 1986, 

an advisory committee appointed by the Surgeon General released a special report on the health consequences 

of smokeless tobacco, concluding that smokeless tobacco 

use can cause cancer and can lead to nicotine addiction 

WSDHHS 1986). In the 1988 report, nicotine was designated a highly addictive substance, comparable in its 

physiological and psychological properties to other addictive substances of abuse (USDHHS 1988). 

Considerable evidence indicates that the health 

problems associated with smoking are a function of the 

duration (years) and the intensity (amount) of use. The 

younger one begins to smoke, the more likely one is to be 

a current smoker as an adult. Earlier onset of cigarette 

smoking and smokeless tobacco use provides more life 

years to use tobacco and thereby increases the potential 

duration of use and the risk of a range of more serious 

health consequences. Earlier onset is also associated 

with heavier use; those who begin to use tobacco as 

younger adolescents are among the heaviest users in 

adolescence and adulthood. Heavier users are more 

likely to experience tobacco-related health problems and 

are the least likely to quit smoking cigarettes or using 

smokeless tobacco. Preventing tobacco use among you”g 

people is therefore likely to affect both duration and 

intensity of total use of tobacco, potentially reducing 

long-term health consequences significantly. 

Health Consequences of Tobacco Use 

Among Young People 

Active smoking by young people is associated 

with significant health problems during childhood 

and adolescence and with increased risk factors for 

health problems in adulthood. Cigarette smoking 

during adolescence appears to reduce the rate of lung 

growth and the level of maximum lung function that 

can be achieved. Young smokers are likely to be less 

physically fit than young nonsmokers; fitness levels 

are inversely related to the duration and the intensity 

of smoking. Adolescent smokers report that they are 

significantly more likely than their nonsmoking peers 

to experience shortness of breath, coughing spells, 

phlegm production, wheezing, and overall diminished physical health, Cigarette smoking during child: 

hood and adolescence poses a clear risk for respiratory 

symptoms and problems during adolescence; these 

health problems are risk factors for other chronic con 

ditions in adulthood, including chronic obstructive 

pulmonary disease. 

Cardiovascular disease is the leading cause 01 

death among adults in the United States. Atheroscle 

rosis, however, may begin in childhood and becorn 

clinically significant by young adulthood. Cigarett~ 

smoking has been shown to be a primary risk facto: 

for coronary heart disease, arteriosclerotic periphera 

vascular disease, and stroke. Smoking by childrer 

and adolescents is associated with an increased risk o 

early atherosclerotic lesions and increased risk factor 

for cardiovascular diseases. These risk factors i&,rd, 

increased levels of low-density lipopr&$n &&&d 

increased very-low-density lipoprotein cholesterol 

increased triglycerides, and reduced levels Q 

6 Introduction 
pwzlenting Tobacco Use Among Young People 

h@density lipoprotein cholesterol. If sustained into 

adulthood, these patterns significantly increase the risk 

for early development of cardiovascular disease. 

Smokeless tobacco use is associated with health 

consequences that range from halitosis to severe health 

problems such as various forms of oral cancer. Use of 

Smokeless tobacco by young people is associated with 

early indicators of adult health consequences, including 

periodontal degeneration, soft tissue lesions, and general 

systemic alterations. Previous reports have documented 

that smokeless tobacco use is as addictive for young 

people as it is for adults. Another concern is that smokeless tobacco users are more likely than nonusers to become cigarette smokers. 

Among addictive behaviors such as the use of alcohol and other drugs, cigarette smoking is most likely to 

become established during adolescence. Young people 

who begin to smoke at an earlier age are more likely than 

later starters to develop long-term nicotine addiction. 

Most young people who smoke regularly are already 

addicted to nicotine, and they experience this addiction 

in a manner and severity similar.to what adult smokers 

experience. Most adolescent smokers report that they 

would like to quit smoking and that they have made 

numerous, usually unsuccessful attempts to quit. Many 

adolescents say that they intend to quit in the future and 

yet prove unable to do so. Those who try to quit smoking 

report withdrawal symptoms similar to those reported 

by adults. Adolescents are difficult to recruit for formal 

cessation programs, and when enrolled, are difficult to 

retain in the programs. Success rates in adolescent cessation programs tend to be quite low, both ‘in absolute 

terms and relative to control conditions. 

Tobacco use is associated with a range of problem 

behaviors during adolescence. Smokeless tobacco or 

cigarettes are generally the first drug used by young 

people in a sequence that can include tobacco, alcohol, 

marijuana, and hard drugs. This pattern does not imply 

that tobacco use causes other drug use, but rather that 

other drug use rarely occurs before the use of tobacco. 

Still, there are a number of biological, behavioral, and 

social mechanisms by which the use of one drug may 

facilitate the use of other drugs, and adolescent tobacco 

users are substantially more likely to use alcohol and 

illegal drugs than are nonusers. Cigarette smokers are 

also more likely to get into fights, carry weapons, attempt 

suicide, and engage in high-risk sexual behaviors. These 

problem behaviors can be considered a syndrome, since 

involvement in one behavior increases the risk for involvement in others. Delaying or preventing the use of 

tobacco may have implications for delaying or preventing these other behaviors as well. 

The Epidemiology of Tobacco Use Among 

Young People 

Overall, about one-third of high-school-aged adolescents in the United States smoke or use smokeless 

tobacco. Smoking prevalence among U.S. adolescents 

declined sharply in the 197Os, but this decline slowed 

significantly in the 198Os, particularly among white males. 

Although female adolescents during the 1980s were more 

likely than male adolescents to smoke, female and male 

adolescents are now equally likely to smoke. Male adolescents are substantially more likely than females to use 

smokeless tobacco products; about 20 percent of high 

school males report current use, whereas only about 1 

percent of females do. White adolescents are more likely 

to smoke and to use smokeless tobacco than are black 

and Hispanic adolescents. 

Sociodemographic, environmental, behavioral, and 

personal factors can encourage the onset of tobacco use 

among adolescents. Young people from families with 

lower socioeconomic status, including those adolescents 

living in singleparent homes, are at increased risk of 

initiating smoking. Among environmental factors, peer 

influence seems to be particularly potent in the early 

stages of tobacco use; the first tries of cigarettes and 

smokeless tobacco occur most often with peers, and the 

peer group may subsequently provide expectations, reinforcement, and cues for experimentation. Parental 

tobacco use does not appear to be as compelling a risk 

factor as peer use; on the other hand, parents may exert a 

positive influence by disapproving of smoking, being 

involved in children’s free time, discussing health matteGwith children, and encouraging children’s academic 

achievement and school involvement. 

How adolescents perceive their social environment 

may be a stronger influence on behavior than the actual 

environment. For example, adolescents consistently overestimate the number of young people and adults who 

smoke. Those with the highest overestimates are more 

likely to become smokers than are those with more accurate perceptions. Similarly, those who perceive that cigarettes are easily accessible and generally available are 

more likely to begin smoking than are those who perceive more difficulty in obtaining cigarettes. 

behavioral factors figure heavily during adolescence, a period of multiple transitions to physical maturation, to a coherent sense of self, and to emotional 

independence. Adolescents are thus particularly vulnerable to a range of hazardous behaviors and activities, 

including tobacco use, that may seem to assist in these 

transitions. Young people who report that smoking serves 

positive functions or is potentially useful are at increased 

risk for smoking. These functions are associated with 

Introduction 7 
Surgeott General’s Report 

bonding with peers, being independent and mature, and 

having a positive social image. Since reports from 

adolescents who begin to smoke indicate that they have 

lower self-esteem and lower self-images than their nonsmoking peers, smoking can become a self-enhancement 

mechanism. Similarly, not having the confidence to be 

able to resist peer offers of tobacco seems to be an important risk factor for initiation. Intentions to use tobacco 

and actual experimentation also strongly predict subsequent regular use. 

The positive functions that many young people 

attribute to smoking are the same functions advanced in 

most cigarette advertising. Young people are a strategically important market for the tobacco industry. Since 

most smokers try their first cigarette before age 18, young 

people are the chief source of new consumers for the 

tobacco industry, which each year must replace the many 

‘consumers who quit smoking and the many who die 

from smoking-related diseases. Despite restrictions on 

tobacco marketing, children and adolescents continue to 

be exposed to cigarette advertising and promotional activities, and young people report considerable familiarity with many cigarette advertisements. In the past, this 

exposure was accomplished by radio and television programs sponsored by the cigarette industry. Barred since 

1971 from using broadcast media, the tobacco industry 

increasingly relies on promotional activities, including 

sponsorship of sports events and public entertainment, 

outdoor billboards, point-of-purchase displays, and the 

distribution of specialty items that appeal to the young. 

Cigarette advertisements in the print media persist; these 

messages have become increasingly less informational, 

replacing words with images to portray the attractive 

ness and function of smoking. Cigarette advertising frequently uses human models or human-like cartoon 

characters to display images of youthful activities, independence, healthfulness, and adventure-seeking. In presenting attractive images of smokers, cigarette 

advertisements appear to stimulate some adolescents 

who have relatively low self-images to adopt smoking as 

a way to improve their own self-image. Cigarette advertising also appears to affect adolescents’ perceptions of 

the pervasiveness of smoking, images of smokers, and 

the function of smoking. Since these perceptions are 

psychosocial risk factors for the initiation of smoking, 

cigarette advertising appears to increase young people’s 

risk of smoking. 

Efforts to Prevent the Onset of Tobacco Use 

Most of the U.S. public strongly favors policies that 

might prevent tobacco use among young people. These 

policies include mandated tobacco education in schools, 

a complete ban on smoking by anyone on school grounds, 

further restrictions on tobacco advertising and promo 

ti0~1 activities, stronger prohibitions on the sale of to 

bacco products to minors, and increases in earmarked 

taxes on tobacco products. Interventions to prevent initiation among young people--even actions that involve 

restrictions on adult smoking or increased taxes-have 

received strong support among smoking and nonsmoking adults. 

Numerous research studies over the past 15 years 

suggest that organized interventions can help prevent 

the onset of smoking and smokeless tobacco use. Schoolbased smoking-prevention programs, based on a model 

of identifying social influences on smoking and providing skills to resist those influences, have demonstrated 

consistent and significant reductions in adolescent smoking prevalence; these program effects have lasted one to 

three years. Programs to prevent smokeless tobacco use 

have used a similar model to achieve modest reductions 

in initiation of use. The effectiveness of these schoolbased programs appears to be enhanced and sustained, 

at least until high school graduation, by adding coordinated communitywide programs that involve parents, 

youth-oriented mass media and counteradvertising, community organizations, or other elements of adolescents’ 

social environments. 

A crucial element of prevention is access: adolescents should not be able to purchase tobacco products in 

their communities. Active enforcement of age-at-sale 

policies by public officials and community members appears necessary to prevent minors’ access to tobacco. 

Communities that have adopted tighter restrictions have 

achieved reductions in purchases by minors. At the state 

and national levels, price increases have significantly 

reduced cigarette smoking; the young have been at least 

as responsive as adults to these price changes. Maintaining higher real prices of cigarettes provides a barrier to 

adolescent tobacco use but depends on further tax increases to offset the effects of inflation. The results of this 

review thus suggest that a coordinated, multicomponent 

campaign involving policy changes, taxation, mass media, and behavioral education can effectively reduce the 

onset of tobacco use among adolescents, 

s-ary 

Smoking and smokeless tobacco use are almost 

always initiated and established in adolescence. besides 

its long-term effects on adults, tobacco use produces 

specific health problems for adolescents. Since nicotine 

addiction also occurs during adolescence, adolescent tobacco users are likely to become adult tobacco users. 

Smoking and smokeless tobacco use are associated with 

other problem behaviors and occur early in the sequence 

of these behaviors. The outcomes of adolescent smoking 

8 Introduction 
pr~lenting Tobacco Use Among Young People 

and smokeless tobacco use continue to be of great public relevant, and tobacco use may begin. This process most 

health importance, since one out of three U.S. adoles- affects adolescents who, compared with their peers, have 

cents uses tobacco by age 18. The social environment of lower self-esteem and self-images, are less involved with 

adolescents, including the functions, meanings, and im- school and academic achievement, have fewer skills to 

ages of smoking that are conveyed through cigarette resist the offers of peers, and come from homes with 

advertising, sets the stage for adolescents to begin using lower socioeconomic status. Tobacco-use prevention 

tobacco. As tobacco products are available and as peers programs that target the larger social environment of 

begin to try them, these factors become personalized and adolescents are both efficacious and warranted. 

References 

us DEPARTMENT OF HEALTH AND HLJMAN SERVICES. US DEPARTMENT OF HEALTH .AND HUMAN SERVICES. 

The health consequences of using smokeless tobacco. A report of the 

advisory committee to the Surgeon General. US Department of 

Health and Human Services, Public Health Services, National 

Institutes of Health. NIH Publication No. 86-2874, 1986. 

Reducing the health consequences ofsmoking: 25 years of progress. 

A report of the Surgeon General. US Department of Health and 

Human Services, Public Health Service, Centers for Disease 

Control, Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health. DHHS Publication 

US DEPARTMENT OF HEALTH AND HUMAN SERVICES. 

The health consequences of smoking: nicotine addiction. A report of 

the Surgeon General, 1988. US Department of Health and 

Human Services, Public Health Service, Centers for Disease 

Control, Center for Health Promotion and Education, Office 

on Smoking and Health. DHHS Publication No. (CDC) 

M-8406, 1988. 

No. (CDC) 89-8411, 1989. 
prezIenting Tobacco Use Among Young People 

Chapter 2: The Health Consequences of Tobacco Use by Young People 

htroduction 

The health consequences of tobacco use among 

adults have been reviewed extensively in previous 

Surgeon General’s reports (Public Health Service 

[PHSI 1964; U.S. Department of Health and Human 

Services [USDHHS] 1986b, 1989). Among young people, 

the short-term health consequences of smoking include 

respiratory and nonrespiratory effects, addiction to a 

toxic substance (nicotine), and the associated risk of other 

drug use. Long-term health consequences of adolescent 

smoking may be seen in the association between early 

onset of tobacco use and future (adult) smoking, with 

concomitant health consequences. Passive (also called 

“involuntary”) smoking during adolescence is also associated with harmful respiratory and nonrespiratory 

effects. Lastly, the use of smokeless tobacco poses serious health consequences to young people. 

Health Consequences of Smoking Among Young People 

Introduction 

The health effects of cigarette smoking have been 

the subject of intensive investigation since the 19%. 

Extensive evidence, documented in numerous reports of 

the Surgeon General, has causally linked cigarette 

smoking to a wide array of health outcomes that extend 

from annoying symptoms to fatal malignancies 

(USDHHS 1989). Until recently, this research was largely 

directed at the effects of smoking on adults. As is 

discussed in Chapter 3 (see “Age or Grade When Smoking Begins”), the onset and development of cigarette 

use occur primarily during adolescence (USDHHS 1989); 

the health consequences of smoking among young 

people thus have great public health significance. In 

recent years, investigations of the health effects in schoolage youth have reported sufficient data to support 

conclusions about adverse effects of smoking during 

childhood and adolescence. 

Most of the evidence reviewed here is gathered 

from epidemiologic studies of young people ranging 

from 10 through 20 years old. Selected studies that relate 

to older age groups, yet are relevant to young people, 

are also included. Emphasis is placed on the respiratory effects of smoking, for which the evidence is 

abundant. Data on smoking and cardiovascular 

risk factors and atherogenesis are also addressed, as 

are the adult health implications of starting to smoke 

during childhood. 

overview of the Toxicology of 

Tobacco Smoke 

Cigarette smoke is a complex mixture of organic 

and inorganic compounds generated by the combustion 

of tobacco and additives. Current knowledge about the 

physicochemical nature of tobacco smoke is well described in earlier Surgeon General’s reports (PHS 1964; 

USDHHS 1981, 1989). Thousands of individual compounds have been isolated in cigarette smoke, including 

pharmacologically active agents (e.g., nicotine), toxic 

agents (e.g., carbon monoxide, hydrogen cyanide, and 

acrolein), and mutagens and carcinogens (e.g., polycyclic aroma tic hydrocarbons). 

Cigarette smoke is further classified as mainstream 

smoke (MS), the smoke drawn through the mouthpiece 

of the cigarette, and sidestream smoke (SS), the smoke 

given off by smoldering tobacco between puffs and the 

smoke diffusing through the cigarette paper and escaping from the burning cone during puffing. Because of the 

differing combustion conditions under which MS and SS 

are generated, their chemical compositions differ; in particular, undiluted SS tends to have higher concentrations 

of many toxic and tumorigenic agents (USDHHS 1986a, 

1989). The quantitative yields of tar (the material deposited in a filter as MS is being drawn), nicotine, and carbon 

monoxide from cigarettes can be assessed by using a 

smoking machine standardized to a particular pattern of 

puffing (USDHHS 1989). 

Passive smoking refers to nonsmokers’ inhalation 

of tobacco smoke. The term “environmental tobacco 

smoke” (E’TS) is now widely used to refer to the mixture 

of predominantIy SS and exhaled MS that is inhaled by 

the passive smoker. Passive smoking was the subject of 

the 1986 Surgeon General’s report (USDHHS 1986a); that 

report reviews in detail the components of ETS, as did a 

contemporaneously prepared report of the National Research Council (1986). In 1991, the National Institute for 

Occupational Safety and Health recommended that ETS 

be regarded as a potential occupational carcinogen and 

Health Consequences 21 
Surgeon General’s Reports 

that exposures to ETS be reduced to the lowest feasible 

concentration (USDHHS 1991b). A recent monograph 

by Guerin, Jenkins, and Ton&ins (1992) updates and 

extends these earlier revie.ws. The U.S. Environmental 

Protection Agency (USEPA) also recently reviewed the 

evidence on invohmtary smoking and respiratory health 

(USEPA 1992). These and other health consequences of 

passive smoking are discussed later in this chapter. 

Many of the components of SS and MS have been 

identified in ETS. On the other hand, ETS is an inherently 

dynamic mixture that changes in physical and chemical 

characteristics as it ages and reacts with other pollutants 

in indoor air and with surfaces (USDHHS 1986a; Guerin, 

Jenkins, Tomkins 1992). The 1986 Surgeon General’s 

report concluded, however, that ETS was sufficiently 

close to MS and SS to permit generalization of the evidence on the health consequences of active smoking to 

passive smoking (USDHIHS 1986a). 

The human body is most susceptible to these health 

consequences along cigarette smoke’s path of ingress 

through the respiratory tract. The respiratory tract includes the upper airway (nose, oropharynx, and larynx) 

and the lung (airways and the parenchyma). The airways are lined by an epithelium that varies in form and 

function at different levels of the respiratory tract. The 

parenchyma includes the alveoli pulmonis (the delicate 

gas-exchanging surface of the lung) and the interstitiurn 

(the location of the blood and lymphatic vessels and of 

the lung’s supporting connective tissue). 

The effects of active’ cigarette smoking on these 

structures of the lung and on many ,physiological functions of the lung have been extensively studied (USDHHS 

1984, 1990; Bates 1989). Changes in lung physiology 

attributable to smoking include the weakening of an 

individual’s defenses against infectious organisms and 

inhaled particles and gases, changes in the numbers and 

types of cells present within the lung, and the activation 

of potentially damaging proteolytic enzymes and the 

inactivation of the proteins that inhibit them. Many of 

theseeffects of smoking have been demonstrated in young 

adult smokers who have served as volunteer research 

subjects WSDHHS 1984). 

The effects of smoking on lung structure and fun& 

tion have been demonstrated repeatedly in young adult 

smokers (USDHHS 1984; Bates 1989). Studies using 

spirometry, tests of small airway function, and lung volume measurements have shown a higher frequency of 

abnormalities in smokers than nonsmokers (USDHHS 

1984; Bates 1989). Effects of smoking on lung structure, 

particularly the small airways, have been found in smokers in their mid-twenties. Niewoehner, Kleinerman, and 

‘Unless otherwise indicated, “smoking” will hence refer to 

active smoking. 

Rice (1974) examined peripheral airways of 20 nonsmokers and 19 smokers who had died from nonrespiratory 

causes at an average age of 25. A characteristic lesion, 

termed “respiratory bronchiolitis,” was found in all 19 of 

the smokers but in only 5 of the nonsmokers. The 

affected small airways of the smokers demonstrated 

an inflammatory process consisting of aggregates of 

pigment-containing macrophages with edema, fibrosis, 

and epithelial hyperplasia in adjacent bronchioles 

and alveoli. 

These observations on the effects of smoking in 

young people are consistent with current concepts of 

pathogenesis and natural history in adult smokers 

WSDHHS 1984,WO). Severe chronic airflow obstruction, sufficient to result in a clinical diagnosis of chronic 

obstructive pulmonary disease (COPD), follows sustained 

smoking and lung injury with progressive loss of respiratory function through adulthood. In smokers whc 

develop COPD, decline of lung function at a rate weE 

beyond that associated with aging alone eventually lead: 

to impairment. Changes in lung function can be demon 

strated in young adult smokers; these losses are consis 

tent with the histopathologic evidence that the smal 

airways of young smokers are damaged (USDHHS 19841 

Epidemiologic Evidence of Respiratory 

Effects 

Respiratory Symptoms 

The cardinal symptoms of respiratory tract iniur] 

and disease are cough, sputum production, wheezing 

and dyspnea (or shortness of breath). In epidemiologi 

studies of respiratory diseases, symptoms are usual& 

discovered through responses to a standardized ques 

tionnaire @met 1978). In adults, the occurrence of cougl 

and phlegm is causally associated with cigarette smok 

ing; the frequency of the symptoms rises with the num 

ber of cigarettes smoked per day (USDHHS 1984). I: 

some studies, wheezing is also more frequent in adti 

smokers than in adults who have never smoke1 

(Schenker, Samet, Speizer 1982). The frequency E 

dyspnea rises as the extent of smoking-related impati 

ment of lung function increases &met 1978). 

Questionnaire-based epidemiologic studies of chi 

dren and adolescents document that smoking is also 

cause of respiratory symptoms in preteen and teenag 

regular smokers (those who smoke at least weekly 

Studies conducted from the 1960s through the 198( 

involving thousands of children provide consistent ev 

dence that smoking is associated with the occurrence 4 

cough and phlegm (Table 1; see Table 31 in Chapter 3 fc 

additional data). In several studies, smoking also in 

creased the frequency of wheezing and dyspnea. Ther 

associations have been found in studies conducted in ti 

22 Health Consequences 
preventing Tobacco Use Among Young People 

United States, the United Kingdom, New Zealand, and 

Scandinavia and at levels of smoking as low as one 

cigarette per week. 

In one of the first studies on smoking and respiratory symptoms in children, Holland and Elliott (1968) 

administered a questionnaire concerning reSpiratOI’y 

symptoms and cigarette smoking to all children in 

schools in four areas of southeast England. Smoking 

education was then p!ovided to half of the schools, and 

the questionnaire was readministered one year later. 

Although the intervention had no effect on the prevalence of smoking, the study documented that smoking in 

childhood was associated with cough and phlegm and 

that these symptoms were reduced in those who had 

stopped smoking. 

Many later studies continued to show that smoking increased the frequency of respiratory symptoms in 

children and adolescents. In the United States, reseaich 

with high school students (Addington et al. 1970; Seely, 

Zuskin, Bouhuys 1971; Rush 1974) and college students 

(Peters and Ferris 1967) provided early evidence of adverse effects of smoking on young smokers. Large studies of schoolchildren (including preteens) in the United 

Kingdom showed that symptom rates were increased by 

smoking. Bewley, Halil, and Snaith (1973) reported that 

the frequency of cough was increased in boys and girls 

no older than 11.5 years who reported smoking at least 

one cigarette per week. Other studies in the United 

Kingdom and the United States found further evidence 

of the effects of smoking on symptom frequency in children of similar ages (Bewley and Bland 1976; Charlton 

1984; see Table 31 in Chapter 3). 

The health effects of smoking among adolescents 

may be confounded by a history of passive smoking if 

the parents of an adolescent smoker also smoke. However, in a study of 5,835 secondary schoolchildren in 

Derbyshire (United Kingdom), students who smoked at 

least one cigarette per week persisted in having an increased risk for cough and dyspnea even after parental 

smoking was taken into account (Bland et al. 1978). 

Control for other potential confounding or mediating factors varies among the investigations. Residence 

location, a surrogate for exposure to ambient air pollution, was considered in several of the studies (Bewley, 

Hahi, Snaith 1973; Bewley and Bland 19761, and a study 

of 20-year-olds (Colley, Douglas, Reid 1973) controlled 

for socioeconomic status. 

Lung Function 

Numerous cross-sectional studies of adults have 

shown that cigarette smokers have a lower level of lung 

function, as assessed by tests of lung mechanics and gas 

exchange, than persons who have never smoked 

(USDHHS 1984; Bates 1989). Longitudinal studies show 

that smoking speeds the age-related decline of lung function. The most abundant evidence describes changes in 

lung function as assessed by spirometry, or the measure 

of the volume of air entering and leaving the lungs. One 

measure of scientific and clinical interest obtained through 

spirometry is the forced expiratory volume in one second (FEV,), the volume of air blown out during the 

first second of the forced vital capacity maneuver. 

FEV, increases with lung growth and development during childhood, and rises even more steeply with the 

growth spurt of adolescence (Tager et al. 1988; Sherrill 

et al. 1992). In persons who have never smoked, 

FEV, begins to decline from a maximum at some time 

during the third or fourth decades of life (Beck, Doyle, 

Schachter 1982; Tager et al. 1988). In smokers, the agerelated decline commences at a younger age and proceeds at a steeper average rate (Beck, Doyle, Schachter 

1982; USDHHS 1984; Tager et al. 1988). When people 

stop smoking, their average decline gradually returns 

to the rate observed in those who never smoked 

(USDHHS 1990). 

Cross-sectional and longitudinal data show that 

smoking also adversely affects lung function in children 

and adolescents (Table 2). The evidence comes principally from spiromev studies of high school students, 

although one of the first studies to show reduced lung 

function in young people involved college seniors (Peters and Ferris 1967). In these studies, impaired lung 

function has been primarily indicated through reduced 

flow rates after 50 percent or more of the vital capacity 

has been exhaled. This effort-independent, latter portion 

of the flow-volume loop is sensitive to abnormalities of 

the lung’s small airways and the lung parenchyma (Bates 

1989). Several studies have also found that smokers have 

a reduced peak expiratory flow rate (PEER) (Table 2). 

This effortdependent portion of the flow-volume loop is 

more sensitive to abnormal function of the lung’s larger 

airways than of its small airways (Bates 1989). 

Among the first researchers to study smoking 

among younger people were Peters and Ferris (1%7L who 

obtained spirometric and peak-flow data from 124 Harvard 

College seniors. Smokers had lower (although not significantly) FEV, than persons who had never smoked. Spirometric flow rates and PEFR were significantly lower in the 

smokers. In an early study involving high school students, 

Seely, Zuskin, and Bouhuys (197l) found evidence of abnormal function of the small airways in both boys and girls who 

smoked. subsequent crossBhonal studies of teenageIs 

have tended to confirm that smokers have reduced lung 

function, as assessed by spir&netry or PEFR measurement. 

More recent, longitudinal data show that smoking 

reduces the rate of lung growth, as would be anticipated 

Health Consequences 13 
Surgeon General’s Report 

Table 1. Published studies of the effects of smoking on respiratory symptoms among young people, 

various countries, 1965-1983 

Reference* Location/year Study population 

Peters and Ferris 1967 Massachusetts, 1965 124 Harvard College seniors 

Addington et al. 1970 Oklahoma” 557 high school students, 

(grades 9-12) aged 13-19 years 

Bewley, Halil, Snaith 1973 England, 1971 8,682 schoolchildren 

aged 10 and 11 years 

Rush 1974 New York, 1968 12,595 high school students aged 

13-18 years 

*Listed chronologically by publication date. 

§Year not provided. 

14 Health Consequences 
preventing Tobacco Use Among Young People 

Symptoms Prevalence (o/o) by smoking status 

Never smoker Smoker+ 

Phlegm b 3 months/yr 

Breathlessness 

Wheezing (apart from colds) 

Colds go to chest 

2.4 26.5’ 

2.4 20.5t 

7.3 31.3* 

4.9 31.3r 

Never smoker Smoker’ 

Daily cough L 3 months 4 10 

Daily phlegm 2 3 months 3 9 

Dyspnea when hurrying 16 30 

Chest cold for 1 week 22 30 

Wheezing or asthma 12 13 

Morning cough 

Boys 

Girls 

Never smoker Smoker’ 

5.4 18.2 

5.9 19.8 

Cough 3 months 

Boys 

Girls 

3.8 15.4 

3.5 12.1 

Nonsmoker Ex-smoker Smoker 

Number of cigarettes smoked per day 

Cough 2 3 months/yrT I l-9 10-14 L 15 

BOYS 2.9 4.5 9.2 16.2 29.0 

Ci*lc2 AA 6.0 12.0 23.1 35.9 

‘At Least one cigarette daily for the past year. 

‘p < 0.01. 

Smoking at least one cigarette weekly. Percentages combine data reported separately in authors’ Table 4 for urban 

and rural children. 

‘For white children only. 

Health Consequences 25 
Surgeon Generals Repor 

Table 1. Continued 

Reference Location/year Study population 

Stanhope and Prior 1975 

_ _. -I .y- 1‘;..., 1 ;“‘-; 

BewIey and Bland 1976 

: . / 

. 

._ ~. 

: .;_’ 

._ 

New Zealand, 1972 Maori and European high school 

students aged 13-15 years 

Bland et al. 1978 England, 1974 5,835 schoolchildren; first-year 

level in secondary school 

Charlton 19&I ‘. : .’ .’ 

_- -,* 

Adams et al. 1984 England, 1975-1979 405 secondary schoolchildren 

Oechsli, Seltzer, 

van den Berg 1987 

California, 1977-l 979 1,445 children in a cohort 

study 

“Smoking at least one c@ar&e weekly, Percentages combine data reported separately in authorsTable ’ V for urban and rural children. 

“RR = Relative risk for &U-en smoking z one cigarette weekly versus children who had never smoked, adjusted for parental smoking. 

@Smoking at least one cigarette weekly. 

16 Health Consequences 
prczlenting Tobacco Use Among Young People 

Symptoms Prevalence (o/o) by smoking status 

&werul finding: Cough grade, phlegm grade, and loose cough sign significantly associated with smoking. 

Morning cough 

Boys 

Girls 

Cough day or night 

Boys 

Girls 

BreathIessness 

Boys 

Girls 

Never smoker Smoker# RR% 

3.1 19.2 5.9 

1.8 13.5 6.8 

20.4 46.5 2.4 

18.5 47.3 2.6 

11.8 34.9 2.9 

16.5 39.2 2.3 

Cough all day 1 2 8 

Phlegm all day 1 1 7 

Wheezing 5 13 22 

General findings: Increased risk of cough, dyspnea, and phlegm. 

Genernl findings: Starting smoking associated with bronchitis and pneumonia. 

“RR = Relative risk for children smoking at least one cigarette weekly versus children who had never smoked. 

UNon.smoker = Never smoking and smoking not more than one cigar&e daily for I one year. 

“Exsmoker = Smoking one month or more before date of the interview. 

“Smoker = Smoking t lg of tobaox daily; one cigarette was estimated to contain lg of tobacco. 

smoking daily, cigamites < I Omg of tar. 

“Smoking daiIy, cigarettes lo-18mg of tar. 

Health Consequences 17 
Surgeon General’s Repor 

Table 2. Published studies of the effects of smoking on lung function among young people, various 

countries, 19651981 

Reference* Location/year 

Study 

population Findings+ Comment 

Peters and Ferris 

1967 

Massachusetts, 

1965 

124 Harvard 

College seniors 

Significant reduction 

in spirometric flow 

Age distribution 

not given, nonrates when comparing NS with persons 

significant reducsmoking a pack a day 

tion for FEV,. 

for four years during 

college; dose response 

with amount smoked. 

Seely, Zuskin, 

Bouhuys 1971 

Connecticut’ 195 male and 170 

female high 

school students 

aged 15-19 years 

From MEFV curves, 

V, and V, significantly reduced in boys 

smoking > 15 c&s/day 

and girls smoking z= 10 

cigs/day, when 

compared with NS. 

Age distribution 

not given, nonsignificant reduction for FEV,. 

Comstock and 

Rust 1973 

Nationwide, 

1970-1971 

3,409 U.S. Navy 

recruits, median 

age = 19 years 

PEFR lower in 

smokers (99.5% 

predicted) than in 

nonsmokers (100.7% 

predicted). 

No definition of 

smoker, nonsmoker; 

tests of statistical 

significance not 

provided. 

*Listed chronologically by publication date. 

‘NS = never smoker; FEV, = forced expiratory volume in one second; VC = vital capacity; MEFV = maximal expiratory flov 

volume; V, = flow rate at 50% of vital capacity; V, = flow rate after exhalation of 75% of vital capacity; FVC = forced vital 

capacity; PEFR = peak expiratory flow rate; FEFsz = forced expiratory flow from 25% to 75% of FVC. 

*ear not provided. 

18 Health Consequences 
Preventing Tobacco Use Among Young People 

Table 2. Continued 

Reference 

Study 

Loca tionlyear population Findings’ Comment 

- 

Backhouse 1975 United 

Kingdom* 

195 boys at a PEFR on arrival None 

detention center, dropped significantly 

mean age = 18 years with daily smoking 

amount; significant 

improvement during 

&week stay while 

unable to smoke 

Woolcock et al. Australia, 

1979 1971-1980 

10,898 school No overall effect of See text for review 

children, mean ages smoking on spiromet- of longitudinal 

= 8.9 years for ric values in 1974 findings. 

primary school and data; decreased lung 

12.6 years for high growth in smoking 

school groups boys who had had 

bronchitis before age 

2 years. 

Kujala 1981 Finland, 1976 1,075 male military Significantlymduced None 

recruits, mean age = E’E’V, and +rometric 

20 years flows when comparing 

NS with smokers at 

interview. 

Health Consequences 19 
Surgeon General’s Report 

from the findings from cross-sectional studies. Beck, 

Doyle, and Schachter (1982) examined white residents 

of Lebanon, Connecticut, in 1972 and 1978. Among 

male and female subjects aged 15 through 24 in 1972, 

smoking had reduced the increment of FEV, during the 

six-year follow-up interval. 

In a IO-year study in Sydney, Australia, Woolcock 

et al. (1984) periodically measured lung function in an 

initial cohort of 11,497 schoolchildren. Two groups of 

children were included: a younger cohort that was 8.9 

years of age on average at enrollment and an older 

cohort aged 12.6 years on average at enrollment. The 

investigators followed up the cohort annually, measuring respiratory function and assessing symptoms, illnesses, and smoking. A small number of children were 

studied more intensively with the single-breath nitrogen test. The effect of smoking was examined only in 

the older cohort. Cross-sectional assessment of these 

data showed that at 50 percent of vital capacity, smokers tended to have lower maximal expiratory flow than 

nonsmokers. For example, adolescents who smoked at 

least 10 cigarettes per week had about a 5 percent lower 

expiratory flow rate than nonsmokers. The investigators concluded that abnormalities attributable to smoking were found in adolescents as young as age 14 and as 

soon as one year after beginning to smoke at least 10 

cigarettes per week. They also concluded that smoking 

was more harmful for children and adolescents who 

had a history of respiratory illness, particularly asthma. 

A cohort study of children in East Boston, Massachusetts, has been informative on the effects of pgssive 

and active smoking on lung function (Tager et al. 1979, 

1983,1985,1988). In 1974, the study enrolled a cohort of 

children aged five through nine who were sampled 

from schools in East Boston. The families of these 

children were then invited to participate in the initial 

survey and in periodic follow-up examinations that 

included a respiratory questionnaire and spirometry. 

Several relevant longitudinal analyses of the East 

Boston data have been reported (Tager et al. 1985,1987, 

1988). Using data from the first seven follow-up examinations, Tager et al. (1985) described the effect of 

smoking on the growth rates of FEV, and on forced 

expiratory flow (FED from 25 to 75 percent of forced 

vital capacity (FEF,,) in a group of 669 subjects aged 5 

through 19 years at enrollment. Using a Markov-type 

autoregressive model, researchers found significant effects of smoking on both measures of lung function. 

The model predicted that a child’s smoking, beginning 

at age 15 and continuing through age 20, would reduce 

FEV, to 92 percent of the expected value and FEF,, to 

90 percent of the expected value. A subsequent analysis 

using a nonparametric curve-smoothing method on 

these same data showed that male smokers had a smaller 

increase of FEV, at the end of the growth phase (a 

suggestion of a lower maximum lung function) than 

males who had not smoked; those who continued to 

smoke into early adulthood also showed no evidence of 

the plateau observed in never smokers before lung function began to decline. Similar findings were reported 

for females. 

Relevant information is also available from a community population study in Tucson, Arizona (Lebowitz 

and Holberg 1988). The Tucson cohort was derived 

from a population sample of 325 non-Hispanic white 

residents, originally sampled in 1972 when they were 

an average age of 8.8 years. Like the East Boston study, 

the Tucson study was directed primarily at passive 

smoking but also gathered information on active smoking by measuring FEV, and FEFsz. The Tucson study 

found effects of comparable magnitude with those observed in the East Boston study. Although these effects 

did not reach statistical significance in the Tucson data, 

they were in the same direction as those from East 

Boston, and the sample population was only half the 

size. 

Sherrill et al. (1992) examined the longitudinal 

effects of active and passive smoking on lung function 

in a cohort of New Zealand children observed from 

ages 9 through 15. Active smoking did not have statistically significant effects on FEV,, vital capacity, or 

FEV, /vital capacity (percent), but the numbers of regular smokers were small. By age 15‘43 percent reported 

occasional smoking (during the last year but not every 

day), but only 10 percent were daily smokers (smoking any number of cigarettes on a daily basis). 

Jaakkola et al. (1991) carried out an eight-year 

longitudinal study of lung function in a cohort of young 

adults aged 15 through 40 at enrollment. Of 1,044 

enrolled, 391 were subsequently followed. Smoking 

was found to have a significant effect on change in FEV, 

during the study period, but the results were not reported by age interval. 

Respiratory Morbidity 

In adults, smoking is associated with increased 

morbidity, as indexed by such measures as use of outpatient medical services and absenteeism from work, 

and with increased respiratory morbidity, as indexed 

by frequency or severity of respiratory infections 

(USDHHS 1990). Because smoking has been shown to 

alter immune and inflammatory responses (U.S. Department of Health, Education, and Welfare [USDHEW] 

1979b), these effects on an individual’s defenses could 

20 Health Consequences 
prpventing Tobacco Use Among Young People 

plausibly lead to increased frequency and severity of 

r~p~ato~ infections in smokers. 

Studies involving a wide age range of young 

people indicate that smoking increases respiratory morbidity (Table 3). A number of these studies compared 

mdical care by smokers and nonsmokers in settings 

ivhere all medical care was obtained at a single clinic. In 

one of the earliest studies, Haynes, Krstulovi~, and Bell 

(1966) examined the numbers of diagnoses for respiratory tract illnesses among male students (aged 14-19 

years) at a preparatory school. Nearly half of the students were smokers. AlI respiratory illnesses were 

more common in the smokers; the increase was greatest 

for the illnesses considered “severe.” The findings of 

studies involving student nurses (Parnell, Anderson, 

Kinnis 1966) and military cadets (Finklea et al. 1971) 

were similar. 

A series of studies have included military recruits 

as subjects (Table 3); their ages ranged from 18 through 

22. In the study of PoIIard et al. (1975), the rates of 

respiratory diagnoses were not significantly different 

between smokers and nonsmokers. In the more recent 

study of military recruits by Blake, Abell, and Stanley 

(19881, self-report of smoking was associated with increased risk for diagnosis of an upper respiratory tract 

infection during a 13-week basic training period. Kark 

and Lebiush (1981) and Kark, Lebiush, and Rannon 

(1982) examined attack rates for influenza and infIuenza-like illnesses in Israeli military recruits and found 

that smoking was associated with an increased attack 

rate in both male and female recruits. 

Recently, in a study that examined adolescents 

and young adults who had sickle cell anemia, Young et 

al. (1992) found a strong relationship between cigarette 

smoking and acute chest syndrome, In sickle cell anemia patients, acute chest syndrome is characterized by 

fever, cough, chest pain, leukocytosis, and pulmonary 

infiltrates in the chest radiograph. All smokers in this 

study had a history of acute chest syndrome, whereas 

65 percent of the nonsmokers did. Smoking also appeared to increase the frequency of sequelae of sickle 

cell lung disease. 

A study in the United Kingdom (Charlton and 

Blair 1989) associated smoking with increased absenteeism from school among 2,885 children aged 12 and 

13 years. Children who on an initial questionnaire 

reported regular smoking were more likely than nonsmokers to be absent when a follow-up questionnaire 

was administered four months later. The authors interpreted these findings as showing a higher rate of minor 

ailments in children who smoked; however, the design 

could not exclude other plausible explanations (such as 

truancy) for the difference. In a survey of adolescents 

invited for an overall evaluation in three general practices in the United Kingdom, smokers reported a higher 

prevalence of health problems than nonsmokers (25 

percent vs. 16 percent, p = .06) (Townsend et al. 1991). 

Epidemiologic Evidence of Nonrespiratory 

Effects 

Cardiovascular Disease 

In adults, cigarette smoking is a cause of coronary 

heart disease, arteriosclerotic peripheral vascular disease, and stroke (USDHHS 1989). Although these 

diseases rarely occur in children and adolescents, autopsy studies of young male victims of combat during 

the Korean and Vietnam conflicts and community-based 

autopsy studies of adolescents and young adults have 

shown that atherosclerosis begins in childhood and 

may become clinically significant in young adulthood 

(McNamara et al. 1971; Enos, Holmes, Beyer 1986; Strong 

1986). 

Several autopsy-study series Iink cigarette smoking to the occurrence and extent of atherosclerosis in 

young adults. Strong and Richards (1976) described the 

association of cigarette smoking with atherosclerosis in 

1,320 men from the New Orleans area. In the youngest 

group (aged 25 to 34 years), the development of atherosclerosis in the coronary arteries and the abdominal 

aorta was consistently greater with higher levels of 

smoking. 

More recently, an eight-community study by the 

Pathobiological Determinants of Atherosclerosis in 

Youth (PDAY) Research Group (1990) found associations of smoking with atherosclerosis in 390 males aged 

15 through 34 years who died of violent causes (e.g., 

accidents, homicides, suicides). In this study, lipids 

were measured in postmortem serum, and smoking 

was assessed by the level of serum thiocyanate. After 

controlling for lipid levels, age, and race, a multiple 

regression analysis revealed a significant association 

between smoking and atherosclerosis (i.e., having raised 

lesions greater than or equal to 5 percent of the intimal 

surface area) in the abdominal aorta. A multipIe logistic 

analysis controlling for the same factors found that 

smoking was a significant predictor of atherosclerosis 

in both the abdominal aorta and the right coronary 

artery. 

The Bogalusa Heart Study is an epidemiologic 

study of cardiovascular disease risk factors encountered 

from birth through age 26. Among deceased subjects 

whose average age was 18 years, cigarette smoking was 

not associated with aortic fatty streaks or involvement of 

the coronary arteries with atherosclerosis (Newman et 

al. 1986;Freedmanetal. 1988). However,insubjects who 

Health Consequences 21 
Surgeon General’s Repot 

Table 3. Published studies of the effects of smoking on respiratory morbidity among young people, 

various countries, 1963 -1987 

Reference* 

Haynes, Krstulovic, Bell 1966 

Location/year 

New Jersey’ 

Study population 

191 male prep school students 

aged 14-19 years 

Kark and Lebiush 1981 Israel, 1979 Female military recruits, 

mean age = 18.5 years 

Blake, Abell, Stanley 1988 Georgia, 1982 1,230 Army recruits, 

most aged < 22 years 

Schwartz and Zeger 1990 California+ 100 student nurses 

*Listed chronologically by publication date. 

‘Year not provided. 

22 Health Consequences 
pr,.l,crrting Tobacco Use Among Young People 

Health effect Prevalence (%I by smoking status 

Nonsmoker Occasional smokert Regular smoke@ 

Annual illness rates”/ 10 students All respiratory 

Severe respiratory 

Number of cigarettes smoked peE day 

0 5 1 pack > 1 pack 

Incidence rate** (per 100 school years) 

Upper respiratory Outpatient 

Hospital 

52.5 59.9 67.0 

7.6 12.0 10.2 

Lower respiratory 

Outpatient 

Hospital 

2.5 3.0 6.8 

0.4 0.7 0.9 

Attack of influenza-like morbiditya 

Occasional/regular smoke@ Never/past smoker 

60% 40% 

General Findings: Relative risk = 1.46 for upper respiratory infection for smokers versus nonsmokers. Illnesses 

ascertained by visits to clinics. 

. 

General Findings: Smoking significantly associated with incidence of cough and phlegm. (h-rent amount smoked 

significantly predicted duration of an episode of phlegm or chest discomfort. 

fSmoked at least 1 cigarette or pipe per week. 

$moked at least 1 cigarette or pipe per day. 

‘Illness rates based on infirmary visits during a school year. 

‘[ltness incidence based on records of the health service. 

**Incidence rates based on self-administered questionnaire. 

-Respiratory-related (similar symptoms) visits to dispensary, 

with one week grouped. 

“Based on self-administered questionnaire. 

@These categories were not defined. 

MIllness occurrence based on medical records and serology. 

Health Consequences 23 
Surgeon General’s Report 

died after age 20, smoking appears to have been related 

to atherosclerosis (Berenson et al. 1992). 

Smoking among young people has been associated 

with serum lipid profiles in a pattern predictive of increased risk for cardiovascular diseases. In a published 

meta-analysis of studies on children who smoke, Craig 

et al. (1990) found that among 8- through lPyear-olds, 

smoking increased levels of low-density lipoprotein cholesterol by 4 percent, triglycerides by 12 percent, and 

very-lowdensity lipoprotein cholesterol by 12 percent. 

Levels of highdensity lipoprotein (HDL) cholesterol were 

reduced by 9 percent. These changes were comparable 

to-and of larger magnitude than-those observed in 

smoking adults. 

Physical Fitness 

Even among young people trained as endurance 

runners, smoking appears to compromise physical 

fitness in levels of both performance and endurance. 

Cigarette smoking reduces the oxygen-carrying capacity 

of the blood and increases both heart rate and basal 

metabolic rate-changes that counter the benefits of physical activity in a direct relation to the duration of smoking 

and the number of cigarettes regularly smoked (Royal 

College of Physicians of London 1992). In a study of 19- 

year-old army conscripts (N = 6,500), those who smoked 

ran a significantly shorter distance in 12 minutes and 

took significantly longer to sprint 80 meters than their 

nonsmoking counterparts (Marti et al. 1988). In the same 

study, the smokers among 4,100 joggers in a 16kilometer’ 

race were consistently slower than the nonsmokers. 

Young adult smokers also have chronic, mild adverse cardiovascular physiologic changes, including diminished exercise performance on standard treadmill 

testing and blunted heart rate response to exercise (Sidney 

et al. 1993). The left ventricular mass is increased in 

young adult smokers, and their resting heart rates are 

two to three beats per minute more rapid than nonsmokers’ (Gidding et al. 1992). 

Health Outcomes in Pregnancy 

Cigarettesmokingduringpregnancyhasbeenlinked 

with a variety of adverse outcomes KJSDHHS 1989,199O). 

Early reports of the Surgeon General KJSDHEW 1971, 

1973,1979a) concluded that smoking by a mother during 

pregnancy retards fetal growth and may cause fetal death 

late in pregnancy as well as infant mortality. The 1977- 

1978 report KJSDHEW 1979a) further concluded that 

smoking during pregnancy has dose-response relationships with abruptio placenta, placenta previa, bleeding 

during pregnancy, premature and prolonged rupture 

of placental membranes, and preterm delivery. The 

comprehensive reviews of the 1979 and 1980 reports 

(USDHEW 1979a; USDIIIIS 1980) concluded that the risk 

of spontaneous abortion increases with the amount of 

smokingand thattheriskofsuddeninfantdeathsyndrome 

(SIDS) is increased by maternal smoking. A more recent 

study confirms the increased risk of SIDS with maternal 

smoking (Schoendorf and Kiely 1992). Impaired fertility 

was linked to smoking in the 1980 report (IJSDIIIIS 1980). 

These adverse health effects of smoking on reproduction 

have not been specifically investigated in young women in 

the lO- through 20-year age range. 

Epidemiologic Evidence of the Health Effects 

of Passive Smoking 

The health effects of passive smoking were comprehensively addressed in the 1986 report of the Surgeon 

General (USDHHS 1986a) and in a report of the National 

Research Council (1986). These reviews and subsequent 

reports (Samet, Cain, Leaderer 1991; USEPA 1992) have 

demonstrated that exposure to parental smoking during 

childhood significantly increases the occurrence of lower 

respiratory illnesses during the first years of life, increases the frequency of chronic respiratory symptoms, 

and reduces the rate of lung growth during childhood 

and adolescence. Evidence is accumulating to suggest 

that smoking by parents increases the severity of childhood asthma (USDHHS 1991b; Samet, Cain, Leaderer 

19911, as indicated by the need for medication and hospital treatment. SIDS, the most common cause of death in 

the first year of life, has been linked to parental smoking 

in several epidemiologic studies. Children of parents 

who smoke have a twofold increased risk of dying of 

SIDS; this relationship appears to be dose-related 

(Schoendorf and Kiely 1992; Malloy et al. 1988). 

The evidence on passive smoking and respiratory 

health was recently reviewed by the USEPA (1992). This 

review confirmed that ETS is causally linked to lung 

cancer. Janerich et al. (1990) noted that approximately 17 

percent of lung cancers among nonsmokers can be attributed to high levels of ETS during childhood and adolescence. The USEPA report also concluded that exposure 

to ETS causes lower respiratory illness in infants and 

young children; this finding is stronger than that of the 

1986 Surgeon General’s report, which did not characterize this association as causal. The agentis report also 

inferred from its data that childhood exposure to ETS 

reduced lung function, increased respiratory symptoms, 

caused middle ear effusion, and exacerbated asthma. 

For example, the report estimated that ETS exposure 

exacerbates symptoms of asthma in about 20 percent of 

the two million to five million asthmatic children in the 

United States. The report also hypothesized that ETS 

may be associated with the onset of asthma. 

24 Health Consequences 
prt7w ting Tobacco Use Among Young PeopZe 

Many chronic changes in cardiovascular physiolI have been observed in children exposed to ETS. 

Tse changes include lower HDL cholesterol, increased 

carboxyhemoglobin concentration, and increased 

rtd-cell 2.3diphosphoglycerate, as well as physiologic 

response suggesting mild, chronic hypoxemia 

(Moskowitz et al. 1990). ETS is also known to increase 

platelet aggregation (Glantz and Parmley 1991). 

The effect of peer smoking-as a source of ETSon nonsmoking children has not been studied but may 

also be a health risk. 

Adult Health hpkations of Smoking Among Young People 

Respiratory Diseases 

As was discussed previously, sustained smoking 

during adulthood is associated with the development of 

C()PD and the progressive loss of lung function 

(USDHHS 1984,199O). Evidence suggests that smoking 

during childhood may increase the risk for developing 

CORD in adulthood as well as at an earlier age. The 

&dt who smoked during childhood may have experienced early inflammatory changes--childhood smoking 

is known to reduce lung growth-and thereby not attained the level of function achieved during the normal 

growth and development of the lungs. Any age-related 

decline in lung function during adulthood would thus 

start from a lower level-and might begin at a younger 

age-than declines observed in adults who have never 

smoked. In fact, the proportionate impeding effect of 

chiIdhood smoking on lung growth greatly.exceeds the 

loss of lung function associated with smoking during 

‘rdulthood (Tager et al. 1985,1988). 

If one or both parents of an adolescent smoke, the 

cffccts of parental smoking on early childhood respiratory illnesses and on the growth of lung function may 

increase the risk of COPD. Illnesses in the lower respirator-v region during childhood are a suspected risk factor 

for-COPD (Samet, Tager, Speizer 19831, and passive 

smoking reduces the rate at which lung function 

grows (USDHHS 1986a). 

Cardiovascular Disease 

In adults, cigarette smoking has been causally 

associated with coronary heart disease, arteriosclerotic 

peripheral vascular disease, and stroke (USDHHS 1983, 

1989). Smoking contributes to increased risk for coronary heart disease probably through at least five interrelated processes, including the development of 

atherosclerosis (USDHHS 1990). It is likely that the 

earlier the age at which one starts to smoke, the earlier 

the onset of coronary heart disease. The recent evidence 

from the PDAY Research Group shows more atherosclerosis in young smokers than in young nonsmokers. 

The unfavorable effects of smoking on lipid levels in 

children may contribute to the development of atherosclerosis in young adulthood. 

Cancer 

The multistage concept of carcinogenesis implies 

that the risk of smoking-related cancers is strongly dependent on the duration and intensity of smoking 

(Armitage and Doll 1954; Doll 1971; Taioli and Wynder 

1991). The relevant epidemiologic data and mathematical analyses are most abundant for lung cancer. Both 

epidemiologic and experimental evidence suggest that 

the risk for lung cancer varies more strongly with the 

duration of cigarette smoking than with the number of 

cigarettes smoked Veto 1977; Doll and Peto 1978). Analysis of data from a cohort study of British doctors showed 

that lung cancer incidence increased with the fourth or 

fifth power of duration of smoking but with the second 

power of number of cigarettes smoked daily (Doll and 

Peto 1978). Although these data can be adequately described by alternative mathematical models that give 

lesser weight to duration (Moolgavkar, Dewanji, Luebeck 

1989), the dependence of lung cancer risk on duration of 

smoking implies that starting smoking at an earlier age 

increases the potential number of life-years of smoking 

and therefore increases lung cancer risk. If one assumes, 

for example, that lung cancer risk rises exponentially as a 

function of the duration of smoking, then the risk at age 

50 for a person who began smoking regularly at age 13 is 

350 percent greater than that for a 50-year-old who started 

smoking at age 23. 

Similar analyses have not been done for other 

smoking-related sites of cancer. Nevertheless, for 

most smoking-related cancers, the risk rises with the 

duration of smoking (USDHI-IS 1982,1989,1990; Intemational Agency for Research on Cancer 1985). One could 

Health Consequences 25 
Surgeon General’s Report 

infer that the risk of smoking-related cancer for sites other 

than the lungs would increase, at a given adult age, 

in inverse proportion to the age an adolescent beg+ 

smoking. 

Recent studies indicate that earlier onset of 

cigarette smoking is also associated with heavier smoking (Taioli and Wynder 1991; Escobedo et al. 1993). 

Heavier smokers are not only more likely to experience 

tobacco-related health problems, they are the least likely 

to quit smoking (Hall and Terezhalmy 1984; USDHHS 

1989). Early use of cigarettes thus appears to influence 

intensity as well as duration of use and increases the 

potential for long-term health consequences. 

Nicotine Addiction in Adolescence 

Introduction 

Nicotine dependency through cigarette smoking is 

not only the most common form of drug addiction but 

the one that causes more death and disease than all other 

addictions combined (USDHHS 1988). Most human 

research on nicotine addiction has been conducted with 

adult subjects, but the basic biologic processes that 

underlie this dependency appear to be similar in adolescents and adults. The research literature on nicotine 

addiction examines its chemistry and addiction potential, its severity, and its pathophysiology and clinical 

course. 

Background and Nomenclature 

Drug addiction is the term most widely used to. 

label various medical and social disorders related to the 

compulsive ingestion of psychoactive chemicals. The 

primary criteria for drug dependence are that the behavior is highly controlled or compulsive, the chemical is 

one whose mood-altering or psychoactive effects are 

central elements of the drug’s activity, and the drug itself 

has the demonstrated capability of reinforcing behavior 

(Table 4). The American Psychiatric Association (APA) 

has identified two medical disorders that pertain to nice 

tine addiction: nicotine dependence and nicotine 

withdrawal (APA 1987). 

Nicotine dependence is classified as a psychoactive 

substance-use disorder characterized by “a cluster of 

cognitive, behavioral, and physiologic symptoms that 

indicate that the person has impaired control of 

psychoactive substance use and continues use of the 

substance despite adverse consequences” (APA 1987, 

p. 166). In the case of nicotine, the most common form of 

use is cigarette smoking, in part because the rapid absorption of nicotine through the processes of smoking 

‘leads to a more intensive habit pattern that is more 

difficult to give up” than other forms of use (APA 1987, 

p. 181). Nicotine dependence also occurs through other 

routes of delivery, including smokeless tobacco and 

nicotine gum. 

26 Health Consequences 

Nicotine withdrawal, an organic mental disorder 

induced by the removal of psychoactive substance, is 

described as “a characteristic withdrawal syndrome due 

to the abrupt cessation of or reduction in the use of 

nicotine-containing substances (e.g., cigarettes, cigars and 

pipes, chewing tobacco, or nicotine gum) that has been at 

least moderate in duration and amount. The s-yndrome 

includes craving for nicotine; irritability, frustration, or 

anger; anxiety; difficulty concentrating; restlessness; de 

creased heart rate; and increased appetite or weight gain” 

(APA 1987, p. 150). 

Physical dependence refers to the condition in which 

withdrawal symptoms have been observed. Physical 

dependence can complicate the process of achieving and 

Table 4 . Criteria for drug dependence 

Primary criteria 

Highly controlled or compulsive use 

Psychoactive effects 

Drug-reinforced behavior 

Additional criteria 

Addictive behavior often involves the following: 

Stereotypic patterns of use 

Use despite harmful effects 

Relapse following abstinence 

Recurrent drug cravings 

Dependence-producing drugs often manifest the 

following: 

Tolerance 

Physical dependence 

Pleasant (euphoric) effects 

Source: Adapted from USDHHS (1988). 
prcyvwting Tobacco Use Among Young People 

maintaining drug abstinence, and the symptoms can be 

so unpleasant as to precipitate relapse (Jaffe 1985; 

USDHHS 1988). In surveys by the National Institute on 

Drug Abuse (NIDA), withdrawal and inability to maintain abstinence are COIYUIIO~~~ attributed to cigarette smoking and heroin ux (USDHHS 1988). The majority of 

people monitored who reguIarly use other addictive 

drugs (including cocaine and marijuana) report that they 

have not experienced withdrawal, even though many of 

these people feel dependent and have been unable to 

maintain abstinence (USDHHS 1988). 

Severity of Nicotine Addiction 

Tobacco-delivered nicotine can be highly addictive. Each year, nearly 20 million people try to quit 

smoking in the United States (USDHHS 1990), but O~Y 

about 3 percent have long-term success (Pierce et al. 

1989; Centers for DiseaseControland Prevention [CDCJ, 

Office on Smoking and Health, unpublished data). Even 

among addicted persons who havelost a lung because of 

cancer or have undergone major cardiovascular surgery, only about 50 percent maintain abstinence for 

more than a few weeks (West and Evans 1986; USDHHS 

1988). In a 1991 Gallup Poll, 70 percent of current 

smokers reported that they considered themselves to be 

“addicted” to cigarettes (Gallup Organization 1991). 

These findings are consistent with data from NIDA’s 

I985 National Household Survey on Drug Abuse 

(NHSDA), which showed that 84 percent of 12- through 

17-year-olds who smoked one pack or more of cigarettes 

per day felt that they “needed” or were “dependent” on 

cigarettes (Henningfield, Clayton, Pollin 1990). The 

NHSDA data show that young smokers develop tolerance and dependence, increase the amount they smoke, 

and are unable to abstain from nicotine. These findings 

suggest that the addictive processes in adolescents are fundamentally the same as those studied in adults (USDHHS 

1988; Henningfield, Clayton, Pollin 1990). 

Several studies have found nicotine to be as addictive as heroin, cocaine, or alcohol (Henningfield, Clayton, 

Eollin 1990; Henningfield, Cohen, Slade 1991; Kozlowski 

et al. 1993). Moreover, because the typical pattern of 

tobacco use entails daily and repeated doses of nicotine, 

addiction is more common among all users than is true 

of other drug use, which tends to occur on a far less 

frequent basis (USDHI-IS 1988). For example, only about 

10 to I5 percent of current alcohol drinkers are considered problem drinkers, but approximately 85 to 90 percent of cigarette smokers smoke at least five cigarettes 

every day (Henningfield, Cohen, Slade 1991; Evans et 

al, 1992; Henningfield 1992b; Kozlowski et al. 1993). 

Only 2 to 3 percent of smokers (or about 7 to 10 percent 

of those who try quitting) stop smoking for one year 

(CDC 1993a), and most daily smokers report that they 

feel dependent on smoking and have experienced withdrawal symptoms (USDHHS 1988; Henningfield, 

Clayton, Pollin 1990). 

Chemistry and Addiction Potential 

Many behaviors that become regular, habituaI, and 

hard to give up involve the ingestion of a substance. 

What sets drug addictions apart from less harmful habits 

is that the ingested substance releases a psychoactive 

drug with the demonstrated potential to addict. Several 

thousand chemicals are present in cigarette smoke. Some 

may conceivably modulate nicotine’s addictive effects, 

but the fact that different forms of nicotine delivery can 

be substituted for one another(e.g., nicotine gum or 

transdermal patch in place of cigarettes) suggests that 

nicotine is critical in the addiction process (Henningfield 

1984; Benowitz 1988; USDHHS 1988; Russell 1990). 

Nicotine is a naturalIy occurring aIkaloid present in 

varying concentrations in different strains of tobacco. Most 

cigarettes sold in the United States contain about 8 to 9 

milligrams of nicotine, of which the smoker typically ingests 1 to 2 milligrams per cigarette (Benowitz et al. 1983; 

USDHHS 1988). Nicotine is both a lipid- and watersoluble molecule that can be rapidly absorbed in a mildly 

alkaline environment through the skin or the Iining of the 

mouth and nose. Because of the massive area for absorption in the alveoli of the lungs, nicotine inhaled deeply is 

almost immediately extracted from the smoke into the 

pulmonary veins; this sudden spike or bolus of nicotine is 

delivered to the brain, via arterial circulation, in approximately 10 seconds (USDHHS 1988). In contrast, although 

smokeless tobacco has much higher levels of nicotine than 

cigarettes, the delivery of the drug is much more gradual; 

the effect peaks within approximately 20 minutes of use 

(Benowitz et al. 1988). The peak for nicotine replacement 

medications is even slower-30 minutes or longer for 

nicotine gum (Benowitz et al. 1988), severaI hours for the 

four commercially available transdermaI patch systems 

(Palmer, Bucklet, Faulds 1992). In fact, because of the 

efficiency of the pulmonary route in extracting nicotine 

from inhaIed tobacco smoke, nicotine may be 10 times 

more concentrated in arterial blood than in simultaneously 

sampled venous blood; these levels are much higher than 

those produced by nicotine replacement medications 

(Henningfield, London, Benowitz 1990). 

As vehicles for nicotine delivery, tobacco products 

are convenient to use, and they provide the experienced 

user with a means of regulating dose level. Such control 

does not, however, protect the user against drug dependency, since tobacco products appear to deliver the optimal addiction potential (or abuse liability) of nicotine. 

Chemicals can be tested for their addiction potential to 

Health Consequences 27 
Surgeon General’s Report 

determine if they are psychoactive and if they can serve 

as reinforcers in animals and humans (Brady and Lukas 

1984; USDHHS 1988; Fischman and Mello 1989; 

Henningfield, Cohen, Heishman 1991). These methods 

to test for abuse liability are reliable enough for the Food 

and Drug Administration (FDA) and the World Health 

Organization (WHO> to use them to develop policies 

regarding regulation of new drugs with possible addiction potential (USDHHS 1988; Barcelona Conference 

1991). Nicotine meets the criteria for addiction potential 

in all of the standardized tests used by the FDA and the 

WHO (USDHHS 1987, 1988, 1991a). In humans and 

animals, nicotine produces discrete subjective effects more 

similar to those produced by cocaine than to those produced by sedatives, and nicotine injections are biologically reinforcing to humans and to at least five animal 

species (Henningfield, Miyasato, Jasinski 1985; 

Henningfield and Goldberg 1988; USDHI-IS 1988). Such. 

findings confirm the conclusion of the 1988 report of the 

Surgeon General: nicotine is a drug with a liability for 

addiction (USDHI-IS 1988). 

Pathophysiology of Nicotine Dependence 

The pathophysiology of drug dependence and the 

clinical course of nicotine and other drug dependencies 

have been described in detail elsewhere (Gaffe 1985; 

USDHHS 1988; Benowitz 1992; Henningfield 1992a). In 

brief, exposure to a psychoactive chemical leads to repetitive self-administration because of the chemical’s 

capacity to condition behavior. This powerful conditioning action of nicotine is mediated at least in part by 

the activation of nicotinic receptors in the brain (USDI-IHS 

1988; Bock and Marsh 1990) and the modulation of levels 

of hormones such as epinephrine (adrenaline) and cortisol (Pomerleau and Pomerleau 1984; Sachs 1987; USDHHS 

1988). The mesolimbic dopaminergic reward system, 

which mediates the addicting actions of cocaine, is also 

thought to be involved in producing nicotine’s addictive 

effects (Pomerleau and Pomerleau 1984; USDHHS 1988; 

Bock and Marsh 1990; Balfour 1991a, b; Benwell and 

Balfour 1992). Behaviors that are followed by intense 

neural activation can become highly persistent and difficult to modify (Pomerleau and Pomerleau 1984; Jaffe 

1985; USDHHS 1988). Each year, the daily cigarette 

smoker may experience 50,000 to 100,000 such pairings 

of puffing on cigarettes and resultant effects in the brain, 

thus establishing a persistent need for cigarette smoking. 

Tolerance 

Tolerance refers to a diminishing response to a 

drug through repeated exposures (Gaffe 1985; USDHHS 

1988). Tolerance is often demonstrated when increased 

dose levels are required to obtain the effects formerly 

produced by lower doses. Tolerance to nicotine appears 

to be acquired as people progress from initially smoking 

a few cigarettes to smoking greater numbers of cigarettes 

more often (see ‘Initiation Continuum of Smoking” and 

“Adult Implications of Adolescent Smoking” in Chapter 

3 and “Developmental Stages of Smoking” in Chapter 4). 

The development of tolerance to the aversive effects 

of nicotine, such as nausea and dizziness, may also facilitate the development of dependency (USDHHS 1987; 

Shiffman et al. 1990; Shiffman 1989,199l; McNeill, Jarvis, 

West 1987). Tolerance of nicotine increases over time; 

experienced smokers can self-administer doses of nicotine that would make nonsmokers ill. 

The tolerance the nervous system develops to nicotine exposure can be at least partially overcome by 

increasing the dose. This effect was studied near the 

beginning of the 20th century and has been the subject of 

considerable study since then (Langley 1905; USDHHS 

1988; Benowitz and Jacob 1993). Tolerance to various 

behavioral, physiologic, and subjective effects of nicotine 

has been studied (USDHHS 1988). For example, 

administering nicotine to a tobacco-deprived cigarette 

smoker can produce a substantial increase in heart rate 

and measures of euphoria, along with a decrease in the 

strength of the knee reflex. With repeated doses, the 

heart rate stabilizes at a level between that produced 

by the first dose and that which occurs when nicotinedeprived; subjective effects are minimaI, and the knee 

reflex may become normal (Domino and Von Baumgarten 1969; USDHHS 1988; Swedberg, Henningfield, 

Goldberg 1990). 

Some tolerance of nicotine is lost each night as the 

smoker’s nicotine levels fall; the nicotine from the first 

few cigarettes of the day produces effects on heart rate, 

mood, and other measures that are stronger than the 

effects produced by subsequent doses during the day 

(USDHHS 1988). Repeated exposure to nicotine leads to 

morphological changes in the brain that cause the development of new binding sites for nicotine receptors, which 

mediate the effects of nicotine (Bock and Marsh 1990; 

USDHHS 1988,199la). 

Animal research has shown that nicotine exposure 

results in an increased expression (defined as up-regulation) of nicotine receptors in various regions of the brain 

(Ksir et al. 1985; Morrow, by, Creese 1985; Nordberg et 

al. 198.5; Schwartz and Kellar 1985; Ksir, Hakan, Kellar 

1987). Prenatal exposure to nicotine also produces up 

regulation of nicotine receptors in tissue collected from 

newborn animals (Slotkin, Orband-Miller, Queen 1987; 

Slotkin et al. 1991; Smith, Seidler, Slotkin 1991). These 

data suggest the broad applicability of this up-regulation 

effect, which may be one of the ways in which tolerance 

of nicotine occurs CUSDI-II-IS 1989). 

28 Health Consequences 
prarenting Tobacco Use Among Young People 

Humanresearchismorelimitedthananimalre 

search in this area, but there is evidence that cigarette 

smoking is associated with upregulation of nicotine 

receptors in the human brain. Balfour (1989, 1991a) 

has conducted a series of studies that included the 

examination of postmortem brain tissue from smokers 

and nonsmokers. He and others found evidence of significantly elevated concentrations of nicotine binding sites as 

well as smoking-related changes in other binding sites 

(such as 5hydroxytryptamine) (Benwell, Baifour, Anderson 1988; Balfour 1989,199la; Grant, McMurdo, Balfour 

1989; Bock and Marsh 1990). Morphologic changes in the 

nervous system are presumed to reflect part of the bodfs 

adaptation (resulting in tolerance and physical dependence) to a prolonged exposure to nicotine (Marks and 

Collins 1982; Marks, Burch, Collins 1983; Marks et al. 1985, 

1986;h4ar~,Stitzel,Collins1985,1986,1987;USDHHS1988). 

Physical Dependence 

Nicotine administered to animals and humans prDduces altered spontaneous electroencephalograph (EEG) 

and evoked electrical potentials of the brain, altered local 

cerebral glucose metabolism, modulation of hormonal 

output by the adrenal glands, increased heart rate, and 

changes in skeletal muscle tension (USDHHS 1988). Most, 

if not all, of these effects are related to the dose of nicotine 

given, and tolerance develops to differing degrees across 

these effects. After a period of nicotine exposure that is 

assumed to be at least several weeks (APA 1987), physical dependence on nicotine develops. The dependent 

person then appears to be functioning normally when 

under the influence of nicotine; conversely, the person 

may report feeling “abnormal” or “not right” when deprived for more than a few hours (Casey 1987). 

Although basic pharmacologic research on nicotine has been conducted primarily with adults, most 

people begin to smoke in adolescence and develop characteristic patterns of nicotine dependence before adulthood (USDHHS 1988,199la). That adolescents develop 

physical dependence, as evidenced by their experience 

of withdrawal symptoms, has been well documented by 

the NHSDA (USDHHS 1991~). Moreover, quantitative 

characteristics of the withdrawal syndrome appear to be 

the same in adolescents and adults (McNeill et al. 1986; 

McNeill, Jarvis, West 1987). 

The magnitude of the withdrawal syndrome is 

related to the previous level of nicotine intake, although 

differences in just a few cigarettes a day may not be 

correlated with the severity of the syndrome (Killen et al. 

1988; USDHHS 1988). Environmental context is also a 

factor; in a novel environment (e.g., a hospital setting), 

the symptoms of nicotine withdrawal may be less than 

in the smoker’s usual environment, with its various 

psychological cues for smoking (Hatsukami, Hughes, 

Pickens 1985). The time course of withdrawal symptoms 

varies among individuals and for different responses. 

Most withdrawal symptoms peak within the first few 

days of nicotine abstinence and then begin to recover 

along a variable course; the most severe total withdrawal 

syndrome usually lasts about three to four weeks 

(LJSDHHS 1988; Gross and Stitzer 1989). For example, 

certain measures of brain function (such as P3OO-evoked 

electrical potential) recover within a few days, but others 

may take weeksor more (such as NlOO-evoked potential, 

hunger, and craving). Powerful urges to smoke may 

recur for many years (Hughes and Hatsukami 1986; 

USDHHS 1988). 

Although questions remain, the pathophysiology 

of nicotine dependence clearly ‘&olves the brain, the 

endocrine system, and behavior, and the process begins 

when cigarette smoking is initiated. Moreover, although 

the effects of nicotine administration and deprivation are 

complex, they are orderly and are related to factors such 

as the amount of nicotine administered and the time 

since the last dose. 

The Clinical Course of Nicotine Dependence 

Like other drug addictions, nicotine dependence is 

a progressive, chronic, relapsing disorder. The level of 

dependence on nicotine in adults has been found to be 

inversely related to the age at initiation of smoking when 

measured by diagnostic criteria (APA 1987) of the APA 

(Breslau, Fenn, Peterson 1993) and by the Fagerstrtim 

Tolerance Questionnaire Score (Henningfield et al. 1987). 

As is true for most drug addictions, tobacco use is 

not always constant from initiation on; the process of 

graduation from first use to addiction can take months or 

even years (USDHHS 1988). In fact, initial experiences 

with tobacco, as with other addictive substances, are 

sometimes negative and require social pressures and 

other factors to maintain exposure until the addiction 

develops (Haertzen, Kocher, Miyasato 1983). The percentage of people who progress from smoking a few 

cigarettes to smoking at a regular, addictive level has 

been estimated to range from 33 to 94 percent. For 

example, Russell (1990) has reported that a survey of 

adults in Great Britain in the mid-1960s indicated that 94 

percent of those who smoked more than three cigarettes 

became ‘long-term regular smokers.” These data, which 

precede widespread public awareness of the hazards of 

smoking, may have a limited applicability to current 

smoking behavior. Recently collected data in the United 

States and Great Britain suggest that between 33 and SO 

percent of people who try smoking cigarettes escalate to 

regular patterns of use &I&&man Leventhal, Glynn 

1984; McNeilll991; Henningfield, &hen, Slade 1991). 

Health Consequences 29 
Surgeon General’s Report 

The chronic phase of the addictive process is highly 

resistant to substantial modification. For example, efforts to reduce tobacco smoke and nicotine exposure by 

smoking cigarettes with lower ratings of nicotine delivery or to smoke fewer cigarettes are usually partially or 

completely thwarted by compensatory changes in how 

the cigarettes are smoked; smokers may compensate for 

“cutting back” by inhaling more deeply or smoking the 

cigarette farther down to its more potent and more toxic 

end (Kozlowski 1981,1982; benowitz et al. 1983; benowitz 

and Jacob 1984; USDHHS 1988). Abstinence from smoking is generally short-lived; the majority of persons who 

quit on their own or in minimally supportive interventions appear to relapse within one week of their last 

cigarette (Kottke et al. 1989). In fact, in testament to the 

persistence of addiction, nearly one-third of those who 

have abstained for one year after quitting relapse later 

(USDHHS 1990; Giovino 1991). These patterns of relapse 

are similar to those observed with other drug addictions. 

Several potential predictive measures of the severity of addiction in a person may forecast the severity of 

withdrawal and the outcome of an attempt to quit. These 

measures, which have been discussed in detail in the 

1988 report of the Surgeon General (USDHHS 19881, 

include cotinine level in biological fluid such as saliva, 

blood, or urine; number of cigarettes smoked per day; 

score on the Fagerstrom Tolerance Questionnaire; and 

number of symptoms attributed from the Diagnostic and 

Statistical Manual of Mental Disorders (APA 1987). These 

measures tend to predict, although not perfectly, the 

difficulty of achieving abstinence, the severity of withdrawal symptoms, the rapidity of relapse, and the efficacy of replacement therapy (USDHHS 1988). 

One final source of vulnerability to nicotine dependence appears to be genetic predisposition. Research with 

animals has shown that the amount of upregulation 

(increased binding in the brain) of nicotine receptors after 

Smoking as a Risk Factor for Other Drug Use 

nicotine exposure is related to genetic constitution, as are 

certain behavioral and physiologic effects (Marks et al. 

1989; Collins 1990). Data from studies with human twins 

have yielded indices of heritability for cigarette smoking 

similar to those for drinking alcohol (Hughes 1986; 

Kozlowski 1991; Carmelli et al. 1992). 

Nondrug Factors in Nicotine Dependence 

Nondrug factors can affect the prevalence of drug 

addiction in society as well as its severity in individuals. 

Some of the factors are the same as those that determine 

the prevalence and severity of other medical disorders 

resulting from exposure to toxins. Among the most 

important factors in determining the prevalence of drug 

addiction is the exposure to the addicting substance 

(USDHHS 1988). This factor is no less important in the 

spread of drug addiction than it is in the spread of 

disorders such as acquired immunodeficiency syndrome, 

malaria, and influenza infections. Moreover, social factors can determine the type and frequency of exposure to 

the etiologic agent, as well as the time frame over which 

exposure continues. Many nondrug factors associated 

with both abstinence and relapse appear to operate similarly across addictions. These factors include illness 

induced by drug dependence (which will at least tempo 

rarily interrupt drug use), ability to learn to manage 

cravings, social reinforcements for abstinence, availability of the substance, cost of the substance, and perception 

of the risk of using the substance (USDHHS 1988). 

Persons vary in their vulnerability to nicotine and 

other drug addiction, just as they vary in their vulnerability to other medical disorders; some people show a high 

degree of resistance to the disorder despite multiple 

exposures to the agent, and others very quickly become 

addicted (USDHHS 1988). Psychosocial factors affecting 

the vulnerability of the young and the onset of tobacco 

use are discussed in Chapter 4. 

Introduction 

The 1988 Surgeon General’s report (USDHHS 1988) 

showed that among adolescents, cigarette smoking is 

a risk factor in the development of alcohol use and 

illegal drug use. The nature of the interrelationship between tobacco and other drug use is complex; in several 

possible ways, tobacco use may heighten the probability 

that a young person will use other drugs (Slade 1993; see 

“Smoking and Other Drug Use” in Chapter 3 and “Behavioral Factors in the Initiation of Smoking” in Chapter 4). 

Progression of Drug Use 

Kandel(1975) found that studies of the progression 

of drug use in the 1970s showed that cigarette smoking 

and alcohol use generally preceded marijuana smoking 

and other illegal drug use. In fact, Kandel’s study 

30 Health Consequences 
PrlywI tittg Tobacco Use Among Young People 

ronclud~ that virtually everyone who used illegal drugs 

such as marijuana or cocaine had previously used 

bgareHe, alcohol, or both. These findings, primarily 

among white youths, have been repeatedly extended 

and replicated (e.g., Fleming et al. 1989; Kandel and 

\I’amagWhi 1993). 

More recent data hrom the Monitoring the Future 

prop (MTFP) by NIDA. (USDHHS 1988) confirm that 

illegal drug use is rare among those who have never 

smok& and that cigarette smoking is likely to precede 

the use of alcohol or illegal drugs. The 1985-1989 MTFI’ 

show& that first use of tobacco had occurred at the same 

age as first use of alcohol for 33 percent of the sample; 

cigarettes were used before alcohol by 49 percent of the 

simple. The same survey showed that among those who 

had used both cigarettes and marijuana, 23 percent beRon using both in the same year, and 65 percent smoked. 

c@rettes before marijuana. The latter relationship was 

more pronounced for cocaine: 98 percent of persons who 

had used both cocaine and cigarettes smoked cigarettes 

first (see Tables 24-26 in Chapter 3). 

These findings were extended in another longitudinal study that assessed 12-, 1.5, and I&year-olds in 

New Jersey and reinterviewed them at three-year intervals (USDHHS 1987). This study showed that among 15 

year-olds, the use of cigarettes, alcohol, or marijuana was 

the strongest predictor of cocaine use when these same 

Persons were reinterviewed three years later; at that 

time, the persons using cocaine were likely to be using 

cigarettes and alcohol as well. 

Cigarette smoking in combination with alcohol 

use appears to be especially predictive of illegal drug 

use. A longitudinal study by Yamaguchi and Kandel 

(1984) examined initial data from students in the tenth 

and eleventh grades in New York State in 1971. When 

the authors reevaluated the same students in 1981 (average age, 25 years>, the most common sequence of 

drugs used was alcohol, cigarettes, marijuana, illegally 

used psychoactive or prescription drugs, and other illegal drugs. The investigators found that for 87 percent 

of the men, alcohol use preceded marijuana use; alcohol and marijuana use preceded other illegal drug use; 

and use of alcohol, cigarettes, and marijuana preceded 

the use of other psychoactive drugs. For 86 percent of 

the women, a similar, but not identical, pattern emerged: 

alcohol or cigarettes preceded marijuana; alcohol, cigarettes, and marijuana preceded other illegal drugs; and 

alcohol and either cigarettes or marijuana preceded 

other psychoactive drugs. These findings were replicated with 1,108 high school seniors in New York in 1988 

(Kandel and Yamaguchi 1993). This study confirmed 

the importance of cigarette and/or alcohol use in the 

Progression of illegal drug use, with early cigarette 

use being of particular importance in the develop 

ment of other drug use among females. Early onset of 

cigarette smoking and /or alcohol use was a strong predictor of further drug use. 

The relationship between alcohol use and cigarette 

smoking is more complex than would be suggest& by 

examining any one survey. Jn some studies, alcohol is 

more likely to precede than to follow cigarette smoking. 

This variability might be explained by the d&ring study 

criteria for alcohol use. For example, among many adolescents, alcohol consumption is characterized by the occasional light use of beer or wine-a pattern that often 

neither escalates into patterns of heavy drinking nor predicts other drug use fKande1, Marguihes, Davies 1978; 

Huba, Wingard, Bentler 1981; 0’Donnell and Clayton 

1982). This finding is consistent with the observation that 

approximately 85 percent of people who drink alcoholic 

beverages do so in patterns that do not meet criteria for 

abuse (USDHHS 1988). On the other hand, consumption 

of ‘hard liquor,” sometimes accompanied by heavy drinking patterns, appears to develop either along with or 

following the development of regular patterns of cigarette 

smoking (Kozlowski et al. 1993; DiFranza and Gum 

1990). These observations are consistent with the iindings of the 1985 NHSDA, which showed that among 12- 

through 17-year-old adolescents who had never smoked, 

only 3 percent had binged (i.e., had five or mom drinks in 

a row) in the past 30 days, whereas nearly 40 percent of 

daily smokers in this age group had binged in the past 30 

days (USDHHS 1988). 

The progression from cigarette smoking and 

occasional consumption of alcoholic beverages to heavier 

drinking and illegal drug use does not appear limited to 

any single Population group. However, there is some 

evidence that boys with conduct disorders in school and at 

home may be at especially high risk of progression from 

any use of tobacco and alcohol to addictive patterns of 

multiple-drug use. A recent study of 61 males aged 14 

through 18 who had conduct disorders found sequawms of 

acquisitionofdrugusesimilartothosefoundamongadole+ 

cents in general, but with higher rates of addictive use of the 

tobaccoalcohol-marijuana cluster and earlier initiation of 

these substances (Mikulich, Young Gowley 19931. 

Cigarette Smoking and Other Drug Use 

Cigarette smoking is neither necessary nor 

sufficient for other drug abuse or dependence. Not ail 

cigarette smokers subsequently abuse other drugs, and a 

small percentage of abusers of alcohol and illegal drue do 

not use tobacco. However, several studies have 

revealed that cigarette smoking is a predictor of whether 

an individual is using other drugs and of what that 

individual’s level of other drug use is. The 1985 NHSDA 

Health Conse9uencf?s 31 

161-235 95-2 
Surgeon General’s Report 

(USDHHS 1988; Henningfield, Clayton, Pollin 1990) 

showed that 12- through 17-year-olds who had smoked 

cigarettes in the past 30 days were approximately 3 times 

more likely to have consumed alcohol, 8 times more 

likely to have smoked marijuana, and 22 times more 

likely to have used cocaine in the past 30 days than those 

who had not smoked cigarettes. Data from the 1985- 

1989 MTFJ? showed that seniors who had smoked cigarettes in the past 30 days were about 1.6 times more likely 

to have consumed alcohol, 4 times more likely 

to have smoked marijuana, and 5 times more likely to 

have used cocaine in the past 30 days than those who had 

not smoked cigarettes (see “Smoking and Other Drug 

Use” and Table 23 in Chapter 3). 

The 1985 NHSDA CUSDHHS 1988; Henningfield, 

Clayton, Pollin 1990) examined heavier drug use as a 

function of cigarette smoking. Having 5 or more drinks 

in succession in the past 30 days, using marijuana on 

more than 10 occasions, and using cocaine on more than 

10 occasions were considered heavier usage of drugs. A 

strong association was observed between cigarette smoking and other drug use among all age groups in this 

study, although the percentage of the increases in drug 

use from the never-smoker to the daily-smoker levels 

was strongest in the 12- through 17-year-old group (Figure 1). Among these youngest smokers, those who 

smoked daily were approximately 14 times more likely 

to have binged on alcohol, 114 times more likely to have 

used marijuana at least 11 times, and 32 times more likely 

to have used cocaine at least 11 tunes than those who had 

not smoked. 

A similar correlation between frequency of alcohol 

use and level of cigarette smoking was found in a study 

of 7th- through 12th-grade students in New York State 

(welte and Barnes 1987). In the Welte and Barnes study, 

as in the NHSDA, not only were smoking any cigarettes 

and drinking alcohol related, but daily smoking was a 

predictor of binge drinking. These data are consistent 

with those from a study of adult multiple-drug abusers, 

which found that severity of nicotine dependence, as 

measured either by a scale that assesses the strength of a 

given habit or by cigarettes smoked per day, was correlated directly with severity of alcohol consumption problems, as measured by scores on the Michigan Alcoholism 

Screening Test (Kozlowski et al. 1993). These data indicate a strong direct relationship between level of nicotine 

dependence and alcohol abuse but do not in themselves 

show the direction of the relationship or rule out the 

possibility that other factors commonly determine the 

coincidental occurrence of high levels of tobacco and 

other drug use. 

Data from a longitudinal study in which 4,192 

students (grades six through eight) were surveyed three 

times over four years extended the findings that the 

amount of tobacco use is directly related to other drug 

use (Bailey 1992). Specifically, this study showed that 

students who during follow-up periods escalated from 

low-level use of tobacco or alcohol to heavy-1eveI use 

were more likely to begin using other psychoactive 

substances .or to increase their use of these substances 

than students who remained low-level users of tobacco 

or alcohol (Bailey 1992). 

Other studies suggest that the age at onset of 

cigarette smoking determines the probability of subse 

quent use of marijjana and of heavy alcohol use. For 

example, Clayton and Ritter (1985) found not only that 

cigarette smoking, along with alcohol use, was the most 

powerful predictor of marijuana use, but also that the 

effect was strongest when smoking was initiated by age 

17. Similarly, Keenan (1988) found that the age at onset 

of cigarette smoking was significantly younger in people 

with a history of alcoholism than in those who did not 

use alcohol. 

Another study estimated that the relative risk of 

alcoholism was increased tenfold among cigarette smokers and that people who heavily use alcohol represent 

approximately one-third of all cigarette smokers 

(DiFranza and Guerrera 1990). A further analysis of 

these and additional data led Kozlowski et al. (1993) to 

conclude that because the association between smoking 

and drinking is weaker among light smokers, the percentage of heavier smokers who develop problems with 

alcohol might be greater than 30 percent. 

Of all drug users surveyed by the NIDA, cigarette 

smokers were by far the most likely to report experiencing various features of addiction. Among 12- through 

17-year-olds who had used cigarettes, 27 percent were 

daily users and 20 percent felt dependent; of those who 

had used alcohol, 6 percent were daily users and 5 percent felt dependent; of those who had used marihana, 18 

percent were daily users and 10 percent felt dependent; 

of those who had used cocaine, 14 percent were daily 

users and 6 percent felt dependent (USDHHS 1988; 

Henningfield, Clayton, Pollin 1990). Cigarette smoking 

was also, by far, the drug use most commonly associated 

with withdrawal symptoms. Thus, cigarette smoking 

not only occurs early in the progression of drug use, it 

appears to be the first of these drugs to produce features 

of addiction in young people. 

Smoking as a Facilitator for Other Drug Use 

A number of mechanisms could explain how cigarette smoking facilitates the use of alcohol and illegal 

drugs. These mechanisms are not mutually exclusive. 

Moreover, other variables may operate to nondifferentially 

increase the use of tobacco and a wide range of other 

substances. For example, children with conduct disorders 

are at increased risk of using tobacco, heroin, alcohol, 

32 Health Consequences 
F,tc,~~~lltjl~S Tobacco use Among YOUfZg PeOpit? 

fig,,m 1. Use of alcohol mar+a% and cocaine,* by age group, National Household Stuvey on Drug Abuse, 1~ 

12-17-year-olds 

::- B Alcohol 

40 - Marijuana 

F35- l Cocaine 

q 

tJ L 30- 

5 

y25- 

‘Z 

’ 

-2 

20- 

g 15- 

c 

lo- 

.,_l--L 5- 

never + tried 

Smoking history 

26-34-year-olds 2 35year-olds 

never tried 

Smoking history 

current 

current 

18-25-year-olds 

50- 

45- 

40- 

p35- 

‘CI 

po5 

~25- 

‘zi 

7 

2 

zo- 

!i 

k 

15- 

IO5- 

O-- 

m Alcohol 

T, Marijuana 

n Cocaine 

never tried 

Smoking history 

45 

n Alcohol 

2 30 

E 

p 25 

‘Z 

7 

E 

20 

8 b 

k 

15 

10 

neverf trk?d$ 

Smoking history 

current 

Source: USDHHS (1988). 

The criteria for current use are as follows: alcohol = drank five or more drinks in a row at least 1 

day in the past 30 days; marijuana = used marijuana more than 10 times; cocaine = used cocaine 

more than 10 times (N = 8,814). 

values were under 1 for marijuana and cocaine use. 

* Values were under I for cocaine use. 

Health Consequences 33 
Surgeon General‘s Report 

cocaine, and other drugs WSDHI-IS 1988). SimiIarly, a 

longitudinal study showed that first-grade children who 

were characterized by their teachers as either. shy or 

aggressive were significantly more likely than their peers 

to smoke cigarettes, drink alcohol, and use illegal drugs 

in their teenage years (Kellam, Ensminger, Simon 1980). 

Evidence of other predictive factors, however, does not 

rule out the possibility that young people who smoke 

have an increased risk of using other drugs. 

Morphologic changes in brain structure that have 

been induced by nicotine exposure might predispose 

persons to the abuse of other drugs; this mechanism, 

however, has not yet been experimentally investigated. 

One possibility is that common pathways of drugproduced reinforcement in the brain might be altered so 

that the reinforcement produced by subsequent drug 

exposure is intensified. Central nicotinic receptors are 

known to be critical mediators of the reinforcing effects of 

nicotine (USDHHS 1988). In turn, activation of these 

receptors leads to activation of the dopaminergic reward 

system, which is critical in mediating the reinforcing 

effects of a wide variety of abused drugs, including cocaine and heroin. Thus, it is a plausible, but unproven, 

hypothesis that nicotine exposure would lead to a heightened sensitivity to the reinforcing effects of other drugs of 

abuse. This hypothesis is supported by the finding that 

the development of tolerance to nicotine is accompanied 

by the development of tolerance (“cross-tolerance”) to 

alcohol (Burch et al. 1988; Collins et al. 1988). Other 

research with animals also shows that nicotine exposure, 

eitheraloneorincombinationwithotherdrugs, may alter 

the behavioral responses to drugs of abuse, including 

alcohol and cocaine (Signs and Schechter 1986; Horger, 

Giles, Schenk 19921. These data together suggest a plausible biological basis for a causal role for tobacco use in the 

development of other substance abuse patterns, even if 

this role is shared by other risk factors. 

Nicotine produces various effects that have been 

shown to be produced similarly by one or more other 

abused drugs; all of these findings were discussed in 

greater detail in the 1988 Surgeon General’s report 

WSDHHS 1988) and elsewhere (Pomerleau and 

Pomerleau 1984). Nicotine administration produces feelings of pleasure and euphoria that elevate the same 

scales on the Addiction Research Center Inventory as the 

effects of heroin, cocaine, alcohol, and other abused drugs 

(Henningfield, Miyasato, Jasinski 1985; USDHHS 1988). 

Human subjects report, and laboratory rats demonstrate, 

that nicotine produces acute effects that are more like a 

stimulant than a sedative (Henningfield, Miyasato, 

Jasinski 1985; USDHHS 1988). Nicotine administration 

causes cortical EEG activation (increase in alpha and beta 

frequency, decrease in beta power) that is associated 

with increased vigilance and improved cognitive function (USDHHS 1988; Pickworth, Heming, Henningfield 

1989). Conversely, nicotine deprivation leads to EEG 

deactivation and concomitant decreases in vigilance and 

cognitive function WSDI-II-IS 1988; Pickworth, Heming, 

Henningfield 1989). Nicotine administration modulates 

the various levels of catecholamines, which are important in the regulation of mood and reactions to stressful 

stimuli (Pomerleau and Pomerleau 1984; USDHHS 1988). 

Partly through its effects on serotonergic systems 

in the brain, nicotine has some of the same effects on 

appetite as medications prescribed for this purpose. Nicotine can reduce skeletal muscle tension and thereby contribute to the feelings of pleasurable relaxation often 

attributed to various abused drugs. For all of these 

drugs, including nicotine, the specific effect produced is 

related to the dose of the drug administered. Thus, 

depending on the dose of the drug or drugs taken, the 

time since the last dose, and other factors, theoretically 

the user may achieve certain effects with any of several 

drugs, achieve various maximal effects through drug 

combinations, or use certain drug combinations in an 

effort to reduce certain adverse effects (Gardner 1980). 

Certain trends in drug abuse that have become 

prominent over the past decade increase the potential 

role of cigarette smoking in the development of other 

forms of drug use. SpecificaIly, there are increasing 

reports of smokable preparations of various drugs, including cocaine (“crack”), methamphetamine (“ice”), 

phencyclidine (‘TCP”), and heroin, and marijuana continues to be smoked by large numbers of people 

(USDHHS 1988). Drug administration via smoking requires the user to learn to regulate dose and to become 

tolerant of the rapid onset and aversive effects of smoke 

inhalation. These basic ski& may be learned through the 

process of becoming dependent on tobacco, as is discussed in “Developmental Stages of Smoking” in Chap 

ter 4 of this report and in the 1988 report. Once learned, 

these skilIs can be transferred to other smoked drugs and 

can facilitate the process of experimentation with such 

drugs, as well as increase the potential for addiction. 

34 Health Consequences 
prL77ellting Tobacco Use Among Young People 

He&h Consequences of Smokeless Tobacco Use Among Ycwng People 

hmduction 

Smokeless tobacco includes two main types: chewing tobacco and snuff. These products are made from the 

sln,e type of dark- or burley-leaved tobacco. Most smokelt3s tobacco is grown in Kentucky, Pennsylvania, Tennessee Virginia, West Virginia, and Wisconsin. Leaves 

,,re generally aged one to three years, but snuff tobacco 

leaves are aged longer than chewing tobacco leaves 

(Shapiro 1981). People who use chewing tobacco place a 

l,.J of loose-leaf tobacco or a plug of compressed 

tobacco in their cheek; snuff users place a small amount 

‘,f powdered or finely cut tobacco (loose or wrapped in a 

paper pouch) between their gum and cheek (USDHHS 

1992b). Smokeless tobacco users then suck on the tobacco and spit out the tobacco juices with accompanying 

saliva. As a consequence of the way in which smokeless 

products are used, smokeless tobacco is sometimes reicrred to as spit or spitting tobacco (USDHHS 1992b). 

The most notable health consequences associated 

with smokeless tobacco use include halitosis (bad breath), 

discoloration of teeth and fillings, abrasion of teeth, dental caries, gum recession, leukoplakia, nicotine dependence, and various forms of oral cancer (USDHHS 1986b, 

1992a; WHO 1988). SpecificaIly, smokeless tobacco use 

has been implicated in cancers of the gum, mouth, phar-. 

ynx, larynx, and esophagus (USDI-IHS 1986b; Winn 1988) 

and has also been indicated in early reports of the development of verrucous carcinoma (winn 1988). Smokeless 

tobacco use may also play a roie in cardiovascular disease and stroke, through increases in blood pressure, 

vasoconstriction, and irregular heartbeat (Hsu et al. 1980; 

Gritz et al. 1981; !Schroeder and Chen 1985). Since nearly 

25 percent of adult smokeless tobacco users also smoke 

cigarettes (CDC 1993131, the effects on the oral cavity may 

be synergistic, and the risks of developing cancer of the 

oral cavity and pharynx noticeably increase (Blum 1980). 

Epidemiologic Evidence 

The 1986 Surgeon General’s report on smokeless 

tobacco use concluded that there is no safe use of tobacco. 

Despite that report and subsequent legislation, restrictions, and follow-up reports (USDHHS 1992a, b; see 

“Warning Labels on Tobacco Products” in Chapter 6 and 

“Smokeless Tobacco Advertising and Promotional Expenditures” in Chapter 51, smokeless tobacco use in the 

United States remains a serious concern. The use of 

smokeless tobacco by adults has remained relatively constant at about 5 percent for males and 1 percent for 

females. However, smokeless tobacco use among high 

school males has become markedly more prevalent in the 

past two decades; about 20 percent report using smokeless tobacco in the past month (see “Current Use of 

Smokeless Tobacco” in Chapter 3 for documentation and 

further discussion of the prevalence of smokeless tobacco 

use). In some states, nearly one out of three high school 

males uses smokeless tobacco. There is little indication 

that use among young people is significantly declining 

(Glover et al. 1988; Boyd and Clover 1989; USDHHS 

1992b; see “Current Use of Smokeless Tobacco” in 

Chapter 3). 

Smokeless tobacco use primarily begins in early adolescence; some research indicates an average age of onset 

of 10 years (USDHHS 1992b). Among high school seniors 

who had regularly used smokeless tobacco, 23 percent 

reported that they had first tried the product by the sixth 

grade, and 53 percent by the eighth grade (see “Grade 

When Smokeless Tobacco Use Begins” in Chapter 3). 

Health Consequences 

A recent report of the Office of Inspector General 

(LJSDI-IHS 1992b) concluded that smokeless tobacco use 

causes serious, but generally not fatal, short-term health 

consequences among young people. The primary health 

consequences during adolescence include leukoplakia, 

gum recession, nicotine addiction, and increased risk of 

becoming a cigarette smoker. Leukoplakia and/or gum 

recession occur in 40 to 60 percent of smokeless tobacco 

users (USDHHS 1992b). 

Leukoplakia has been defined by the World Health 

Organization as a lesion of the soft tissue that consists of 

a white patch (mucosal macule) or plaque that cannot be 

scraped off (Kramer et al. 1978; Axell et al. 1984). Greer 

and Poulson (1983) examined 117 high school students 

who were smokeless tobacco users; oral soft-tissue lesions were found in 49 percent of these students. Oral 

leukoplakias carry a five-year malignant transformation 

potential of about 5 percent (pindborg 1980,1985; Bouquot 

1987, 1991). If smokeless tobacco use ceases, the 

leukoplakia appears to regress or resolve entirely (Christen, McDonald, Christen 1991). 

Gingival tissue recession (or gum recession) commonly occurs in the area of the oral cavity immediately 

adjacent to where smokeless tobacco is held. When 

smokeless tobacco remains exclusively in a specific 

intraoral location, gingival recession occurs among 30 

percent (Weintraub et al. 1990) to over 90 percent 

(Schroeder et al. 1988) of users. Mock&r, Lavstedt, and 

Ahlund (1980) found that snuff use among 13- and 

Health Consequences 35 
Surgeon General’s Report 

14-year-old students could directly affect the gingival 

tissues, causing gingivitis, or gum inflammation. In a 

study of 565 adolescent male students with gingivitis in 

Georgia, Offenbacher and Weathers (1985) found that 

gingival recession was significantly more prevalent, 

and the odds of developing this condition were nine 

times greater, among smokeless tobacco users than 

among nonusers. Navy recruits from 45 states were 

examined to determine if smokeless tobacco use was 

associated with gingival recession (Weintraub et al. 

1990). Results of the study showed that 31 percent of 

heavy users and 19 percent of nonusers or low users 

had gingival recession. Users’ age and the intensity of 

smokeless tobacco use were significant factors in explaining variations in the degree of gingival recession. 

Two additional studies of adolescents failed to show an 

association between the use of smokeless tobacco and 

gingival recession (Wolfe and Carlos 1987; Creath et al. 

1988), possibly because most of the users had been 

using the product for a short time. 

Nicotine Addiction 

The addictive qualities of smokeless tobacco are also 

a matter of major concern (Christen and Glover 1981; 

Glover, Christen, Henderson 1981; Glover et al. 1989; 

Hatsukami, Nelson, Jensen 1991). Smokeless tobaccousers 

develop a nicotine dependency similar to that of cigarette 

smokers (Benowitz et al. 1988). This is not surprising, since 

smokeless tobacco users absorb at least as much nicotine as 

smokers do (Russell, Jarvis, Feyerabend 198O&perhaps as 

much as twice the amount (Benowitz et al. 1.988). The high 

pH of saliva favors absorption of nicotine through oral 

mucosa, and the degree of absorption increases with the 

increasing pH of the tobacco product. The rate of absorption of nicotine from snuff is particularly rapid (Russell, 

Jarvis, Feyerabend 1980; Edwards, Glover, Schroeder 

1987). With continued use of smokeless tobacco, blood 

nicotine levels remain relatively high; these levels fall more 

slowly after smokeless tobacco is removed from the mouth 

than after a cigarette has been smoked (Benowitz et al. 1988). 

Adolescents develop physical dependence from 

smokeless tobacco use, as is evidenced by their experience of withdrawal symptoms when they try to quit 

(see “Smokeless Tobacco Cessation” in Chapter 6). 

Smokeless tobacco cessation produces withdrawal 

symptoms that are similar to those for smoking cessation (Hatsukami, Gust, Keenan 1987), including cravings, 

irritability, distractibility, and hunger. Adolescents who 

are most addicted to nicotine appear to be less able to 

quit (Eakin, Severson, Glasgow 1989). Thus, as is seen 

with cigarette use (see “Adult Implications of Adolescent Smoking” in Chapter 3 and “Adolescent Smoking 

Behavior as a Risk Factor for Subsequent Smoking” in 

Chapter 4), adolescents who are heavy smokeless tobacco users are likely to become adult users. 

The addictive potential of smokeless tobacco use is 

aggravated by the fact that some smokeless products are 

highly effective in the initiation process and are even 

termed “starter products” by one smokeless tobacco company (Marsee v. United States Tobacco Company 1989; 

Henningfield and Nemeth-Coslett 1988). These products tend to be low in nicotine concentration and low in 

pH (thus reducing absorption); some are in a unit dosage 

form (“tobacco pouch”), which helps first-time users 

avoid placing too much of the substance in their mouths. 

These products may have contributed to the reversal of 

the demographics of smokeless tobacco users from 1970 

to 1986. In 1970, the majority of smokeless tobacco users 

were 50 years old and older; by 1986, the majority were 

35 years old and younger (USDHHS 1987,198s). As is 

discussed in Chapter 5 (see “Smokeless Tobacco Advertising and Promotional Expenditures”), marketing and 

advertising factors have been identified as having instilled the general perception that smokeless tobacco 

products are safe and socially acceptable (Connolly et al. 

1986; USDHHS 1987; Glover et al. 1989). Marketing 

strategies included a heavy reliance on distributing free 

samples of product types designed to introduce new 

users to what one company termed the “graduation 

process” (Marsee v. United States Tobacco Company 

1989). Advertising strategies then encouraged new users 

to experience greater “satisfaction” and “pleasure” by 

switching to maintenance products higher in nicotine 

concentration and pH (Marsee v. United States Tobacco 

Company 1989; Henningfield and Nemeth-Coslett 1988). 

Smokeless Tobacco Use as a Risk Factor for 

Cigarette Smoking 

Young people who use smokeless tobacco appear 

to be at greater risk to smoke cigarettes than are nonusers. Among smokeless tobacco users, 12 to 43 percent 

also smoke cigarettes @kin, Severson, Glasgow 1989; 

Williams 1992; CDC 1993b; Stevens et al., in press; see 

Table 23 in Chapter 3). In the 1986-1989 MTFI’, 44 

percent of high school seniors had tried both smokeless 

tobacco and cigarettes; of those, 63 percent had tried 

smokeless tobacco either before or at about the same time 

as cigarettes (see Table 38 in Chapter 3). In a prospective 

study, Ary, Lichtenstein, and Severson (1987) found that 

smokeless tobacco users were significantly more likely 

than nonusers to initiate cigarette smoking. Smokeless 

tobacco users were also more likely to increase their use 

of cigarettes over a one-year period. For adolescents who 

use both smokeless tobacco and cigarettes, cessation of 

one substance may lead to a direct increase in the other 

(Biglan, La Chance, Benowitz, unpublished data). 

36 Health Consequences 
;‘,.lv~~Lvltjlls Tobacco Use AIIIO~I~ Young People 

smokeless Tobacco Use as a Risk Factor for 

Other Drug Use 

Smokeless tobacco use is also predictive of other 

Linlg use. In a study of more than 3,ooO male adolescents 

intcnie~ved twice at nine-month intervals about their use 

,,i \.arious psychoactive substances (Ary, Lichtenstein, 

+!.er;on 1987), the main findings were that (1) smokeless 

tc,bacco users were significantly more likely to use cigarcttc5, marijuana, or alcohol than nonusers, (2) users of 

.Ir,&eless tobacco were significantly more Likely to take 

L1F7 the use of these other substances by the second inter- 

\.,~‘Iv if they were not using them at the first, and (3) 

,l&¢s who were using any of these substances at the 

ConclLlsions 

first interview were significantly more likely to increase 

their use of the substance if they also used smokeless 

tobacco. 

Two other facts are important to consider when 

evaluating the role of smokeless tobacco products in the 

use of cigarettes and other substances. Fist, the overall 

impact of smokeless tobacco is currently limited primarily to males (the main users of these substances) 

(LJSDHHS 1986b, 1990). Second, smokeless tobacco 

users in the Ary, Lichtenstein, and Severson (1987) study, 

as well as in most other surveys, tend to initiate their 

tobacco use at about the same age as cigarette smokers or 

at a slightly earlier age (see “Grade When Use of Smokeless Tobacco and Cigarettes Begins” in Chapter 3). 

Cigarette smoking during childhood and adolescence produces significant health problems among 

young people, including cough 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. 

^. 7 Among addictive behaviors, cigarette smoking is the 

one most likely to become established during adolescence. 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. 

3. 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 harder 

drugs. 

4. Smokeless tobacco use by adolescents is associated 

with early indicators of periodontal degeneration 

and with lesions in the oral soft tissue. Adolescent 

smokeless tobacco users are more likely than nonusers to become cigarette smokers. 

Health Consequences 37 
prewnting Tobacco Use Among Young People 

Chapter 3: Epidemiology of Tobacco Use Among Young People 

in the United States 

Introduction 

Understanding national trends and patterns of tobacco use among adolescents is crucial to the public 

health effort to reduce. tobacco-related morbidity and 

mortality. Along with information on young people’s 

knowledge, attitudes, and perceptions concerning tobacco use, these data can help elucidate historical patterns, suggest target groups for programs to prevent 

tobacco use, determine the need for future interventions, 

assess the effect of national campaigns against tobacco 

use, and contribute to predictions of the future burden of 

tobacco-related disease. 

Previous reports from the Surgeon General have 

described tobacco use among the nation’s youth (US. 

Department of Health, Education, and Welfare 

[USDHEWI 1979a; U.S. Department of Health and Human Services [USDHHSI 1989b). The following analysis 

both updates and expands these discussions. In particular, the analysis incorporates cross-sectional data from 

four national surveillance systems that track health be 

haviors (including tobacco use) among adolescents and 

from one-adult survey with information on older adolescents (Table 1). Data are also used from a national 

longitudinal survey of adolescents and young adults. 

The National Teenage Tobacco Surveys (NTTS) 

cited in this chapter were conducted by the U.S. Public 

Health Service and the U.S. Department of Education in 

1968, 1970,1972, 1974, and 1979; a modified version of 

the survey was conducted in 1989 as the Teenage Attitudes and Practices Survey (TAPS). The National Household Surveys on Drug Abuse (NHSDA) cited were 

conducted nine times from 1974 through 1991 by the 

National Institute on Drug Abuse (NIDA); the survey is 

now sponsored by the Substance Abuse and Mental 

Health Services Administration (SAMHSA). The Monitoring the Future Project (MTFP) surveys included were 

conducted yearly from 1976 through 1992 for NIDA by 

the University of Michigan’s Institute for Social Research 

(ISR). The Youth Risk Behavior Survey (YRBS), cited 

extensively throughout this chapter, was conducted in 

1991 by the Centers for Disease Control (CDC) as a 

component of the Youth Risk Behavior Surveillance 

System. The National Health Interview Surveys (NHIS) 

cited in this report included yearly data on cigarette 

smoking during 11 years from 1970 through 1991. Survey methodology varied across these surveillance systems (see Appendix 1, “Sources of Data,” for more detail 

on methodologic characteristics), and the different surveys offered several measures of tobacco use (see Appendix 2, “Measures of Ciga,,rette Smoking,” and 

Appendix 3, “Measures of Smokeless Tobacco Use”). 

The most comparable of these data sources are 

TAPS, the NHSDA, the MTFP, and the YRBS. Because 

the questions used, the ages sampled, and the sites and 

modes of administration (school-based self-administered 

questionnaires vs. household-based telephone and inperson interviews) differ, however, even these data are 

not directly comparable. The MTFP, for example, consistently reports higher prevalence estimates than the two 

household surveys, mainly because the study population is limited to high school seniors; these respondents, 

who are usually 17 or 18 years old, are considerably 

older than the 12- through IS-year-old population 

included in TAPS and the NHSDA. When possible, 

most of the comparisons presented in this chapter include age- or. grade-specific estimates. However, even 

after controlling for age differences, the estimates on 

some measures of tobacco use from the household surveys are lower than the estimates from the school surveys (see Appendix 2). 

The purpose of this chapter is to document reported trends and patterns of tobacco use in one source. 

Differences in the age of the target populations employed, 

in the setting of the survey, in the wording of questions, 

and in other factors may cause apparent differences in 

the actual values of some of the estimates reported here. 

However, these difference are frequently resolved when 

methodological issues are taken into consideration. Incorporating data from several types of data collection 

systems has revealed a number of consistencies in patterns and trends of tobacco-use behaviors that apply to 

both school-based and household-based sample frames 

(and thus to school attenders, infrequent school attenders, 

and dropouts). 

Epidemiology 39 
Surgeon General’s Rep-t 

Table 1. Sources of national data on tobacco use among young people, 1968-1992 

Survey title Abbreviated title 

Sponsoring agency Type of 

or organization survey Years 

National Household NHSDA 

Surveys on Drug 

Abuse 

National Institute 

on Drug Abuse/ 

Substance Abuse and 

Mental Health 

Services Administration 

Cross-sectional 1974,1976,1977, 

1979,1982,1985, 

1988,1990,1991 

Youth Risk Behavior YRBS Division of Adolescent Cross-sectional 1991 

Survey and School Health, (national, as 

CDC well as state 

and local) 

Sources: NITS: U.S. Department of Health, Education, and Welfare (1972,1976,1979b); TAPS: CDC (1991a); Allen et al. 

(1991,1993); Moss et al. (1992 1; NHSDA: Abelson and Atkinson (19751; Abelson and Fishbume (1976); Fishbume, Ableson, 

Cisin (1980); Gfroerer (1993); Miller et al. (1983); U.S. Department of Health and Human Services [USDHHSJ (1988a, 1990a, 

1991a, 1992a, 1993); 1991 NHSDA: CDC, OSH (unpublished data); MTFP: Bachman, Johnston, O’Malley (198Oa, b, 1981,1984, 

1985,1987,19911; Johnston, Bachman, O’Malley (198Oa, b, 1982,1984,1986,1991,1992); Johnston, O’Malley, Bachman (1991a, b, 

1992a, b, in press); 1990-1992 MTFP surveys: Institute for Social Research, University of Michigan (unpublished data); YRBS: 

Kolbe (1990); CDC (1992c, d); Kolbe, Kann, Collins 1993; CDC, Division of Adolescent and School Health (unpublished data); 

NHIS: NCHS (1958,1975,1985,1988a, b, 1989); USDHHS (1992a); 1970,1978-1980,1987-1988 NHIS: CDC, GSH (unpublished data). 

“The 1989 TAPS was partially sponsored by the American Cancer Society. 

40 Epidemiology 
f%venting Tobacco Use Among Young People 

Mode of survey Response Ages/ Sample 

administration rate grades size 

Type of 

tobacco use 

examined 

Household 

interview 

Mean of 

approximately 

80%; 84% in 1991 

17-19 years 

(trend data); 

12-18 years 

(1991 analysis); 

30-39 years 

(retrospective 

1991 analysis) 

371-3,429 

9,086 

6,388 

Smoking: all years 

Smokeless: 1988 -1991 

Self-administered 

in school 

For national survey: 9th-12th grades 12,272 in Smoking and 

90% of sampled stu- national smokeless 

dents; 75% of selected survey 

schools 

The Institute for Social Research usually reports the N (weighted), which is approximately equal to the sample size. 

Cases are weighted to account for differential probability of selection and then normalized to average 1.0. The range for 

N (weighted) for questions on smokeless tobacco between 1986 and 1992 = 2,553 -2,991. 

‘N (weighted) for smokeless tobacco = 7,093. 

“N (weighted) for smokeless tobacco = 8,441. 

Epidemiology 41 
Surgeon GeneraI’s Report 

Cigarette Smoking Among Young People in the United States 

Recent Patterns of Cigarette Smoking 

Ever Smoking 

The proportion of, adolescents classified as ever 

smokers (i.e., those who had tried a cigarette [see Appendix 2 for variations in this measure]) varied across survey systems (Table 2). In the 1989 TAPS, 47 percent of 

students aged 12 through 18 had tried smoking. In the 

1991 NHSDA, the prevalence for this same age range 

was 42 percent. The different estimates between these 

two household surveys may reflect actual decreased 

prevalence during the intervening two years or may 

result from sampling error, from slight differences in 

response to different survey questions, or from the different way these home-based surveys were administered (by telephone in TAPS and in person in the 

NHSDA). Of the two self-administered school surveys, 

the 1991 YRBS reported a higher prevalence of ever 

smoking (70 percent) than the 1992 MTFP (62 percent), 

even though the YRBS included students in grades 9 

through 12 (age range generally 14 through 18 years), 

whereas the MTFP was limited to high school seniors. 

This difference may partly result from the questions each 

survey used to elicit information on ever smoking. The 

MTFP survey asked, “Have you ever smoked cigarettes?“, 

and the YRBS asked a question that might have drawn 

additional affirmative responses: “Have you ever tried 

or experimented with cigarette smoking, even one or 

two puffs?” 

What stands out from all four surveys is that by 

age 18, about two-thirds of adolescents in the United 

States have tried smoking. Also evident across the surveys is that the prevalence of ever smoking is greater (if 

only slightly so in one survey) among males than females. Findings by racial/ethnic groups were generally 

in accord across the surveys: whites had the highest 

prevalence of ever smoking and blacks the lowest in 

TAPS, the NHSDA, and the MTFP; Hispanics had the 

highest prevalence of the three groups in the YRBS. 

Ever smoking increased as a function of increasing 

age or grade in all four surveys. Adolescents living in the 

north-central region of the United States were the most 

likely to report having smoked (Table 2). Prevalence for 

individual states were available from the Youth Risk 

Behavior Surveillance System, which besides its yearly 

national YRBS also conducts individual surveys in selected states and cities. In 1991, the percentage of students who had tried smoking ranged from 49 to 82 

percent (median, 71 percent) (Table 3). 

42 Epidemiology 

Current Smoking 

The overall national prevalence of current smoking 

(i.e., having smoked within the last 30 days) for persons 

12 through 18 years old was estimated to be 16 percent in 

the 1989 TAPS and 13 percent in the 1991 NHSDA (Table 

4). These estimates suggest that at least 3.1 million U.S. 

adolescents are current smokers. Among high school 

seniors, the prevalence of past-month smoking was 28 

percent in the 1992 MTFP; 28 percent of high school 

students were past-month smokers in the 1991 YRBS. 

In all the surveys, current prevalence among males 

was equal to or slightly higher than current prevalence 

for females. This pattern differs from that reported for 

the late 1970s and mid-1980s, when the prevalence for 

adolescent females was generally higher than that for 

adolescent males (USDHEW 1979b; USDHHS 1989b). 

The national prevalence of past-month smoking 

among adolescents was higher for whites than for Hispanics and was lowest for blacks (Table 4). Pooled data 

from the 1985-1989 MTFP provided information on smoking among Asian American and Native American adolescents (Bachman et al. 1991). Past-month smoking 

prevalence was higher for Native American male (37 

percent) and female (44 percent) seniors than for white 

male (30 percent) and female (34 percent) seniors. Current smoking was about as common for Asian American 

male (17 percent) and female (14 percent) seniors as it 

was for black male (16 percent) and female (13 percent) 

seniors. Data on Hispanic smoking prevalence, presented in the same report, indicate that smoking prevalence among Hispanic high school seniors from 1985 

through 1989 ranked between that of white and black 

high school seniors, as it did in TAPS, the NHSDA, and 

the YRBS. 

Current prevalence increased with increasing age 

or grade (Table 4). TAPS and the NHSDA reported 

smoking prevalences for persons 17 and 18 years old that 

were slightly lower than those of 12thgrade students 

surveyed by the MTFP and the YRBS. Prevalence estimates from TAPS and the NHSDA for persons 15 and 16 

years old were considerably lower than for 9th- and 

10th~grade high school students in the MTFP and the 

YRBS. These estimates are consistent with the argument 

that estimates of cigarette smoking from household surveys may underreport actual use, especially for younger 

adolescents. 
pr,yvrltitlg Tobacco Use Among Yozrng People 

Table 2. Percentage of young people who have ever smoked cigarettes, by gender, race/Hispanic origin, 

age/grade, and region, Teenage Attitudes and Practices Survey (TAPS), National Household 

Surveys on Drug Abuse (NHSDA), Monitoring the Future Project (MTFP), Youth Risk Behavior 

Survey (YRBS), United States, 1989,1991,1992 

Characteristic 

1989 1991 

TAPS NHSDA+ 

1992 

MTFPg§ 

1991 

YRBS 

Overall 44.5 41.9 61.8 70.1 

Gender 

Male 

Female 

48.3 44.4 63.5 70.6 

44.4 39.3 60.2 69.5 

Race/Hispanic origin 

\Vhite, non-Hispanic 

Male 

Female 

Black, non-Hispanic 

Male 

Female 

Hispanic 

Male 

Female 

49.5 46.5 

51.5 49.1 

49.3 43.7 

36.4 28.1 

38.7 31.0 

34.1 25.0 

43.1 34.4 

42.5 36.1 

43.7 32.5 

65.3 

66.2 

64.6 

42.6 

45.5 

40.4 

NA’1 

70.4 

71.4 

69.3 

67.2 

64.7 

69.3 

75.3 

75.7 

74.9 

Age/grade 

12-14 years 

15-l 6 years 

17-18 years 

8th grade 

9th grade 

10th grade 

11 th grade 

12th grade 

29.7 26.0 

52.5 45.9 

63.9 60.9 

45.2 

64.8 

68.3 

72.8 

74.5 

53.5 

61.8 

Region 

Northeast 

North Central 

South 

West 

46.0 39.7 63.7 70.6 

47.9 46.2 65.2 73.0 

46.5 41.1 61.1 71.3 

45.0 40.3 56.5 65.0 

Sources: 1989 TAPS: Centers for Disease Control and Prevention (CDC), Office on Smoking and Health (OSH) (unpublished 

data); 1991 NHSDA: CDC, OSH (unpublished data); 1992 MTFP: Johnston, O’Malley, Bachman (in press); Institute for 

Social Research, University of Michigan (unpublished data); 1991 YRBS: CDC (19%~); CDC, Division of Adolescent and 

School Health (unpublished data). 

‘1989 TARS, aged 12-18 years. Based on responses to the questions, “Have you ever smoked a cigarette?” and “Have you 

ever tried or experimented with cigarette smoking, even a few puffs. 7“ Respondents who had smoked a cigarette, even a few 

puffs, were classified as ever smokers. 

‘1991 NHDSA, aged 12-18 years. Based on response to the question, “About how old were you when you first tried a 

cigarette?” (“Never tried a cigarette” was a preceded response.) 

‘1992 MTFP survey. Based on response to the question, “Have you ever smoked cigarettes ?I’ 

they had tried cigarettes at least once or twice were classified as ever smokers. 

Respondents who reported that 

‘With the exception of data for 8th and IOth-grade students, all other data points for the MTFP survey reflect estimates for 

high school seniors. 

‘1991 YRBS, grades 9-12. Based on response to the question, 

‘NA = Not available. 

“Have you ever tried cigarette smoking, even one or two puffs?’ 

Epidemiology 43 
Surgeon General’s Report 

Table 3. Percentage of high school students who use cigarettes, by gender, Youth Risk Behavior Surveys, 

United States and selected U.S. sites, 1991 

Site 

Lifetime cigarette use* Current cigarette use+ Frequent cigarette use* 

Female Male Total Female Male Total Female Male Total 

Weighted data 

National survey 

State surveys 

Alabama 

Georgia 

Idaho 

Nebraska 

New Mexico 

New York5 

Puerto Rico3 

South Carolina 

South Dakota 

Utah 

Local surveys 

Chicago 

Dallas 

Fort Lauderdale 

EirViCitY 

Philadelphia 

San Diego 

Unweighted dataq 

State surveys 

Colorado§ 

District of Columbia3 

Hawaii 

Montana 

New Hampshire 

New Jerseys 

Oregon 

Pennsylvania5 

Tennessee 

Wisconsin 

Wyoming 

Local surveys 

Boston 

New York City 

San Francisco 

70 71 70 27 28 28 12 13 13 

70 79 74 24 32 28 11 16 13 

66 72 69 22 26 24 10 12 11 

56 65 61 22 24 23 12 14 13 

70 75 72 28 30 29 15 15 15 

82 81 82 30 30 30 13 14 13 

72 70 71 32 28 30 18 17 17 

46 54 50 13 18 16 3 5 4 

72 76 74 25 26 26 13 13 13 

68 71 69 32 30 31 17 16 16 

43 55 49 16 18 17 8 8 8 

72 73 72 13 20 16 4 7 6 

70 76 73 11 16 14 4 4 4 

65 65 65 18 13 16 10 6 8 

73 70 72 17 16 16 4 4 4 

66 66 66 12 17 15 4 8 6 

82 70 76 22 17 20 11 8 10 

64 71 68 18 18 18 7 7 7 

73 74 74 28 27 27 13 14 14 

70 60 65 5 7 6 2 2 2 

70 70 70 27 25 26 12 13 13 

68 71 69 24 24 24 13 12 12 

71 71 71 28 27 27 16 15 15 

67 61 64 NA*+ NA NA NA NA NA 

63 65 64 22 22 22 9 10 9 

69 73 71 28 28 28 16 15 15 

72 75 74 30 30 30 16 16 16 

72 73 73 30 32 31 16 17 16 

70 74 72 27 28 28 15 17 16 

68 68 68 15 16 15 6 9 7 

76 68 72 26 16 21 12 6 9 

61 63 62 14 15 14 7 6 6 

Source: Centers for Disease Control (19926). 

*Ever tried cigarette smoking, even one or two puffs. 

‘Smoked cigarettes on 1 or more of the 30 days preceding the survey. 

‘Smoked cigarettes on 20 or more of the 30 days preceding the survey. 

Surveys did not include students from the largest city. 

Categorized as a state for funding purposes. 

‘Fourteen sites had overall response rates below 60% or had unavailable documentation; weighted estimates were not reported. 

**NA = Not available. 

44 Epidemiology 
Table 4. Percentage of young people who currently smoke cigarettes (within the past 30 days), by gender, 

race/Hispanic origin, age/grade, and region, Teenage Attitudes and Practices Survey (TAPS), 

National Household Surveys on Drug Abuse (NHSDA), Monitoring the Future Project (MTFP), 

Youth Risk Behavior Survey (YRBS), United States, 1989,199X 1992 

characteristic 

1989 1991 1992 1991 

TAPS” NHSDA+ MTFPu YRBS’ 

&wall 

Gmkr 

\lale 

Female 

;(Jc~/ Hispanic origin 

IVhite, non-Hispanic 

Male 

Female 

Black, non-Hispanic 

Male 

Female 

Hispanic 

Male 

Female 

Age/grade 

12-14 years 

15-16 years 

17-l 8 years 

8th grade 

9th grade 

10th grade 

11 th grade 

12th grade 

Region 

Northeast 

North Central 

South 

West 

15.7 13.1 27.8 27.5 

16.0 13.5 29.2 27.6 

15.3 12.8 26.1 27.3 

18.5 15.4 

18.7 15.5 

18.2 15.3 

6.1 5.3 

7.8 6.0 

4.9 4.6 

11.8 10.1 

11.8 9.5 

11.7 10.8 

5.9 3.9 

17.5 14.0 

27.5 25.5 

17.6 14.7 29.6 23.7 

16.6 14.9 31.7 36.5 

14.0 11.7 26.4 24.8 

15.5 12.3 22.8 23.1 

31.8 

32.1 

31.5 

8.2 

10.8 

5.8 

NA’ 

15.5 

21.5 

27.8 

30.9 

30.2 

31.7 

12.6 

14.1 

11.3 

25.3 

27.8 

22.9 

23.2 

25.2 

31.6 

30.6 

Sources: 1989 TAPS: Centers for Disease Control and Prevention (CDC), Office on Smoking and Health (OSH) (unpublished 

data); 1991 NHSDA: CDC, OSH (unpublished data); 1992 MTFP: Johnston, O’Malley, Bachman (in press); Institute for 

Social Research, University of Michigan (unpublished data); 1991 YRBS: CDC (1992~); CDC, Division of Adolescent and 

School Health (unpublished data). 

$1989 TAPS, aged 12-18 years. Based on responses to the questions, “Have you ever smoked a cigarette?” and “Think about 

the last 30 days. On how many of these days did you smoke?” 

‘1991 NHSDA, aged 12-18 years. Based on response to the question, “When was the most recent time you smoked a 

cigarette?” 

‘I992 MTFP survey. Based on response to the question, “How frequently have you smoked cigarettes during the last 30 

days?” 

‘With the exception of data for 8th- and IOth-grade students, all other data points for the MTFP survey reflect estimates for 

high school seniors. 

‘1991 YRBS, grades 9-12. Based on response to the question, “During the past 30 days, on how many days did you smoke 

cigarettes?” 

‘NA = Not available. 

Epidemiology 45 
Surgeon Ceneral*s Report 

Past-month smoking was generally most common 

in the north-central region of the United States and least 

prevalent in the West and the South (Table 4). Among 

the available state and local surveys of high school students (Table 31, the percentage of students who were 

current smokers ranged from 6 to 31 percent (median 27 

percent>. From the weighted surveys, current smoking 

prevalence was lowest in Puerto Rico and Utah and 

highest in South Dakota, New Mexico, and New York 

(excluding New York City). 

Frequent and Heavy Smoking 

In the 1989 TAPS, 8 percent of U.S. adolescents 12 

through 18 years old were frequent smokers (i.e., had 

smoked on 20 or more of the 30 days preceding the 

survey) (Table 5). In 1991, 13 percent of high school 

students surveyed in the YRBS were frequent smokers. 

In the 1991 NHSDA, 7 percent of persons 12 through 18 

years old were heavy smokers (i.e., had smoked at least 

one-half pack per day); 10 percent of high school seniors 

in the 1992 MTFP survey were heavy smokers. Males 

were slightly more likely than females to report frequent 

or heavy smoking (Table 5). 

To a greater extent than was found for current 

smoking, white adolescents were more likely than black 

or Hispanic adolescents to be frequent or heavy smokers. 

Among white adolescents in the different surveys, frequent and heavy smoking were 2.8 to 7.5 times m&e 

common than among black adolescents and 2.3 to 2.6 

times more common than among Hispanic adolescents. 

As was noted for both ever smoking and current 

smoking, frequent and heavy smoking increased with 

increasing age or grade. Frequent and heavy smoking 

were more prevalent in the north-central and northeast 

regions and less prevalent in the South and the West. 

Sociodemographic Risk Factors for Smoking 

In its surveys of high school seniors from 1985 

through 1989, the MTFP elicited data on several possible 

so&demographic risk factors for adolescent smoking 

(Table 6). The surveys found, for example, that students 

who lived alone had the highest prevalences of pastmonth smoking (47 percent) and heavy smoking (28 

percent). Living in a single-parent household increased 

the risk of past-month or heavy smoking only when the 

mother was the absent parent. Data from the 1968,1970, 

1972, 1974, and 1979 NTE indicate higher smoking 

prevalences among youth living in households with fewer 

than two parents or parent surrogates KJSDHEW 1972, 

1976,1979b). The available published reports, however, 

did not provide more detail on the exact structure of the 

household. 

The 1989 TAPS examined other aspects of family 

structure for possible associations with adolescent smoking status (Allen et al. 1993). The survey findings showed 

that youths 12 through 16 years old who were current 

smokers were-almost twice as likely to be home without 

a parent or other adult for 10 or more hours a week than 

were teens who had never smoked. Furthermore, TAPS 

teens who said that they discussed serious problems 

with friends rather than with a parent, other relative, or 

another adult were two times more likely to be current 

smokers than were teens who reported discussing serious problems with their parents (Moss et al. 1992). 

The 1985-1989 MTFP reported an inverse relationship between both past-month and heavy smoking and 

the population density of the locales in which the seniors 

grew up (Table 6); those seniors who grew up on a farm 

or in the country were more likely to smoke than those 

who grew up in large cities. The MTFP also found that as 

school performance among high school seniors declined 

from above average to below average, past-month smoking prevalence increased from 22 to 41 percent, and 

heavy smoking prevalence increased from 7 to 21 percent. A similar relationship was observed in the 1989 

TAPS (Moss et al. 1992). 

Postgraduation plans were another predictor of 

smoking behavior among MTFP seniors. Students who 

said they planned to complete four years of college were 

less likely to be past-month smokers (24 percent) or 

heavy smokers (7 percent) than were those who did not 

plan to get a college degree (39 percent were past-month 

smokers, 20 percent were heavy smokers). Males who 

planned to enter the armed forces after high school were 

more likely to be past-month smokers (31 percent) or 

heavy smokers 04 percent) than males who did not have 

such plans (26 percent were past-month smokers, 10 

percent were heavy smokers). This association was negligible among females. 

Among MTFP seniors, past-month and heavy 

smoking were least prevalent among those who felt that 

religion was very important in their lives and increased 

uniformly as the self-reported importance of religion 

lessened. Similarly, adolescent smokers in the 1989 TAPS 

were more likely to report that they rarely or never 

attended religious services (54 percent) than were never 

smokers (29 percent) (Amen et al. 19%). 

TAPS also analyzed smoking by dropout status. 

Respondents who had left school before graduating were 

more than twice as likely to report smoking in the past 

week as were those who currently attended or had graduated from high school (43 vs. 17 percent) (CDC 1991a). 

Female high school students and graduates were about as 

likely as their male counterparts to have smoked in the 

past week (17 vs. 18 percent). Female dropouts, however, 

% Epidemiology 
pr‘verrtitjg Tobacco Use Among Young People 

Table 5. Percentage of young people who report frequent or heavy use of cigarettes, by gender, race/ 

Hispanic origin, age/grade, and region, Teenage Attitudes and Practices Survey (TAPS), National 

Household Surveys on Drug Abuse (NHSDA), Monitoring the Future Project (MTFP), Youth 

Risk Behavior Survey (YRBS), United States, 1989,1991,1992 

Characteristic 

1989 1991 

TAPS* NHSDA’ 

1992 

MTFPt,§ 

1991 

YRBS3 

Measure of use 

Overall 

Gender 

Male 

Female 

Race/Hispanic origin 

White, non-Hispanic 

Male 

Female 

Black, non-Hispanic 

Male 

Female 

Hispanic 

Male 

Female 

Age/grade 

12-14 years 

15-l 6 years 

17-18 years 

8th grade 

9th grade 

10th grade 

11 th grade 

12th grade 

Region 

Northeast 

North Central 

South 

West 

Frequent Heavy Heavy Frequent 

8.1 6.6 10.0 12.7 

8.4 6.9 10.4 13.0 

7.7 6.2 9.2 12.4 

10.1 7.9 

10.5 8.1 

9.7 7.6 

1.9 2.8 

2.8 3.7 

1.0 1.8 

4.4 3.0 

4.0 2.4 

4.9 3.6 

1.8 1.2 

8.3 6.5 

16.7 14.4 

8.7 7.7 11.1 12.1 

9.1 7.1 10.9 18.9 

7.3 6.2 10.2 10.5 

7.6 5.7 6.8 9.0 

12.0 

12.2 

11.6 

1.6 

2.4 

0.9 

NAP 

2.9 

6.0 

10.0 

15.4 

15.0 

15.8 

3.1 

4.5 

1.9 

6.8 

8.0 

5.7 

8.4 

11.3 

15.6 

15.6 

Sources: 1989 TAPS: Centers for Disease Control and Prevention (CDC), Office on Smoking and Health (OSH) (unpublished data); 1991 NHSDA: CDC, OSH (unpublished data); 1992 MTFP: Johnston, O’Malley, Bachman (in press); Institute 

for Social Research, University of Michigan (unpublished data); 1991 YRBS: CDC (1992~); CDC, Division of Adolescent and 

School Health (unpublished data). 

*1989 TAPS, aged 12-18 years. Based on responses to the questions, “Have you ever smoked a cigarette?” and “Think about 

the last 30 days. On how many of these days did you smoke. 7” Those who had smoked on 20 or more of the previous 30 

days were classified as frequent smokers. 

‘1991 NHSDA, aged 12-18 years. Based on response to the question, “How many cigarettes have you smoked per day, on 

the average, during the past 30 days ?” Respondents who reported smoking about one-half pack a day (6-15 cigarettes) or 

more were classified as heavy smokers. 

$1992 MTFP survey. Based on response to the question, “How frequently have you smoked cigarettes during the last 30 

days?“ Respondents who reported smoking about one-half pack per day or more were classified as heavy smokers. 

§With the exception of data for 8th- and IOth-grade students, all other data points for the MTFP survey reflect estimates for 

high school seniors. 

‘1991 YRBS, grades 9-12. Based on response to the question, “During the past 30 days, on how many days did you smoke 

cigarettes?” Those who had smoked on 20 or more of the previous 30 days were classified as frequent smokers. 

‘NA = Not available. 

Epidemiology 47 
Surgeon General’s Report 

Table 6. Prevalence (%I of cigarette smoking among high school seniors, by various sociodemographic 

risk factors, Monitoring the Future Project, United States, 1985-1989 

Sociodemographic risk factor N (weighted) 

Smoked during 

past month 

Smoked 2 10 

cigarettes/day 

Household structure 

Lives with both parents 

Lives with father only 

Lives with mother only 

Lives alone 

Other 

58,100 28.3 10.3 

2,657 35.4 16.3 

13,955 29.5 12.2 

547 47.2 28.3 

5,783 34.4 17.8 

Population density of locale in which 

respondent grew up 

Farm 

Country 

Small city 

Medium-sized city or suburb 

Large city or suburb 

Very large city or suburb 

4,445 32.5 12.3 

9,438 30.8 12.4 

23,837 28.9 11.0 

16,096 29.3 10.9 

12,504 28.3 10.8 

7,612 25.9 8.9 

Self-reported overall academic performance 

Above average 

Slightly above average 

Average 

Below average 

24,640 21.6 6.6 

18,688 28.0 9.7 

28,609 34.0 14.2 

5,652 40.6 20.7 

Plans to complete four years of college 50,364 23.9 6.9 

Dbes not plan to complete four years of college 25,379 39.1 19.5 

Plansto enter the armed forces 

Male 

Female 

8,317 31.2 13.7 

2,644 30.4 12.3 

Does not plan to enter the armed forces 

Male 

Female 

25,621 26.1 10.0 

34,669 30.1 11.0 

Importance of religion 

Very important 

Important 

Not/somewhat important 

20,637 19.2 5.9 

25,166 29.5 10.5 

33,104 35.1 15.2 

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

48 Epidemiology 
prezlenting Tobacco Use Among Young People 

ivere less likely to have smoked than male dropouts 

(33 VS. 52 percent). White high school students and 

graduates were more likely than their black counterparts 

to have smoked in the past week (19 vs. 6 percent). White 

dropouts were also more likely to have smoked than 

were black dropouts (46 vs. 17 percent). Data on pastmonth smoking for 16- through l&year-old high school 

seniors and similar-aged youth who reported that they 

had dropped out of school are available from the NHSDA 

(Kopstein and Roth ‘1993). About 28 percent of white 

students and 72 percent of white dropouts were pastmonth smokers, and 7 percent of black students and 30 

percent of black dropouts were past-month smokers. 

Among Hispanic 16- through l&year-olds, however, pastmonth smoking prevalence was less divergent between 

students (25 percent) and dropouts (27 percent). Pirie, 

Murray, and Luepker (1988), using surveys conducted in 

Minnesota, also reported a higher prevalence of smoking 

among dropouts. 

Age or Grade When Smoking Begins 

Smoking initiation at a young age increases the 

subsequent risk of heavy smoking (Escobedo et al. 1993; 

Taioli and Wynder 1991) and of smoking-attributable 

mortality (USDHHS 1989b). As is discussed in detail in 

Chapter 4 (see “Developmental Stages of Smoking”), 

smoking initiation is a complex process that can occur 

over a number of years. The present analysis examined 

two points in this process: the age a person first tries a 

cigarette, and the age a person begins smoking daily. 

Because some initiation occurs after the adolescent 

years, the analysis began with self-reported data recalled by adults in the 1991 NHSDA (Table 7). The 

analysis was further restricted~to adults aged 30 through 

39 because virtually all initiation occurs before the age of 

30 (CDC 1991b; SAMHSA, unpublished data) and be 

cause virtually all of the increased mortality that results 

from cigarette smoking occurs after the age of 40 (National Center for Health Statistics [NCHSI 1992a; 

Table 7. Cumulative percentages of recalled age at which a respondent first tried a cigarette and began 

smoking daily, among persons aged 30-39, National Household Surveys on Drug Abuse, United 

States, 1991 

Age 

(years) 

Persons who had Persons who had 

All persons* ever tried a cigarette ever smoked daily 

First tried a Began First tried a First tried a Began 

cigarette smoking daily cigarette cigarette smoking daily 

< 12 14.1 

< 14 29.7 

< 16 48.2 

< 18 63.7 

I 18 68.8 

< 20 71.0 

~25 76.6 

<30 77.4 

539 78.0 

Never smoked 100.0 

Mean age NA 

0.9 

3.9 

12.2 

26.0 

34.9 

37.8 

46.5 

48.1 

49.0 

100.0 

NA 

18.0 15.6 1.9 

38.0 36.7 8.0 

61.9 62.2 24.9 

81.6 81.9 53.0 

88.2 89.0 71.2 

91.0 91.3 77.0 

98.2 98.4 94.8 

99.3 99.4 98.1 

100.0 100.0 100.0 

NA+ NA NA 

14.5 14.6 17.7 

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

*All persons (N = 6,388). 

+NA = Not applicable. 

Epidemiology 49 
Surgeon General’s Report 

Table 8. Age or grade when respondents first tried a cigarette, Teenage Attitudes and Practices 

Survey (TAPS), National Household Surveys on Drug Abuse (NHSDA), Monitoring the 

Future Project (MTFP), Youth Risk Behavior Survey (YRBS), United States, 1989,199l 

Age /grade* 

5 12 years/< grade 6 

13-14 years/grades 7-8 

15-16 years/grades 9-10 

> 16 years/> grade 10 

Never smoked 

TAPS+ NHSDAX MTFP§ YRBS* 

% 70 70 70 

10.1 25.2 18.5 19.2 

11.4 14.5 21.6 17.7 

22.0 16.6 14.9 15.9 

8.2 3.9 5.3 5.7 

48.3 39.9 39.8 41.4 

Sources: 1989 TAPS: Centers for Disease Control and Prevention (CDC), Office on Smoking and Health (OSH) (unpublished 

data); 1991 NHSDA: CDC, O!SH (unpublished data); 1991 MTFP: Institute for Social Research, University of Michigan 

(unpublished data); 1991 YRBS: CDC, Division of Adolescent and School Health (unpublished data). 

*In TARS, the NHSDA, and the YRBS, respondents reported the age at which they had first smoked; in the MTFP, respondents reported the grade in which they first smoked. 

+Includes 17- and 18-year-old respondents to the 1989 TAPS who had completed the 11th grade and who still attended 

school. Response categories were constructed using the questions, “Have you ever smoked a cigarette?” and “How old 

were you when you smoked your first whole cigarette?“(N = 687). 

%rcludes respondents to the 1991 NHSDA between the ages of 17 and 18 years who had completed the 11th grade and 

responded to the question, “About how old were you when you first tried a cigarette?“ (N = 979). 

SIncludes high school senior respondents to the 1991 MTFP survey who responded to the question, “When if ever did you 

first do each of the following things . . Smoke your first cigarette?” (N [weighted] = 2,012). 

&Includes 12th-grade respondents to the 1991 YRBS who responded to the question, “How old were you when you smoked 

a whole cigarette for the first time?” (N = 3,127). 

Table 9. Age or grade when respondents began smoking daily, National Household Surveys on Drug 

Abuse (NHSDA), Monitoring the Future Project (MTFP), Youth Risk Behavior Survey (YRBS), 

United States, 1991 

NHSDA+ MTFP* YRBS§ 

Age/grade* 70 70 70 

5 12 years/l grade 6 3.3 2.3 3.3 

13-14 years/grades 7-8 4.0 8.5 6.1 

15-16 years/grades 9-10 10.4 11.9 10.2 

> 16 years/> grade 10 4.6 6.0 4.5 

Never smoked daily 77.5 71.2 76.0 

Sources: 1991 NHSDA: Centers for Disease Control and Prevention (CDC), Office on Smoking and Health (unpublished 

data); 1991 MTFP: Institute for Social Research, University of Michigan (unpublished data); 1991 YRBS: CDC, Division of 

Adolescent and School Health (unpublished data). 

*In the NHSDA and the YRBS, respondents reported the age at which they had begun smoking daily; in the MTFP, respondents reported the grade in which they had begun smoking daily. 

‘Includes 17- and l&year-old respondents to the 1991 NHSDA who had completed the 11th grade who responded to the 

question, “About how old were you when you first started smoking daily?” (N = 959). 

%xludes high school senior respondents to the I991 MTF’P survey who responded to the question, ‘When, if ever, did you 

first do each of the following things . . Smoke cigarettes on a daily basis?” (N lwtd.1 = 2,074). 

%xludes 12th-grade respondents to the 1991 YRBS who responded to the question, “How old were you when you first 

started smoking cigarettes regularly? (at least one cigarette every day for 30 days)” (N = 3,074). 

50 Epidemiology 
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 students, while lacking information on postadolescent initiation, 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 percent of MTFI’ respondents, and 37 percent of YRBS respondents 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 cigarettes 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&yearold 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 students smoked more cigarettes daily than younger students; 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 counterparts. 

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 behavior as one that occurs in four stages: initiation, 

experimentation, regular smoking, and dependence 

or addiction (USDHHS 1989b). The report also acknowledged a preparatory stage that occurred before 

any initial smoking (Flay et al. 1983). These five stages 

are examined in detail in Chapter 4 (see “Developmental 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 measures of smoking behavior and measures of the possibility 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- nonHis- Hispanic 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 considered 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 smokers, 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 cigarettes 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 percent), 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 Cessation (COMMIT) evaluation, 43 percent of smokers who 

usually bought their own cigarettes bought Marlboro, 

30 percent bought Camel, and 20 percent bought Newport (CDC 1992b). As TAPS data also indicated, adolescent 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 cigarettes than did smokers from other regions of the nation. 

Other studies conducted after TAPS report rates of Camel 

preference among adolescent smokers that are consistent with the COMMIT survey results (DiFranza et al. 

1991; Pierce, Gilpin, et al. 1991). 

In June and July 1992, the George H. Gallup International 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 adolescents 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 conducted WSDHHS 1980,1985,1991b; Harris 1983). Using 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 period was more common among white and black adoIescent 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, prevalence 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 females 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 considerably, especially for males. In the MTFP surveys, the pastmonth 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 generally 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 adolescents; 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 performance, 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 American 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 prevalence 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 declined 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 prevalence 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 smoking was 34 percent in 1980 and 29 percent in 1991. Among 

seniors whose parents had some postgraduate education, 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 conducted 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 investigators 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 determined 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 adjustment 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 adjustment 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 likelihood 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 

lo3 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 lo3 5 7 9 11 13 15 17 

Age when respondent began smoking regularly (years) 

40- 

Age at time of survey: 

25-34 years 

30- 

25- 

2 

8 20- 

% 

a 15- 

10- 

5- 

3 5 7 9 11 13 15 17 

Age when respondent respondent began smoking smoking regularly regularly (years) (years) 

30- 

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

20- 

F 

8 15- ti ti 

f, 

lo5- 

0 

3 5 7 9 11 13 15 17 

Age when respondent began smoking regularly (years) 

12- 

Age at time of survey: 

lo- lo- 2 65 years 

8- 

5 

2 2 6- 

k 

4- 

2- 

0 

3 5 7 9 11 13 15 15 17 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 proportion of heavy smokers (2 one-haIf pack per day) has 

decreased and the proportion of never smokers has increased (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 seniors 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 preceding 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 smoking 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 association 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 Michigan, 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 nonsmokers 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 smoking entails a great risk to health increased from 56 percent 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 believed 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” increased 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, University 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 smoking 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, unpublished 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 smokers-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 control, 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 behavioral 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 proportion 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 nonsmokers 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 nonsmokers (Allen et al. 1993). 

Adolescents seem to be more concerned about 

people smoking around them. In the MTFP, the percentage 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 remained 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 “probably” 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 definitely 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 cigarettes 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. Somewhat 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 nonsmokers 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 halfpack-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, seniors’ 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). 

l 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 ‘. l .’ ,.** ‘0.. 

‘*. ,.’ %, 

,.*h 

. ‘a,, ,.*’ 

,.a’ ‘0. 

*.*’ ‘5, 

i ‘*. 

‘s, ‘, 

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 cigasmoking 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 per day 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 cigarettesper day in high school. Expectations were predictive 

only for those smokers who smoked less than one cigarette 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 prevalence of past-month use and comparisons of the selfreported 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. Cigarette 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 drinkers. Almost one-half (45 percent) of cigarette smokers were also marijuana smokers, 11 percent were 

cocaine users, 5 percent used inhalants, and 33 percent 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 prevalent 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 percent 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 respondents 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 cigarettes 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 marijuana; 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 adolescents 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 I60 

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 l * l * 0.2 0.2 4.8 5.2 

12 l * * * * 0.1 .2.5 2.6 

Never used * l 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). 

l < 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 substances and to be prevalent among users of other drugs. 

Cigarette Smoking and Other Health-Related 

Behaviors 

Available data on the relationships between cigarette smoking and other health-related behaviors are 

derived from cross-sectional studies and thus suggest 

that other behaviors may covary with adolescent smokkg. 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 syndrome 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 pastmonth 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 
Surgeon General’s Report 

Table 29. Percentage of high school students who used tobacco, by participation on sports teams and 

steroid use, Youth Risk Behavior Survey, United States, 1991 

Category Number 

Any Current Current Current 

cigarette cigarette frequent smokeless 

use* use+ cigarette us& tobacco uses 

Participation on sports team+ 

Total 

0 teams 

2 1 team 

Female 

0 teams 

2 1 team 

Male 

0 teams 

2 1 team 

Steroid useq 

Total 

0 times 

2 1 time 

Female 

0 times 

2 1 time 

Male 

0 times 

2 1 time 

5,738 73.6 31.3 6.6 

6,429 67.2 24.3 13.5 

3,608 72:O 29.0 0.7 

2,635 66.3 24.8 2.1 

2,125 76.1 34.8 15.5 

3,794 67.8 23.9 21.0 

11,868 69.7 26.8 12.1 9.7 

382 87.2 54.8 35.7 38.7 

6,164 69.3 26.9 12.2 1.1 

116 88.5 61.8 29.9 16.5 

5,700 

265 

70.0 26.6 12.0 18.1 

86.8 52.6 27.0 44.6 

Source: Centers for Disease Control and Prevention, Division of Adolescent and School Health (unpublished data). 

*During the respondent’s lifetime. 

+ Cigarette use on 2 1 day during the 30 days preceding the survey. 

‘Cigarette use on 120 days during the 30 days preceding the survey. 

5During the 30 days preceding the survey; includes chewing tobacco or snuff. 

*During the 12 months preceding the survey; includes sports teams sponsored by school and other organizations. 

TDuring the respondent’s lifetime, without a doctor’s prescription. 

76 EpidemioIogy 
preventing Tobacco Use Among Young People 

(under 20 years old) was highest among women aged 18 

and 19 (24 percent) and lowest among women younger 

&an 15 years of age (8 percent) (Table 30). White nonHispanic adolescent mothers were more likely to have 

smoked during pregnancy than white non-Hispanic 

mothers 20 through 49 years old, Black non-Hispanic 

adolescent mothers were less likely to have smoked than 

those 20 through 49 years old; Hispanic adolescent mothers were about as likely as older Hispanic mothers to 

have smoked. Among the mothers who smoked during 

pregnancy, about 23 percent of those younger than 15 

years of age smoked more than 10 cigarettes per day; 34 

percent of mothers 15 through 19 years old, and 44 

percent of mothers 20 through 49 years old smoked more 

than 10 cigarettes per day during the pregnancy (NCHS 

1992b). 

Self-Reported Indicators of Health Status Among 

Smokers 

The MTFl? collected data on self-reported indicators of health status among the nation’s high school 

seniors. A five-category scale of lifetime smoking history 

was constructed from questions on lifetime smoking and 

on the grade in which the respondent began smoking 

daily (Table 31). Nine measures of health status were 

analyzed in terms of lifetime smoking history. Adjusted 

odds ratios were calculated by regressing the logit-transformed prevalence of each health measure over the prior 

year on the variable for lifetime smoking history and Qn 

the covariates of current marijuana use, lifetime cocaine 

use, parental education, and time (Hosmer and.L.emeshow 

1989). Alcohol use was also included as a covariate for 

the measures of staying at home because of not feeling 

well and of overall physical health. Current smokers 

were more likely than never smokers to report all of the 

symptoms or indicators listed. A trend test (using the 

linear contrast of the estimated regression coefficients for 

smoking history [Miller 19861) revealed that these 

adolescent smokers were more likely than never smokers to experience all but two of the health status measures 

(e.g., sinus congestion and sore throat). 

Self-Reported Indicators of Nicotine Addiction 

Among Smokers 

The research of McNeil1 (McNeil1 et al. 1986; 

McNeill, Jarvis, West 1987; McNeill 1991) has demonstrated the presence of nicotine addiction in young smokers (11 through 16 years old) in Great Britain. A majority 

of these young smokers experienced withdrawal symp 

tams during abstinence or had some difficulty quitting 

(McNeilI et al. 1986; McNeill, Jarvis, West 1987). The 1991 

NHSDA asked 12- through 18-year-olds questions that 

probed various components ‘of nicotine addiction 

(USDHHS 1988b). Current smokers who had smoked at 

least 100 cigarettes in their lifetime were the most likely 

of adolescent smokers to report having experienced several indicators of nicotine addiction Crable 32). Four of 

every five of these heavier smokers who tried to cut 

down on cigarettes during the previous 12 months had 

failed. Seventy percent felt that they needed or were 

dependent on cigarettes. 

Persons who had smoked at least 100 cigarettes in 

their lifetime but none in the last month were the next 

most likely to report that they felt dependent on cigarettes 

and that they had experienced withdrawal during the 

previous 12 months. These persons were more likely to 

have become regular smokers than were those who had 

not yet smoked 100 cigarettes. Though these respondents were more likely to show signs of’addiction, they 

were evidently able to discontinue smoking for at least 

one month-a finding consistent with the observation 

that less-addicted smokers are more able to quit 

(USDHHS 1988b). Respondents who had not smoked 

100 cigarettes by the time they were surveyed appeared 

less likely to become addicted to nicotine than those who 

had smoked at least 100 cigarettes. 

Table 30. Cigarette smoking prevalence (%) during pregnancy among mothers of live-born infants, by age 

and race/Hispanic origin, 43 states and the District of Columbia, 1989 

Age (years) 

Race/Hispanic origin c 15 

Overall 7.7 

White, non-Hispanic 21.2 

Black, non-Hispanic 2.7 

Hispanic 5.9 

Source: National Center for Health Statistics (1992b). 

15-17 18 -19 20- 49 

19.0 23.9 19.1 

32.1 33.3 20.5 

6.2 10.4 20.2 

7.5 8.7 8.0 

Epidemiology 77 
Surgeon General’s Report 

Table 31. Adjusted odds ratios* (and 95% confidence intervals) for symptoms of diseases and smoking status 

among high school seniors who have smoked occasionally or regularly, Monitoring the Future 

Project, United States, 1982-1989 

Self-reported 

symptom/ 

indicator+ 

Have smoked 

occasionally, 

but not 

regularly 

Smoked regularly at 

one time, but not in 

the past 30 days 

Smoke regularly 

now, began daily 

smoking in 

grades 10-12 

Smoke regularly now, 

began daily smoking 

by grade 9 

Shortness of 

breath when not 

exercising 

1;38 (1.24,1.52) 

Chest cold 1.34 (1.23,1.46) 

Sinus congestion, runny nose, 

sneezing 

1.31 (1.20,1.44) 

Coughing spells 1.33 (1.24, 1.43) 

Cough with 

phlegm or blood 

1.42 (1.28,1.56) 

Wheezing or 

gasping 

1.41 (1.26, 1.48) 

Sore throat or 

hoarse voice 

1.36 (1.26, 1.48) 

Stayed home 

most or all of 

day because not 

feeling wellt 

1.43 (1.31,1.55) 

Overall physical 

healthts 

1.47 (1.32,1.63) 

1.90 (1.56,2.31) 

1.34 (1.13,1.60) 

0.99 (0.83,1.19) 

1.28 (1.11, 1.48) 

1.73 ( 1.44,2.09) 

2.45 <1.9’9,3.01) 

1.07 (0.92, 1.26) 

1.38 (1.17,1.62) 

2.39 (1.98,2.90) 

2.32 (2.03,2.64) 

1.53 (1.35, 1.73) 

1.17 (1.02,1.34) 

2.04 (1.83,2.27) 

2.31 (2.02,2.63) 

2.36 (2.06,2.70) 

1.34 ( 1.19, 1.52) 

1.53 (1.35,1.73) 

1.98 (1.72,2.28) 

2.72 (2.40,3.08) 

1.72 (1.52,1.93) 

1.19 (1.05,1.35) 

2.20 ( 1.98,2.45) 

2.32 (2.04.2.64) 

2.57 (2.25,2.95) 

1.17 (1.04, 1.32) 

1.56 (1.39,1.76) 

2.08 (1.81,2.38) 

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

*Adjusted for past-month marijuana use, lifetime cocaine use, parental education, and time. Odds ratios are relative to 

those for seniors who had either never smoked cigarettes or had smoked cigarettes once or twice only. 

‘Occurrence during the previous 30 days, with the exeption of overall physical health. 

*Also adjusted for past-month alcohol use. 

Qdds ratios based on the percentage who reported that their health was poorer than average during the preceding year. 

78 Epidemiology 
prLenting Tobacco Use Among Young People 

Table 32. Self-reported indicators of nicotine addiction among 12-M-year-olds (N = 1,589), by smoking 

history, National Household Surveys on Drug Abuse, United States, 1991 

Smoking history* 

Indicator’ 

Have smoked Have smoked Have smoked Have smoked 

l-99 2 100 l-99 2 100 

cigarettes, cigarettes, cigarettes cigarettes 

but none in but none in and smoked in and smoked in 

past month past month past month past month 

(o/o) (%I,) (%Jo) (%) 

- 

Tried to cut down on 

use of cigarettes 

43.7 

Unable to cut down on 

use of cigarettes* 

46.9 

72.2 

40.4 59.5 81.2 

44.9 73.4 

Felt need to have more 

cigarettes to get the same effect 

Felt need to have cigarettes 

or felt dependent on 

cigarettes 

Felt sick because of stopping 

or cutting down on cigarettes* 

10.9 14.2 12.2 27.1 

12.2 37.2 16.2 70.1 

15.9 24.9 14.1 37.4 

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

*Among people who smoked cigarettes at all in the past 12 months. 

‘Occurrence during the past 12 months. 

*Analysis limited to people who tried to cut down on cigarettes during the last 12 months. 

Smokeless Tobacco Use Among Young People in the United States 

Recent Patterns of Smokeless Tobacco Use 

Ever Use of Smokeless Tobacco 

The overall national estimates for adolescents who 

had tried smokeless tobacco were 18 percent for 12- 

through Wyear-olds in the 1989 TAPS, 13 percent for the 

same age group in the 1991 NHSDA, and 32 percent for 

high school seniors surveyed by the MTFP in 1992 (Table 

33). In all three surveys, males were much more likely 

than females to have tried smokeless tobacco. White 

males were more likely than any other subgroup to have 

tied this product. 

The prevalence of adolescents who had used smokeless tobacco increased with increasing age. Twentyeight percent of 17- and B-year-old TAPS respondents, 

21 percent of 17- and B-year-old NHSDA respondents, 

and 32 percent of high school seniors in the 1992 MTFP 

survey reported that they had tried smokeless tobacco. 

Adolescents in the northeast region of the United States 

were less likely than those in the other regions to have 

tried smokeless tobacco. 

Current Use of Smokeless Tobacco 

Available data suggest that there was an increase 

in the use of smokeless tobacco among adolescents 

between 1970 and the mid-1980s. The prevalence of 

chewing tobacco use was 1.2 percent among 17- through 

19-year-old males in the 1970 THIS KJSDHHS 1986, 

1989b), 3.0 percent among 16- through 19-year-old males 

in the 1985 Current Population Survey (Marcus et al. 

1989; USDHHS 19861, and 5.3 percent among 17- through 

19-year-old males in the 1986 Adult Use of Tobacco 

Epidemiology 79 
Surgeon Generd’s Reporf 

Table 33. Percentage of young people who have ever used smokeless tobacco, by gender, race/Hispanic 

origin, age/grade, and region, Teenage Attitudes and Practices Survey (TAPS), National 

Household Surveys on Drug Abuse (NHSDA), Monitoring the Future Project WTFP), 

United States, 1989,1991,19!I2 

Characteristic TAPS* NHSDAt MTFPS 

Overall 18.4 13.2 32.4 

Gender 

Male 

Female 

31.3 

4.4 

22.3 

3.5 

53.7 

12.1 

Race/Hispanic origin 

White, non-Hispanic 

Male 

Female 

Black, non-Hispanic 

Male 

Female 

Hispanic 

Male 

Female 

22.4 16.6 38.2 

38.6 28.4 61.6 

4.8 4.4 15.2 

7.6 4.5 10.7 

11.9 6.7 18.0 

3.1 2.1 4.9 

8.1 4.8 NA* 

13.4 8.8 NA 

2.3 0.5 NA 

Age/grade 

12-14 years 

15-16 years 

17-18 years 

8th grade 

10th grade 

12th grade 

Region 

Northeast 

North Central 

South 

West 

9.6 6.5 

20.8 15.0 

28.2 20.9 

20.7 

26.6 

32.4 

14.0 9.0 25.3 

19.7 14.0 38.6 

21.4 13.9 31.5 

15.8 14.5 32.0 

Sources: 1989 TAPS: Centers for Disease Control and Prevention (CDC), Office on Smoking and Health (OSH) (unpublished data); 1991 NHSDA: CDC, OSH (unpublished data); 1992 MT’FP: Johnston, O’Malley, Bachman (in press); Institute 

for Social Research, University of Michigan (unpublished data). 

*1989 TARS, aged 12-18 years. Based on response to the question, “Have you ever tried using chewing tobacco or snuff?” 

‘1991 NHSDA, aged 12-18 years. Based on response to the question, “When was the most recent time you used chewing 

tobacco or snuff or other smokeless tobacco? (“Never used smokeless tobacco in lifetime” was a preceded response.) 

$1992 MTFP survey of high school seniors. Based on response to the question, “Have you ever taken or used smokeless 

tobacco (snuff, plug, dipping tobacco, chewing tobacco) ?“ Respondents who reported that they had taken or used smokeless tobacco at least once or twice were classified as ever users. 

§With the exception of data for 8th- and IOth-grade students, all other data points for the MTFP surveys reflect estimates for 

high school seniors. 

*NA = Not available. 

80 Epidemiology 
prn~enfing Tobacco Use Among Young People 

Survey (AUTS) CUSDHHS 1989b). The same surveys 

indicated that the prevalence of snuff use was 0.3 percent 

among 17-through 19-year-old males in 1970,2.9 percent 

among 16 through 19-year-old males in 1985, and 5.3 

percent among 17- through 1 g-year-old males in 1986. 

In the 1986-1989 MTFP surveys, high school seniors’ past-month use of smokeless tobacco declined 

slightly for all respondents (from 12 to 8 percent), for 

whites (from 13 to 10 percent), and for males (from 22 to 

16 percent) (Bachman, Johnston, O’MaIIey 1987, 1991; 

Johnston, Bachman, O’MalIey 1991, 1992). In the 1992 

MTFP survey, however, past-month use of smokeless 

tobacco was 11 percent for all respondents, 14 percent for 

whites, and 21 percent for males (ISR, University of 

Michigan, unpublished data). In the NHSDA, the prevalence of past-month use of smokeless tobacco among 12- 

through 17-year-old males was 6.6 percent in 1988 and 

5.3 percent in 1991 (USDHHS 1989a, 1992a). In the same 

survey, use of smokeless tobacco in the past year was 

estimated to be 11.1 percent in 1985,7.0 percent in 1988, 

6.1 percent in 1990, and 6.1 percent in 1991. A parallel 

decline has been reported among young adults (18 

through 25 years old): the prevalence of past-year use of 

smokeless tobacco in this group was 11 .l percent in 1985, 

8.9 percent in 1988,9.2 percent in 1990, and 8.7 percent in 

1991 (USDHHS 1988a, 1989a, 1991a, 1992a). 

The reduction in the late 1980s may be attributed to 

increased awareness resulting from several events: (1) 

the much-publicized Sean Marsee case, in which a star 

high school athlete who used snuff died of oral cancer 

(Fincher 1985); (2) the 1986 convening of a major national 

conference on smokeless tobacco use and the 1986 release 

of a report by the Advisory Committee to the Surgeon 

General on smokeless tobacco (Journal of the American 

Medical Association 1986; USDHHS 1986); (3) the introduction in 1986 of health warnings on smokeless tobacco 

packages and advertising; and (4) the enactment in 1986 

of a ban on the advertising of smokeless tobacco products through the electronic media (USDHHS 1989b, 

1992b). 

The overall national prevalence estimates for current smokeless tobacco use (within the 30 days preceding the survey) were 3 percent for past-month users 

among persons 12 through 18 years old surveyed in the 

1991 NHSDA (reflecting about 800,000 users), 11 percent 

for high school seniors in the 1992 MTFP survey, and 11 

percent for students in grades 9-12 in the 1991 YRBS 

(Table 34). Current use was substantially more prevalent among males than females; 6 percent of the males in 

the NHSDA and 20 percent of the males in the other two 

surveys reported current use, whereas only about 1 percent of the females in the three surveys reported current 

use. Smokeless tobacco use was highest among white 

males; Hispanic males had the next highest prevalence, 

and black males had the lowest. Although reliable national data are not currently available on smokeIess to 

bacco use among American Indian and Alaskan Native 

adolescents, local surveys have reported very high prevalence (e.g., CDC 1987, 1988; Schinke et al. 1987; HaII and 

Dexter 1988; see aIso “Sociodemographic Factors in the 

Initiation of Smokeless Tobacco Use” in Chapter 4). 

Smokeless tobacco use increased with increasing 

age in the NHSDA survey of 12- through l&year-olds 

and by grade in the 1992 MTFP survey, but did not 

change appreciably among students in the four high 

school grades surveyed by the YRBS. 

Individual YRBS surveys conducted in several state 

and local communities found that male high school students were far more likely than females to use smokeless 

tobacco (Table 35); nonetheless, smokeless tobacco was 

used by as much as 10 percent of female respondents in a 

given state survey. In some states (Alabama, Idaho, 

South Dakota, Colorado, Wyoming, and Montana), males 

were as likely to report current smokeless tobacco use as 

they were to report current cigarette use (see Table 3). 

The 1992 MTFP survey gathered data on the frequency of smokeless tobacco use among approximately 

2,600 high school seniors (ISR, University of Michigan, 

unpublished data). Users were classified according to 

the number of days they had used smokeless tobacco 

over a period of 30 days. Thirty-eight percent of male 

users and 20 percent of female users reported that they 

had used smokeless tobacco at least once every day. 

Seventy percent of the female users reported that they 

had used the product less than once each week. Thirtynine percent of white users and 12 percent of black users 

reported daily use of smokeless tobacco. Almost 60 percent of the black users reported that they had used the 

product less than once each week. Among past-month 

users, 46 percent of those living in the West and 43 

percent of those from the South had used smokeless 

tobacco at least once each day. Thirty-three percent of 

users who lived in the north-central and 22 percent from 

the northeast United States used smokeless tobacco on a 

daily basis. 

Use of Smokeless Tobacco and Cigarettes 

As was shown in Table 23,43 percent of male high 

school seniors who used smokeless tobacco also smoked 

cigarettes. Tobacco, either in the form of cigarettes or 

smokeless tobacco, was used by 15 percent of 12- through 

18year-olds in the 1991 NHSDA, 32 percent of high 

school students in the 1991 YRBS, and 33 percent of high 

school seniors in the 1992 MTFP (Table 36). Males were 

substantially more likely than females to use tobacco. 

Regardless of gender, the prevalence of tobacco use for 

Epidemiology 81 
Surgeon General’s Report 

Table 34. Percentage of young people who currently (within the past 30 days) use smokeless tobacco, by 

gender, race/Hispanic origin, age/grade, and region, National Household Surveys on Drug 

Abuse (NHSDA), Monitoring the Future Project (MTFP), Youth Risk Behavior Survey 

(YRBS), United States, 1991,1992 

Characteristic NHSDA* MTFPti YRBSS 

Overall 

Gender 

Male 

Female 

Race/Hispanic origin 

White, non-Hispanic 

Male 

Female 

Black, non-Hispanic 

Male 

Female 

Hispanic 

Male 

Female 

Age/ grade 

12-14 years 

15-16 years 

17-18 years 

8th grade 

9th grade 

10th grade 

11 th grade 

12th grade 

Region 

Northeast 

North Central 

South 

West 

3.4 

6.0 20.8 19.2 

0.6 2.0 1.3 

4.4 13.5 13.0 

8.1 23.9 23.6 

0.5 2.5 1.4 

0.7 2.5 2.1 

0.5 5.2 3.6 

0.8 0.2 0.7 

1.2 NA* 5.5 

2.1 NA 10.7 

0.3 NA 0.6 

11.4 

1.5 

3.6 

5.9 

7.0 

0.8 8.2 8.8 

3.9 12.3 13.3 

4.0 12.5 8.6 

3.9 11.1 10.5 

9.6 

11.4 

10.5 

9.0 

10.1 

12.1 

10.7 

Sources: 1991 NHSDA: Centers for Disease Control and Prevention (CDC), Office on Smoking and Health (unpublished 

data); 1992 MTFPz Johnston, O’Malley, Bachman (in press); Institute for Social Research, University of Michigan (unpublished data); 1991 YRBS: CDC (1992~); CDC, Division of Adolescent and School Health (unpublished data). 

*1991 NHSDA, aged 12-18 years. Based on response to the question, ‘When was the most recent time you used chewing 

tobacco or snuff or other smokeless tobacco?” 

‘1992 MTFP survey of high school seniors. Based on response to the question, “How frequently have you taken smokeless 

tobacco during the past 30 days?” 

twith the exception of data for 8th- and IOth-grade students, all other data points for the MTFP survey reflect estimates for 

high school seniors. 

“1991 YRBS, grades 9-12. Based on response to the question, “During the past 30 days, did you use chewing tobacco, such as 

Redman, Levi Garrett, or Beechnut, or snuff, such as Skoal, Skoal Bandits, or Copenhagen?” 

ANA = Not available. 

82 Epidemiology 
preventing Tobacco Use Among Young People 

Table 35. Percentage of high school students who use smokeless tobacco, by gender, Youth Risk Behavior 

Surveys, United States and selected U.S. sites, 1991 

Smokeless tobacco use* 

Site 

Weighted data National survey 

Female 

1 

Male Total 

19 10 

State Alabama surveys 2 31 16 

Georgia 2 

22 12 

3 24 14 Idaho 

2 26 14 Nebraska 

New Mexico 4 27 16 

New York’ 2 19 11 

Puerto Rico* 0 5 2 

South Carolina 2 20 11 

South Dakota 10 29 20 

Utah 2 12 7 

Local surveys 

Chicago 2 

5 3 

Dallas 1 7 4 

Fort Lauderdale 1 9 4 

1 

6 3 Jersey City Mimi 1 6 3 

2 6 4 Philadelphia 

San Diego 1 7 4 

Unweighted data5 

State surveys 

Colorado’ 

District of Columbia* 

Hawaii 

Montana 

New Hampshire 

New Jersey’ 

Oregon 

Pennsylvania+ 

Tennessee 

Wisconsin 

Wyoming 

Local surveys 

Boston 

New York City 

San Francisco 

6 

2 

2 

7 

4 

2 

5 

2 

1 

3 

5 

1 5 3 

1 5 3 

2 6 4 

32 19 

5 4 

14 8 

33 20 

22 13 

14 7 

28 16 

29 16 

34 17 

19 11 

31 19 

Source: Centers for Disease Control (1992d). 

*Respondents used chewing tobacco or snuff on 1 or more of the 30 days preceding the survey. 

‘Surveys did not include students from the largest city. 

tCategorized as a state for funding purposes. 

gFour&n sites had overall response rates below 60 percent or had unavailable documentation; weighted estim&s 

were not reported. 

Epidemiology 83 
Surgeon GeneraI’s Report 

Table 36. Percentage of young people who currently (within the past 30 days) use cigarettes and/or 

smokeless tobacco, by gender, race/Hispanic origin, region, and age/grade, National Household 

Surveys on Drug Abuse (NHSDA), Monitoring the Future Project (MTFP), Youth Risk 

Behavior Survey (YRBS), United States, 1991,1992 

Characteristic NHSDA’ MTFP+ YRBS’ 

Overall 

Gender 

Male 

Female 

Race/Hispanic origin5 

White, non-Hispanic 

Male 

Female 

Black, non-Hispanic 

Male 

Female 

Hispanic 

Male 

Female 

Age/grade 

12-14 years 

15-16 years 

17-18 years 

8th grade 

9th grade 

10th grade 

11 th grade 

12th grade 

Region 

Northeast 

North Central 

South 

West 

15.1 33.2 31.8 

17.1 38.8 35.8 

13.0 27.3 27.6 

17.9 38.4 36.2 

20.3 43.0 40.0 

15.4 33.3 32.0 

6.0 8.8 13.7 

6.6 14.3 16.0 

5.4 4.5 11.6 

10.9 NA§ 28.1 

10.8 NA 33.6 

10.9 NA 23.1 

5.1 

16.2 

28.5 

20.5 

28.2 35.1 

17.0 37.7 

14.5 30.3 

14.2 30.0 

27.6 

33.2 

26.7 

29.6 

36.3 

34.7 

40.8 

28.8 

27.6 

Sources: 1991 NHSDA: Centers for Disease Control and Prevention (CDC), Office on Smoking and Health (unpublished 

data); 1992 MTFP: Johnston, O’Malley, Bachman (in press); Institute for Social Research, University of Michigan (unpublished data); 1991 YRBS: CDC, Division of Adolescent and School Health (unpublished data). 

*1991 NHSDA, aged 12-18 years. Based on responses to the questions, “When was the most recent time you smoked a 

cigarette?” and “When was the most recent time you used chewing tobacco or snuff or other smokeless tobacco?” 

‘1992 MTFP surveys of high school seniors. Based on responses to the questions, “How frequently have you smoked 

cigarettes during the past 30 days?“ and “How frequently have you taken smokeless tobacco during the past 30 days?” 

t1991 YRBS, grades 9-12. Based on responses to the questions, “During the past 30 days, on how many days did you smoke 

cigarettes?” and “During the past 30 days, did you use chewing tobacco, such as Redman, Levi Garrett, or Beechnut, or 

snuff, such as Skoal, Skoal Bandits, or Copenhagen?” 

§NA = Not available. 

84 Epidemiology 
prL~,enting Tobacco USZ Among Young People 

&te adolescents was higher than for Hispanics and 

b@S. TObXCO Use hCreased with increasing age and 

ts~as most common in the north-central region of the 

un&cI states. 

sociodemographic Risk Factors for Smokeless 

Tobacco Use 

Current use of smokeless tobacco among male 

high school seniors varied according to several 

hodemographic indicators, as shown by the 1986-1989 

MTFI’ surveys (N [weighted] = 5,277). The prevalence of 

current smokeless tobacco use was 28 percent among 

those who lived alone, 29 percent among those living in 

father-only households, 16 percent among those living in 

mother-only households, and 20 percent among those 

living with both parents. Current use was more common 

among male seniors living on farms (34 percent) and in the 

country (31 percent> than among those living in mediumsized to very large cities or suburbs (11 to 17 percent). The 

prevalence of current use was greater among students 

who rated their academic performance as average (25 

percent) or below average (26 percent) than among those 

whoratedtheirperformanceasslightlyaboveaverage(18 

percent) or far above average (16 percent). Smokeless 

tobacco use was more common among male seniors who 

planned to enter the armed forces after high school than 

among those who did not have such plans (23 vs. 19 

percent). The self-reported importance of religion did not 

affect the prevalence of smokeless tobacco use among 

these MTFP seniors. 

Grade When Smokeless Tobacco Use Begins’ 

The grade distribution for which MTFP seniors 

reported first trying smokeless tobacco was more similar 

to that reported for cigarettes than it was for those reported for alcohol, marijuana, and cocaine (Figure 8). 

Among seniors who had used smokeless tobacco, 23 

percent had first done so by grade six, 53 percent by 

grade eight, and 73 percent by the ninth grade. 

Attempts to Quit Using Smokeless Tobacco 

Twenty-two percent of the male high school 

seniors in the 1986-1989 MTFP who had regularly 

used smokeless tobacco reported that they had not 

used the product during the 30 days preceding the 

survey. In the 1986-1989 TAPS, 12- through l&yearolds who regularly used smokeless tobacco were 

asked to report the number of times they had tried to 

quit. Nineteen percent of males and 14 percent of 

females reported never making a quit attempt. Thirtythree percent of males and 72 percent of females had 

made one attempt to quit, 27 percent of males and 14 

percent of females had tried quitting two or three 

times, and 21 percent of males and no females had 

tried to quit four or more times (1989 TAPS, CDC, 

OSH, unpublished data). 

Smokeless Tobacco Brand Preference 

TAPS also asked those who had regularly used 

smokeless tobacco what brand they usually bought. 

Among males in this subgroup (N = 300), 38 percent 

usually bought Copenhagen, 26 percent purchased Skoal 

or Skoal Bandits, 9 percent purchased Redman, 6 percent 

bought Levi Garrett, 2 percent purchased Beechnut, and 

19 percent purchased other smokeless tobacco brands 

(1989 TAPS, CDC, OSH, unpublished data). 

Trends in Perceived Health Risks of Smokeless 

Tobacco Use 

High school seniors in the MTFP were asked, “How 

much do you think people risk harming themselves 

(physically or in other ways) if they use smokeless tobacco 

regularly (chewing tobacco, plug, dipping tobacco, 

snuff)?” Overall in 1991,37 percent reported that great 

risk of harm is associated with smokeless tobacco use 

(ISR, University of Michigan, unpublished data); more 

females (43 percent) than males (32 percent) and more 

blacks (44 percent) than whites (36 percent) were of this 

opinion. Western respondents more frequently held this 

belief (43 percent) than respondents in the South (37 

percent), the Northeast (36 percent), and the north-central United States (35 percent). Respondents who planned 

to attend college for four years were more likely to report 

this belief than those without college plans (39 vs. 33 

percent). 

When the overall percentage of seniors in the 1986 

1989 MTFP who believed that great risk is associated 

with smokeless tobacco use is plotted against the 

percentage of seniors who had used smokeless tobacco, 

the trends of these percentages are inversely related 

(Figure 9). between 1986 and 1988, the percentage of 

seniors who believed that great risk is associated with 

smokeless tobacco use increased from 26 to 33 percent. 

between 1988 and 1989, this percentage remained relatively stable. The percentage of seniors who had used 

smokeless tobacco increased slightly between 1986 (31 

percent) and 1987 (32 percent) and decreased by 1989 (29 

percent). This finding is similar to that observed for 

cigarette smoking (Figure 5). 

In the 1989 TAPS, 94 percent of 12- through 1& 

year-old males reported that use of chewing tobacco and 

snuff can cause cancer. Ninety-three percent of those 

males who had never used smokeless tobacco and 96 

percent of those who had regularly used the product 

endorsed that statement (Allen et al. 1993). 

Epidemiology 85 
Surgeon General’s Report 

Figure 9. Trends in the percentage of high school seniors who believe that regular use of smokeless 

tobacco is a serious health risk and who have ever used smokeless tobacco, Monitoring the 

Future Project, United States, 1986-1989 

40 

38 

36 

32 

E 

8 30 $ CI 

28 

26 

24 

22 

20 

- Ever use 

1986 1987 

Year 

1988 1989 

Sources: Bachman, Johnston, O’Malley (1987,1991); Johnston, Bachman, O’Malley (1991,1992). 

Smokeless Tobacco Use and Other Drug Use 

Prevalence of Smokeless Tobacco Use and Other 

Drug Use 

The majority of male high school seniors in the 

1986-1989 MTFP who used alcohol, marijuana, cocaine, 

or inhalants did not use smokeless tobacco (Table 37). 

Smokeless tobacco use, however, was from 1 .S to 3.9 times 

higher among users of these drugs than among nonusers. 

Most notably, 90 percent of smokeless tobacco users were 

also alcohol drinkers. Almost one-third (31 percent) of 

smokeless tobacco users also used marijuana, 7 percent 

used cocaine, and 5 percent used inhalants. The prevalence of other drug use was from 1.4 to 1.9 times greater 

among smokeless tobacco users than nonusers. 

Grade When Use of Smokeless Tobacco and 

Cigarettes Begins 

In the 1986-1989 MTFP, 28 percent of all males had 

never tried cigarettes or smokeless tobacco by the 12th 

grade; 44 percent had tried both; 18 percent had tried 

cigarettes but not smokeless tobacco; and 9 percent had 

tried smokeless tobacco but not cigarettes (Table 38). Of 

those male seniors who had tried both, 37 percent had 

tried cigarettes before smokeless tobacco, 24 percent had 

tried smokeless tobacco before cigarettes, and 40 percent 

had first tried both at about the same time. 

Smokeless Tobacco Use and Other HealthRelated Behaviors 

In the 1991 YRBS, male high school students were 

more likely to report past-month use of smokeless tobacco 

if they rarely or never wore seat belts, were frequently 

involved in physical fights, carried weapons during one 

or more of the preceding 30 days, and had made one or 

more suicide attempts during the preceding 12 months 

(Table 27). These students were also more likely to 

currently use smokeless tobacco if they had ever had 

sexual intercourse (Table 28). Smokeless tobacco use did 

not vary appreciably (compared with cigarette smoking) 

86 Epidemiology 
p~mnting Tobacco Use Among Young PeopJe 

Table 37. Prevalence (o/o) of smokeless tobacco use among users of other drugs and prevalence of other drug 

use among smokeless tobacco users,+ male high school seniors, Monitoring the Future 

Project, United States, 1986 -1989 

Other drugs 

Prevalence of Prevalence of Prevalence of Prevalence of 

smokeless smokeless other drug use other drug use 

tobacco use tobacco use among smoke- among nonusers 

among users of among nonusers .less tobacco of smokeless 

other drugs of other drugs users tobacco 

Alcohol 26.3 6.8 89.6 

Marijuana 27.6 17.6 30.9 

Cocaine+ 28.7 19.6 7.4 

Inhalants* 32.3 19.6 5.0 

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

‘Any use of smokeless tobacco or other drugs during the past month. 

‘Includes “coke, ” “crack,” and “rock.” 

t Glue, aerosols, laughing gas, etc. 

63.8 

20.0 

4.6 

2.6 

Table 38. Percent distribution of male high school seniors (N [weighted] = 4,254), by grade in which they 

first used cigarettes and smokeless tobacco (used in the past 30 days), Monitoring the Future 

Project (MTFP), United States, 1986-1989 

Grade when respondent first tried smokeless tobacco 

Grade when 

respondent 

first tried 

cigarettes <6 7-8 9 10 11 12 

Never Row 

used total 

56 7.1 4.9 2.3 1.4 0.7 0.3 5.8 22.4 

7-8 2.1 5.8 2.5 1.3 0.8 0.3 4.7 17.5 

9 1.3 2.0 2.3 0.9 0.4 0.2 3.2 10.3 

10 0.6 0.7 1.0 1.5 0.2 0.1 2.3 6.4 

11 0.1 0.5 0.7 0.5 0.5 0.1 1.5 3.9 

12 + 0.3 0.2 0.1 0.1 0.3 0.9 1.9 

Never used 2.0 2.7 1.9 1.1 1.3 0.2 28.3 37.6 

Column total 13.3 16.9 11.0 6.9 4.0 1.4 46.7 100.0 

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

l < 0.05. 

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

by how many lifetime sexual partners these males had 

had or by whether they had used a condom during their 

most recent sexual intercourse. Lastly, students were 

consistently more likely to currently use smokeless tobacco if they had participated on a sponsored sports 

team (Table 29). This finding is opposite to that found 

for cigarette smoking and sports. Smokeless tobacco use 

was also more likely among students who had used 

steroids without a doctor’s prescription. 

Epidemiology 87 
Surgeon General’s Report 

Conclusions 

1. 

2. 

3. 

Tobacco use primarily begins in early adolescence, 

typically by age 16; almost all first use occurs before 

the tune of high school graduation. 

Smoking prevalence among adolescents declined 

sharply in the 1970s but the decline slowed significantly in the 1980s. At least 3.1 million adolescents 

and 25 percent of 17- and Wyear-olds are current 

smokers. 

4. 

5. 

Although current smoking prevalence among female adolescents began exceeding that among males 

by the mid- to late-1970s both sexes arenow equally 

likely to smoke. Males are significantly more likely 

than females to use smokeless tobacco. Nationally, 

white adolescents are more likely to use all forms of 

tobacco than are blacks and Hispanics. The decline 

in the prevalence of cigarette smoking among black 

adolescents is noteworthy. 

Many adolescent smokers are addicted to cigarettes; 

these young smokers report withdrawal symptoms 

similar to those reported by adults. 

Tobacco use in adolescence is associated with a range 

of healthcompromising behaviors, including being 

involved in fights, carrying .weapons, engaging in 

higher-risk sexual behavior, and using alcohol and 

other drugs. 

88 EpidemioIogy 
praenting Tobacco Use Among Young People 

Chapter 4: Psychosocial Risk Factors for Initiating Tobacco Use 

Introduction 

Tobacco use begins primarily through the 

dynamic interplay of sociodemographic, environmental, behavioral, and personal factors. These 

psychosocial risk factors increase a person’s chances both 

of beginning to use tobacco and of experiencing the 

immediate and long-term health problems associated 

with tobacco use. Young people (aged 10 through 18 

years) are particularly affected by psychosocial factors 

and are thus particularly vulnerable to adopting tobacco 

use. Since psychosocial risk factors are the initial 

influences in the causal chain that leads to tobacco-related 

health consequences, primary prevention efforts to reduce smoking prevalence must take these influences 

into account. 

Psychosocial risk factors for tobacco use can be 

viewed as a continuum of proximal to distal factors. 

Personal and behavioral factors that directly affect an 

individual’s choice to use tobacco (when a cigarette is 

offered, for example) areconsidered proximal risk factors, 

whereas environmental and so&demographic factors 

(such as billboard advertising and household income) 

that indirectly affect the accessibility or acceptability of 

tobacco use are classified as distal factors. Proximal 

factors are considered more immediate to a person’s 

decision to use tobacco than distal factors. Still, as is 

shown in Chapter 5 (see “Research on the Effects of 

Cigarette Advertising and Promotional Activities on 

Young People”), distal factors acquire potency if they are 

pervasive and provide consistent, repetitive messages 

across multiple channels. Distal factors are also powerful 

because, over time, they affect proximal factors as these 

influences become interpreted and internalized, particularlyamongadolescentsastheytrytoshapeamatureselfidentity. 

This review examines each of these sets of risk 

factors to provide a comprehensive view of the antecedents of tobacco use, first for cigarette smoking, then for 

smokeless tobacco use. The database for this review 

includes research studies that have been published primarily in peer-refereed journals or books during the past 

15 years. Results from these studies were grouped 

according to psychosocial risk factor, and conclusions 

were based on the availability and conclusiveness of the 

evidence for a given risk factor. Table 1 summarizes the 

major psychosocial risk factors examined in this chapter 

and in Chapter 5. 

Table 1. Psychosocial risk factors in the initiation 

of tobacco use among adolescents 

Smokeless 

Risk factors Smoking tobacco 

Sociodemographic factors 

Low socioeconomic status X 

Developmental stage X X 

Male gender X 

Environmental factors 

Accessibility X X 

Advertising X X 

Parental use 

Sibling use X 

Peer use X X 

Normative expectations X X 

Social support X 

Behavioral factors 

Academic achievement X X 

Other problem behaviors x X 

Constructive behaviors X 

Behavioral skills X 

Intentions X X 

Experimentation X X 

Personal factors 

Knowledge of consequences X 

Functional meanings X X 

Subjective expected utility x 

Self-esteem/self-image X X 

Self-efficacy X 

Personality factors X 

Psychological well-being x 

Psychosocial Risk Factors 89 
Surgeon GeneraIs Report 

Initiation of Cigarette Smoking 

Introduction 

Early public health efforts to prevent smoking 

among adolescents were largely informed by healthrelated and demographic findings from research stimulated by the landmark 1964 Surgeon General’s report 

on smoking and health (Public Health Service 1964; 

Chassin, Presson, Sherman 1990). By the mid-1970s, the 

ineffectiveness of these attempts to reduce rates of smoking onset among adolescents further stimulated research 

into what motivates young people to begin smoking 

(Thompson 1978). Significant support for such research 

was provided by the National Clearinghouse for Smoking and Health, the National Institutes of Health, the 

National Institute on Drug Abuse (NIDA), and various 

private health organizations, including the American 

Lung Association, the American Cancer Society, and the 

American Heart Association. 

The application of psychosocial theories to the area 

of adolescent smoking behavior provided a major breakthrough in the understanding of smoking initiation and 

development, pioneered by the conceptual and pilot work 

of Leventhal(19681, Bandura (1977), Evans et al. (19781, 

McAlister, Perry, and Maccoby (1979), and McGuire 

(1984). Rather than view cigarette smoking as a health 

behavior, these researchers examined smoking as a social behavior, with social causes, functions, and reinforcements. Although this early work involved mostly 

correlational research, such as examining the relationship between parental smoking and children’s smoking 

behavior, research became increasingly theory-driven, 

longitudinal, prospective, and multivariate during the 

1980s (Chassin, Presson, Sherman 1990). Conrad, Flay, 

and Hill (1992) recently reviewed 27 prospective studies 

on smoking initiation published since 1980 (see Table 2 

for characteristics of these studies). The large number of 

such methodologically sophisticated studies provides a 

sufficient base of knowledge to begin drawing conclusions about the relative importance of a variety of risk 

factors for the onset of tobacco use. 

The process of onset requires clarification. Regardless of the age at which they smoke their first cigarette, 

young people appear to progress through a sequence 

of stages that takes them from receptivity 

to dependence on tobacco use (Leventhal and Clear-y 

1980; Flay et al. 1983). Not all young people who try a 

cigarette become daily smokers; still, almost all of 

those who become daily smokers have experienced sin+ 

lar, well-defined stages in the behavior-acquisition 

process. The risk factors for each of these stages appear 

to differ; this -variation suggests that even within the 

seven years of adolescence (ages 11 through 17), developmentally appropriate prevention programs should be 

used (Leventhal, Fleming, Glynn 1988). 

Developmental Stages of Smoking 

Flay (1993) discusses the five primary stages of 

smoking initiation among children and adolescents (Figure 1). During the first or preparatory stage, attitudes 

and beliefs about the utility of smoking are formed. At 

this stage, even if no actual smoking behavior is enacted, 

the child or adolescent may see smoking as functionalas a way to appear mature, cope with stress, bond with a 

new peer group, or display independence (Perry, Murray, 

Klepp 1987). The second or trying stage encompasses 

the first two or three times an adolescent smokes. Peers 

are usually involved in situations that encourage trying 

(Conrad, Flay, Hill 1992). Whether the physiological 

effects of smoking are perceived to be negative and 

whether these tries are socially reinforced determine if 

an adolescent will proceed to the next stage (Leventhal, 

Fleming, Ershler, unpublished data), experimentation, 

which includes repeated but irregular smoking. At this 

third stage, smoking is generally a response to a particular situation (such as a party> or to a particular person 

(such as a best friend). These influences will not yet have 

prompted a regular pattern of use. In the fourth stage, 

regular use, an adolescent smokes on a regular basis, 

usually at least weekly, and increasingly across a variety 

of situations and personal interactions. The final stage, 

nicotine dependence and addiction (see “Nicotine Addiction in Adolescence” in Chapter 21, is characterized 

by a physiological need for nicotine. This need includes 

tolerance for nicotine, withdrawal symptoms if the person tries to quit, and a high probability of relapse if the 

person does quit (Flay 1993). These stages have been 

further quantified and validated by Stem et al. (1987). 

The time interval from the initial try to the stage of 

regular use takes an average of two to three years, with 

considerable interval variation among individuals 

(Leventhal, Fleming, Glynn 1988). McNeill(1991) found 

in a prospective study that of those who experimented 

with cigarettes, approximately half were smoking on a 

daily basis within one year. Leventhal, Fleming, and 

Glynn (1988) suggest that the time interval from the 

initial try to the stage of regular use may be extended, 

particularly if the time is lengthened between the first 

90 Psychosocial Risk Factors 
preventing Tobacco Use Among Young People 

and second try. This observation suggests that to delay 

both the onset of first trials as well as the progression to 

regular use, it seems critical to examine risk factors for 

first use. Since a young person may become a reguIar 

smoker in ody two to three years, the adolescent period 

of development (particularly middle school, junior high 

school, and senior high school) is a cruciaI time for pn+ 

vention efforts (Evans et al. 1978). 

Sociodemographic Factors in the Initiation 

of Smoking 

Sociodemographic factors involve the economic, 

political, social, and educational systems of a society. 

These factors can be determinants of behavior, such as 

tobacco use, even if the systems they originate in are not 

directly associated with the choice to begin that behavior. Within these systems, social disorganization or 

Table 2. Characteristics of 27 prospective studies of smoking onset, various countries, 1980-1991 

Study 

Year of 

publication Place 

Age* Time+ Numbefi 

(years) (months) (nonsmokers) 

Ahlgren et al. 

Alexander et al. 

Ary et al. 

Ary and Biglan 

Bauman et al. 

Brunswick and Messeri 

Charlton and Blair 

Chassin et al. 

Chassin et al. 

Collins et al. 

de Vries et al. 

Goddard 

Kellam, Ensminger, Simon 

Krohn et al. 

Lawrance and Rubinson 

M&au1 et al. 

McNeil1 et al. 

Mittelmark et al. 

Murray et al. 

Newcomb, McCarthy, BentIer 

Pulkkinen 

Semmer, Cleary, et al. 

Semmer, Lippert, et al. 

Skinner et al. 

Stacy et al. 

Sussman et al. 

Urberg, Cheng, Shyu 

1982 

1983 

1989 

1988 

1984 

1984 

1989 

1984 

1986 

1987 

1990 

1990 

1980 

1983 

1986 

1982 

1988 * 

1987 

1983 

1989 

1982 

1987 

1987 

1985 

unpublished 

1987 

1991 

Minnesota 

NSW Australia5 

Oregon 

Oregon 

North Carolina 

New York City 

Manchester, UK 

Indiana 

Indiana 

Los Angeles 

Netherlands 

England 

Chicaga 

Iowa 

Illinois 

Minnesota 

Bristol, UK 

Minnesota 

Derbyshire, UK 

Los Angeles 

Finland 

Berlin-Bremen 

Berlin-Bremen 

Iowa 

Los Angeles 

Los Angeles 

Detroit suburb 

lo-11,11-12 

10,11,12 

12-13,14-15,X%16 

12-15,15-16 

14-15 

12-16 

12-13 

11-16 

11-16 

12-13 

Secondary 

11-15 

6-7 

12-18 

12-14 

12-13 

11-13 

12-14,14-16 

11-12 

12-13,13-14,14-15 

8-9 

12-13 

12-14 

12-18 

12-13 

12-13 

X&14,16-17 

6 

12 

6 

12 

12 

84 

4 

12 

12 

16 

12 

24 

120 

12 

8 

12 

30 

18 

48 

96 

144 

24 

6 

24 

16 

16 

12 

562 

5,065 

801 

737 

519 

380 

1,513 

1,207 

145 

1,354 

555 

2,251 

705 

NAA 

346 

268 

1,261 

887 

2,217 

NA 

135 

761 

763 

426 

1,116 

338 

NA 

Source: Adapted from Conrad, Flay, Hill 0992). 

*Age = Age (in years) of students at the beginning of the study. 

‘Time = Number of months from the beginning of the study to the final follow-up wave. 

*Number = Number of nonsmoking students at the beginning of the study. 

SNSW Australia = New South Wales, Australia. 

;INA = Not available. 

Psychosocial Risk Factors 91 
Surgeon General’s Report 

Figure 1. Stages of smoking initiation among children and adolescents 

Preparatory Stage 

Psychosocial risk factors 

include advertising and 

adult/sibling role models 

who smoke cigarettes. 

Psychosocial risk factors 

include peer influences 

to smoke, the perception 

that smoking is normative, 

and the availability of 

cigarettes. 

Psychosocial risk factors 

include social situations and 

peers that support smoking, 

low self-efficacy in ability to 

refuse offers to smoke, and 

the availability of cigarettes. 

Psychosocial risk factors 

include peers who smoke, 

the perception that smoking 

has personal utility, and 

few restrictions on smoking 

in school, home, and community 

settings. 

Adolescent forms attitudes 

and beliefs about 

the utility of smoking. 

w Never smokes 

Trying Stage 

Adolescent smokes 

first few cigarettes. 

L, No longer smokes 

Experimental Stage 

Adolescent smokes 

repeatedly but irregularly. 

fl No longer smokes 

Regular Use 

Adolescent smokes at least 

weekly across a variety of 

situations and personal 

interactions. 

t Quits smoking 

Addiction/Dependent Smoker Adolescent has developed the 

physiological need for nicotine. 

Sources: Adapted from Flay (1993); U.S. Department of Health and Human Services (19911. 

breakdown and discrepancies between role aspirations behavioral factors, such as normative expectations of 

and achievements may lead to incomplete or inappro- smoking, that affect the choice to use tobacco Flay 1993). 

priate social development of adolescents. Inappropriate Tobacco use may vary according to broad factors such as 

social development, in turn, can alter personal and an individual’s socioeconomic status, family 

92 Psychosocial Risk Factors 
Gtrume, age, gender, and ethnicity, especially when 

cta~ed across an entire population. Many of these 

ta,-tors are covered in Chapter 3 (see “Recent Patterns of 

Cigarette Smoking”). 

socioeconomic Status 

Low socioeconomic status (SE9 has been shown to 

predict smoking initiation in multiple longitudinal stud- 

,es (Conrad, Flay, Hill 1992). Sernrner, Lippert, et al. 

(1987) examined tobacco use among students in two 

&ools in Germany. These investigators found that 

seventh- and eighth-grade students from the school in a 

low-income area (children of primarily blue-collar parents) had higher baseline rates of tobacco use than youth 

horn the school in a higher-income area. Low-income 

students were also more likely to begin smoking over the 

course of this six-month study. Low-income students 

had greater expectations of positive consequences of 

smoking, lower self-image scores, and more friends who 

smoked. One possible explanation of the impact of SES 

supported by these findings is that lower-income students may have to cope more often with stressful situations, such as lacking sufficient resources or living in a 

one-parent family, and are therefore more likely to perceive smoking as a quick, easy coping strategy for stress 

or loneliness-and as a strategy that is socially accepted 

and effective (Semmer, Cleary, et al. 1987). Adolescents 

from low-income families may also have more role models who smoke and less supervision to discourage experimentation than adolescents from higher-income 

families (Perry, Kelder, Komro 1993). . 

Parental Education 

The level of parental education has been shown to 

have a significant impact on adolescent smoking lo+ 

havior in some studies. Although Ary et al. (1983) failed 

to find a relationship between parental education and 

children’s smoking behavior, in a later report, 

Ary and Biglan (1988) found that low educational attainment among fathers was predictive of smoking onset 

in middle school youth. Waldron and Lye (1990) reported that high school seniors who had less-educated 

parents were more likely to have tried a cigarette and to 

have adopted cigarette smoking and were less likely to 

have quit smoking. Finally, Mittelmark et al. (1987) 

found that both adolescent femalesat all grade levels and 

adolescent males in grades 9 through 11 who began to 

smoke during the course of the study had parents with 

fewer years of formal education than their peers who 

remained nonsmokers. However, for seventh- and eighthgrade males in this study, parental educational level 

did not help to predict smoking initiation. See “Trends 

in Cigarette Smoking” in Chapter 3 for a trend analysis 

of adolescent smoking behavior and level of parental 

education. 

Number of Parents Living in the Home 

Several studies document an association between 

beginning to sinoke during childhood or adolescence 

and living in a single-parent home 05, Egan, Silva 1986; 

Elder, Molgaard, Gresham 1988; Isohanni, Moilanen, 

Rantakallio 1991; Goddard 1990; see ‘Sociodemographic 

Risk Factors for Smoking” in Chapter 3). These findings 

must be interpreted with caution, since most are from 

cross-sectional studies that were unable to determine 

with certainty which occurred first--living in a single 

parent home or smoking. If a predictive relationship 

does exist, a mechanism described by Castro et al. (1987) 

may help to explain the causal link. Their analyses 

found that living in a disrupted family system is an 

initial stressor that appears to predict social nonconformity and affiliation with cigarettesmoking peers. In 

turn, as will be discussed later in this chapter, both social 

nonconformity and peer affiliation are significant predictors of cigarette smoking among adolescents. 

Developmental Challenges of Adolescence 

The life stage of adolescence itself has been a consistent predictor of smoking initiation across studies 

(Alexander et al. 1983; Coombs, Fawzy, Gerber 1986; 

Bauman et al. 1990). The transition years from elementary to secondary school seem to be a particularly highrisk time for adolescent initiation of tobacco use 

(Alexander et al. 1983; Coombs, Fawzy, Gerber 1986). 

Indeed, both the rate of onset of smoking and the prevalence of regular smoking may level off during the high 

school years (Kandel and Logan 1984; McDermott et al. 

1992). The relationship between adolescence and smoking initiation that is seen in these studies may be related 

to the developmental challenges of adolescence and to 

the social meaning of smoking. 

Adolescence is characterized by three major types 

of developmental challenges (Hooker 1991). The first 

involves physical maturation, particularly sexual maturation, and the establishment of intimate relationships. 

A second group of challenges involves responses to cultural pressures to begin making the transition to adult 

roles and responsibilities and to emotional independence 

from parents. The third area, the personal, involves 

establishing a coherent sense of self and a set of values to 

guide future behavior. As adolescence begins, efforts to 

meet these various challenges are characterized by experimentation and risk-taking behaviors (Konopka 1991). 

Cigarette smoking is a risk behavior portrayed by 

Psychosocial Risk Factors 93 
Surgeon General’s Report 

advertising and role models as a way to be attractive to 

one’s peers (see “Contemporary Strategies of the Tobacco Industry” in Chapter 3, and smoking appears to 

contribute to a positive social image in some settings 

(Sussman et al. 1987). The functions of smoking established by advertising and adult role models coincide 

with the challenges of adolescence and thus make this 

age group the most vulnerable for experimentation and 

initiation. 

Gender 

Although current smoking prevalence is roughly 

equal among males and females in the United States, 

different historical trends for men and women are evident (Grunberg, Winders, Wewers 1991). Between 1974 

and 1985, smoking initiation declined from 45 to 33 percent among young men but remained constant at 34 

percent among young women (Fiore et al. 1989; see 

“Trends in Cigarette Smoking” in Chapter 3). Two studies have discussed the impact of changing gender roles 

(e.g., more women are in traditionally male positions of 

authority) on smoking behavior and the resulting difference in meaning that smoking has for males and females 

(Gritz 1984; Gilchrist, Schinke, Nurius 1989). Though 

some have suggested that generic factors that influence 

smoking initiation, such as appealing to the opposite 

gender, become more pronounced for one gender or the 

other at certain ages (Chassin et al. 1986), others have 

further concluded that the complex combinations of risk 

factors and processes leading to smoking are fundamentally different for females and males (Brunswick and 

Messeri 1984). In a review of research on gender differences, Clayton (1991) found both considerable similarities (for instance, the influence of peer and parent models) 

and a number of possible differences between adolescent females and males who smoke. For example, adolescent girls who smoke are more socially skilled (e.g., 

more at ease with their peers, with strangers, or with 

adults) than their nonsmoking peers, whereas adolescent boys who smoke tend to lack such skills. Concern 

about body weight and the belief that smoking might 

help control body weight may also lead adolescent females to begin smoking (Gritz and Crane 1991; Camp, 

Klesges, Relyea 1993). Further longitudinal research is 

needed to investigate gender differences in the determinants of tobacco use and thus to clarify the effect of 

gender on smoking initiation. 

from seventh to eighth grade, onset rates were higher for 

Hispanics and blacks than for whites and were lowest 

for Asians. Similarly, Maddahian, Newcomb, and Ben&r 

(1986) found that among California students followed 

from 7th through 12th grades, black youth maintained 

higher rates of smoking than youth of other ethnic groups. 

White and Hispanic students had intermediate rates of 

smoking, and Asian youth reported the lowest levels, 

although this difference decreased over time. Other 

national reports; however, indicate a higher percentage 

of smoking among white adolescents and young white 

adults than among their black or Hispanic counterparts 

(Remington et al. 198.5; Fiore et al. 1989; Bachman et at. 

1991; see ‘Trends in Cigarette Smoking” in Chapter 3). 

These findings suggest different onset and quitting patterns among ethnic groups, as welt as potential regional 

differences in these patterns. 

Maddahian, Newcomb, and Bentler (1986) have 

proposed antecedents that may help explain these ethnic 

differences in tobacco use, including income levels that 

preclude or enable the acquisition of cigarettes, different 

levels of tobacco availability, and psychosocial influences associated with belonging to a particular ethnic 

group. These investigators found that among California 

students, the level of income earned by youth had a 

significant impact on explaining ethnic differences in 

tobacco use. However, ethnic differences were virtually 

eliminated when availability and ease of cigarette acquisition from friends were considered. 

Sussman et al. (1987) found that unique combinations of psychosocial factors may be relevant to the ethnic differences in smoking initiation. Three 

variables-availability of cigarettes, difficulty in refusing offers of cigarettes, and intentions to smoke in the 

futurewere significant predictors among youth from 

all ethnic groups included in their study. However, only 

among select groups were certain other variables important predictors of smoking initiation. For instance, social 

environmental variables (including peer smoking and 

adult smoking) were important predictors for white 

youth, but direct personal and social reinforcement variables (including improved self-image and adult and peer 

approval of smoking) were more important variables for 

Hispanic youth. General risk-taking behavior was an 

important additional predictor for black youth only. The 

strongest additional predictors for Asian students included lack of general self-esteem and decreased schoolrelated self-esteem. 

Ethnicity 

Research also indicates that the rate of smoking 

initiation varies among ethnic groups. Sussman et al. 

(1987) found that among California youth progressing 

Environmental Factors in the Initiation of 

Smoking 

Environmental factors are those that are external (or perceived as external) to adolescents and yet 

94 Psychosocial Risk Factors 
Preuen ting Tobacco Use Among Young People 

may influence and affect their behavior. These factors include the availability of cigarettes in the community, the acceptability of smoking, peer and 

parental smoking, and adolescents’ perceptions of 

the environment. 

Factors That Influence Tobacco Acceptability and 

Availability 

for example, communities choose to restrict exposure 

to tobacco-promoting images or restrict access to tobacco 

products (see Chapter 6 for further discussion of such 

restrictions). Currently, as more commumties and states 

adopt a variety of restrictive policies and programs, 

evaluation research is needed to examine the effective 

ness of these strategies for reducing onset of tobacco use. 

Factors that increase the acceptability and availability of cigarette use at a societal or community level 

serve also to influence adolescent smoking behavior. 

Acceptability and availability are affected, in part, by the 

tobacco industry through advertising and other promotional activities; this topic is discussed thoroughly in 

Chapter 5. Acceptability of tobacco use may also be 

accomplished through persuasive, multiple, attractive 

role models who smoke on television programs or in 

movies (Bandura 1977). Acceptability is further reinforced by community norms and policies that make tobacco products relatively accessible for adolescents-for 

example, through sales to underage buyers and unrestricted access to cigarette vending machines (see “Restrictions on Minors’ Access to Tobacco” in Chapter 6). 

The National Adolescent Student Health Survey (American School Health Association et al. 1989) found that 79 

percent of 8th graders and 92 percent of 10th graders 

considered it to be “very easy” or “fairly easy” to get 

cigarettes. Likewise, in the 1991 Monitoring the Future 

Project study (Johnston, O’Malley, Bachman 1992) 73 

percent of 8th graders and 88 percent of 10th graders 

reported that it would be “fairly easyll or “very easy” to 

get cigarettes. In a study of adolescents in southern 

California, Sussman et al. (1987) found that both genders 

and all racial/ethnic groups except Asians tended to 

believe that they could obtain cigarettes with little difficulty. Findings from a national sample of teenaged (12- 

17 years old) smokers confirm these perceptions and 

suggest that 1.5 million of an estimated 2.6 million underage smokers buy their own cigarettes (Centers for 

Disease Control [CDC] 1992). Of those who buy their 

own cigarettes, 84 percent purchase them from a small 

store, 50 percent from a large store, and 14 percent from 

a vending machine, either often or sometimes (CDC 

1992). These reports have been substantiated by observational studies of cigarette buying by young teenagers 

(see “Studies of Young People’s Access to Tobacco” in 

Chapter 6). Several studies have found that the general 

availability of cigarettes predicts the onset of smoking 

(Bauman et al. 1984; Semmer, Cleary, et al. 1987). 

Factors that increase acceptability and availability 

support a social milieu in which cigarette smoking may 

appear socially functional. On the other hand, a social 

milieu can decrease the risk of adolescent smoking-if, 

Interpersonal Factors 

Interpersonal factors in the initiation of smoking 

involve opportunities for adolescents to perceive, through 

modeling by adults and peers who smoke, apparent 

advantages of smoking. These role models (particularly 

peers) also provide the situations (e.g., parties, staying 

overnight) in which cigarettes are first tried by adolescents (Lawrance and Rubinson 1986). Interpersonal factors have also been labeled “social learning variables” 

(Bandura 1977; Flay 1993) because the social functions or 

meanings of smoking are learned in the context of social 

interactions. The research on interpersonal factors has 

carefully explored the roles of parents, siblings, friends, 

and peers in the process of initiation. 

Parental Smoking 

The research on the influence of parents’ smoking 

behavior on their children’s cigarette use has included 

multiple studies of the relative risk of initiation if one or 

both parents smoke. Bauman et al. (1990) found a consistent relationship between parental and adolescent smoking in a cross-sectional study of 12- through 14year-olds 

in 10 urban areas in the southeastern United States. Compared with adolescents whose parents had never smoked, 

those whose parents currently smoked were almost twice 

as likely to smoke; those whose parents had once smoked 

were three times as likely to smoke. A similar influence 

of parental smoking was noted by Chassin et al. (1986) 

for females in a longitudinal study of 12- through 18 

year-olds from the midwestem United States. In Sussman 

et al. (1987), a longitudinal study of ll- through 14yearolds in southern California, parental smoking was predictive of a child’s smoking for whites but not for 

Hispanics, blacks, or Asians. This finding matches that 

of Hunter et al. (1987) in a longitudinal study of 8- through 

17-year-olds in the southern United States, in which parental behavior was predictive of children’s smoking 

initiation for whites but not for blacks. 

By contrast, parental smoking behavior was a poor 

predictor of smoking initiation in several other studies, 

including the longitudinal study McCaul et al. (1982) 

conducted among II- through 14year-old whites living 

in the north-central United States. No relationship was 

found in the Botvin et al. (1992) cross-sectional study of 

Psychosocial Risk Factors 95 

161-235 95-4 
Surgeon General’s Rf2port 

608 inner&-y blacks aged 11 through 13 or in the longitudinal study of 2,209 primarily white ll- through 17- 

year-olds in Minnesota Wittelmark et al. 1987). In Quine 

and Stephenson’s (1990) cross-sectional study of over 

2,000 Australians aged 10 through 12, parental smoking 

was not associated with children’s smoking but was 

related to children’s intentions to smoke when older. 

Conrad, Flay, and Hill (1992) summa rizai the findings of 27 prospective studies on the onset of 

smoking that have been publish4 since 1980 (see Table 

3). In 15 of the studies, parental smoking factors were 

investigated. The researchers concluded that parental 

smoking was predictive in seven studies, predictive only 

for females in two studies, and not predictive in six 

others. Chassin et al. (1984) suggested that parental 

smoking may influence the preparatory or initial trying 

stages, as well as the stability of smoking patterns from 

adolescence to adulthood (Chassin et al. 19911, but parental smoking appeared to be less influential during the 

transition to regular smoking. 

Sibling Smoking 

Over the past two decades, extensive reseamh on 

the influence of sibling smoking indicates a primarily 

positive relationship between an older sibling’s 

smoking and a younger (adolescent) sibling’s begin&g 

to smoke. In a IO-year longitudinal study of 6,311 adolescents Gnitially 11 through 13 years old), sibling smoking was found to be one of four factors that was 

predictive of increased risk of initiating regular 

smoking and predictive of smoking prevalence after 10 

years (Swan, Creeser, Murray 1990). In the McNeill et al. 

(19881 longitudinal research with 2,159 British 

1 l- through 13year-olds, having a sibling who smoked 

appeared to increase the odds of smoking initiation 

by a factor of 1.69. Botvin et al. 0992) reported that 

sibling smoking was one of five variables that accounted 

for 29 percent of the variance in smoking in their crosssectional study of 522 inner-city blacks aged 11 through 

13. O’Connell et al. (1981) found sibling smoking to be 

among the first three factors associated with weekly 

Table 3. Predictors of smoking onset in 27 prospective studies 

Prediction of 

smoking onset 

Number of 

supportive 

findings 

Number of 

unsupportive 

findings 

Percent 

support 

Socioeconomic status 

Environmental factors 

Family smoking 

Family approval 

Other adult influences 

Peer use and approval 

Normative estimates 

Offers/availability 

Family bonding 

Peer bonding 

School influences 

Religious influences 

Behavioral factors 

skills 

Other behaviors 

Personal factors 

Knowledge/beliefs 

Attitudes 

Personality factors 

Intentions to smoke 

16 5 76 

18 8 69 

6 8 43 

5 3 63 

27 5 84 

4 1 80 

7 1 88 

9 6 60 

11 4 73 

20 5 80 

0 1 0 

3 

12 

16 

8 

23 

8 

100 

86 

64 

73 

77 

89 

Source: Adapted from Conrad, Flay, and Hill (1992). 

96 Psychosocial Risk Factors 
prezvnting Tobacco Use Among Young People 

smoking among 6,224 students aged 10 through 12 in 

New South Wales, Australia. Mittelmark et al. (1987) 

found that experimenting with cigarettes was associated 

rvith sibling smoking only for females and ll- through 

13-year-old students. This finding was similar to the 

Chassin et al. (1984) research that found sibling smoking 

more influential in the early stages of cigarette use than 

in the later stages. 

Gender and race differences in the effect of sibling 

smoking have also beeri noted. Hunter et al. (1987) 

found sibling smoking predictive for white males, a 

sister’s smoking predictive for white females, and a 

brothex’s smoking predictive for black males and females. Brunswick and Messeri (1983) found sibling smoking influential only for males. In the Muscatine Study 

(Krohn, Naughton, Lauer 1983, the maintenance (not 

initiation) of smoking was associated with a brother’s 

smoking. Finally, in Conrad, Flay, and Hill’s (1992) review of 27 prospective studies, four of the five studies 

that examined this factor indicated that sibling smoking 

was associated with onset. 

Peer Smoking and Peer Behaviors 

One of the areas of widest investigation in the 

antecedents of cigarette smoking concerns peer smoking 

and related peer behaviors. Peers may be defined as 

persons of about the same age who feel a social identification with one another. The influence of peers has 

been posited as the single most important factor in determining when and how cigarettes are first tried. Flay et 

al. (1983) suggest that smoking may primarily represent 

an effort to achieve social acceptance from peeis and that 

it may particularly be an experimental “adult” activity 

that is shared with the peer group. Leventhal and 

Keeshan (1993) suggest that adolescents are not only 

influenced by, but also influence and construct, their 

peer groups. These researchers propose that small groups 

of adolescents “construct shared so&l environments in 

which they perceive themselves and other(s) as having 

mutual cognitive, emotional, and valuative reactions.. . , 

the intersubjectivity created by sharing generates a sense 

of wellness. This se- of mutuality enhances the attractiveness of the group and may lead to incorporation of 

the self-image of the others into the image of one’s own 

self” (p. 269). 

Multiple cross-sectional and longitudinal studies 

worldwide substantiate the relationship between 

smoking onset and pee=’ (or friends’) smoking (Shean 

1991; DConneIl et al. 1981; Ogawa et al. 1988). In their 

research, Bauman et al. (1990) found that smoking most 

often occurred in the presence of best friends. Sixty 

percent of 1 l- through 17-year-olds reported that they 

had first smoked, and 72 percent reported that they had 

most recently smoked, with close friends (Hahn et al. 

1990). Among 12- through 14-year-olds, those whose 

best friend smoked were four times more likely to be 

smokers than those whose best friend did not smoke. 

Best friend’s smoking predicted both smoking experimentation and prevalence among urban San Diego adolescents from a variety of ethnic groups (Elder, Molgaard, 

Gresham 1988) and among white and black 8- through 

17-year-olds in Louisiana (Hunter, Vizelberg, Berenson 

1991). Best friend’s cigarette use was predictive of the 

first try at smoking, whereas having a majority of friends 

who smoke was predictive of the second cigarette 

(Leventhal, Fleming, Glynn 1988). 

In the Conrad, Flay, and H+ (1992) review of the 

recent prospective research, friends’ smoking was predictive of some phase of smoking in all but one 

(Newcomb, McCarthy, Bentler 1989) of 16 studies. A 

positive association of peer smoking with onset of smoking in 88 percent of these more rigorous, longitudinal 

studies suggests a clear link between peers’ smoking and 

cigarette use. This link may be mediated by personal 

factors, such as self-efficacy (or self-confidence), and ap 

pears to be most potent in the earlier stages of smoking 

(Pomerleau 1979; Pederson and Lefcoe 1986; Chassin, 

Presson, Sherman 1990). 

Social Bonding 

The interpersonal environment has also been characterized by the degree of, social bonding, or attachment, between the adolescent and important others or 

illStitUtiOIlS. 

The findings on family bonding variables in smoking onset, particularly attachment to mothers or fathers, 

have been inconsistent; those related to peer bonding, 

including the number of friends, level of social life, 

participation in antisocial activities, and having a boyfriend or girlfriend, were all found to be predictive of 

onset (Conrad, Flay, HiU 1992). Bonding with peers who 

smoke appears to increase the risk of smoking, perhaps 

because such bonding takes precedence over attachments 

to the family. 

Perceived Environmental Factors 

The perceived environment includes the smokingrelated norms, social support, expectations, reactions, 

and barriers that adolescents sense in their environment. 

The perceived environment may be a more proximal 

influence on smoking initiation than the actual environment (Lessor and Jessor 1977). For example, 12-year-olds 

who believe that ‘lots of people” their age smoke may 

Psychosocial Risk Factors 97 
Surgeon General ‘S Report 

be more inclined to begin smoking to fit in than if they 

were aware that only 5 to 7 percent of their peers actually smoke. 

Norms 

Norms may be defined as what an individual in a 

particular group perceives she or he ought to do and 

what is perceived as acceptable behavior for a given age 

group, gender, or other subgroup. Gerber and Newman’s 

(1989) research on smoking-related norms details adolescents’ perceptions of the percentage of all adults, peers, 

and classmates they think are smokers. These investigators found that experimental adolescent smokers who 

increased their smoking levels over the course of the 

one-year study period perceived more smoking among 

their classmates than did those who had decreased their 

smoking in the same time period. Similarly, Leventhal, 

Fleming, and Glynn (1988) report that youth who par&ipated in their studies greatly overestimated the proportion of peers and adults who smoke. The adolescents 

believed that 66 percent of their peers and 90 percent of 

adults were smokers, thus overestimating smoking prevalence by at least a factor of three. 

Collins et al. (1987) examined the predictive influence of norms in a longitudinal study of 3,295 students 

aged 11 and 12 in 56 junior high schools in Los Angeles. 

Like Chassin et al. (Chassin et al. 1984; Chassin, Presson., 

Sherman 1990), they found that adolescents who made 

relatively high estimates of regular smoking prevalence 

were more likely to try smoking, to become smokers, or 

to increase the amount they smoked over 1 and 1.5 years 

of the study. Sussman et al. (1993) discussed further 

aspects of normative influence and implications for the 

content of prevention programs. Previous smoking and 

peer smoking were the main predictors of overestimates 

in the Collins et al. (1987) study. In Shean’s (1991) re 

search in Australia, beliefs about the number of adolescents and adults who smoke predicted smoking in young 

adulthood eight years later. In part, these normative 

expectations may be a function of these beginning smokers’ actual exposure to a disproportionate number of 

smokers, including adults and peers. 

Social Support for Smoking 

Social support includes perceived approval or disapproval of adolescent cigarette smoking by parents, 

siblings, peers, and important others, such as teachers or 

employers. One way that social support is manifested is 

through peer-group pressure, either through support or 

discouragement of smoking. 

Peer pressure is not always negative; it has been 

used successfully in many prevention programs (Klepp, 

Halper, Perry 1986). Still, in the study by Hahn et al. 

(19901, the urging of one or more acquaintances--most 

likely peers or close friends-prompted over half the 

instances of adolescents’ trying a cigarette for the first 

time. In the Chassin et al. (1986) study, females who saw 

their friends as more supportive than critical about their 

smoking were more likely than those who saw their 

friends as less supportive to become regular smokers 

one year later. Similarly, many adolescent smokers in 

another study reported, ‘My friends like me because I 

smoke” (Hunter et al. 1987). In the same study, smokers 

were less likely than nonsmokers to report, “My parents 

don’t want me to smoke.” Peer approval of smoking 

was an important predictor for smoking onset among 

whites and Hispanics, whereas adult approval was an 

important predictor for Hispanics and Asians among 

874 southern California ll- through 13-year-olds 

(Sussman et al. 1987). 

Social support also includes the general support or 

approval the adolescent receives from others. This kind 

of support appears to play a role in predicting onset (see 

‘Trends in Knowledge and Attitudes About Smoking’ 

in Chapter 3). Chassin et al. (1986) found that those 

adolescents who reported that their parents were generally supportive of them were less likely to begin smoking 

or to become regular smokers than were those who 

perceived that their parents were not generally supportive of them. However, those who reported that their 

friends were supportive of them were more likely to 

become smokers than were those who did not report 

such support. Similarly, males who reported that they 

lived in families in which they had limited involvement 

in family decisions were more likely to become smokers 

than males from families where high involvement in 

family decisions was reported (Mittelmark et al. 1987). 

Adolescents who reported regularly caring for themselves after school were at increased risk of smoking 

(Richardson et al. 1989). Finally, adolescents who believed that parents, siblings, friends, and teachers would 

not care if they smoked were at higher risk of initiating 

smoking after 2.5 years than were those who believed 

that others would care if they smoked (McNeill et al. 

1988). Lack of concern by parents appears to increase 

risk, particularly for males (Swan, Creeser, Murray 1990). 

General parental support of the adolescent and concern 

about the adolescent’s smoking appears to decrease risk. 

Parental Reaction to Smoking 

Parental reaction to use and perceived 

parental strictness have also been associated with 

onset. Hansen et al. (1987) examined the influence of 

perceived parental reactions to cigarette smoking (as 

well as alcohol and marijuana use) among 293 Los Ange 

les lO- through 12-year-olds. Parental anger toward the 

98 Psychosocial Risk Factors 
pmwrzting Tobacco Use Among Young People 

adolescent’s smoking or approval of the adolescent’s 

&using to smoke, together with two other drug-related 

Variables, indirectly predicted low levels of use. Chassin 

rt al. (1986) evaluated perceptions of parental strictness; 

their findings support the need for interventions tailored 

to different age groups of adolescents. Among the younget subjects (10 through 12 years old), those who perceived that their parents were more strict than other 

parents were actually more likely to begin smoking over 

a one-year interval. Among the oldest subjects (14 

through 16 years old), however, those who perceived 

that they had stricter parents were less likely to begin to 

smoke. Those aged 12 through 14 years were not affected by parental strictness. Other researchers have 

further noted that extremes of parental strictness, from 

inadequate restraint to overcontrol, are associated with 

problem behaviors (Pandina and Schuele 1983). 

Adult Discrepancy 

Shean (1991) developed the concept of adult discrepancy-the discrepancy between the “adult” behaviors in which an adolescent wants to participate at age 14 

(such as going to a nightclub) and what was actually 

done by his or her parents when they were age 14. Those 

adolescents with high discrepancy were more likely to 

be smokers as young adults than those with low discrepancy, which may suggest that adolescents with high 

discrepancy tend to make the transition to an adulthood 

not modeled by parents. The adult discrepancy factor, in 

addition to peer, sibling, and parental smoking, intentions to smoke, and effects of cigarette advertisements, 

predicted young adult smoking over an eight-year 

interval. This study points to the strong effect of the 

social environment on the onset and maintenance of 

adolescent smoking. 

Behavioral Factors in the Initiation 

of Smoking 

Behavioral factors involve patterns of behaviors 

that are directly related to cigarette use, such as academic achievement, health-compromising and healthenhancing behaviors, and smoking-related skills. These 

associated behavior patterns may increase the risk of 

smoking by providing opportunities to view smoking 

as functional or appropriate. 

Academic Achievement 

The onset of smoking has been shown repeatedly 

to be related to poor academic achievement (see Table 6 

in Chapter 3). Relevant indicators of students’ achievement include scholastic performance (grades), high school 

graduation, truancy rates, and future professional or 

educational aspirations. Borland and Rudolph (1975) 

examined the relative predictability of scholastic performance, parental smoking, and socioeconomic status 

among 1,814 high school students in Pennsylvania. 

The strongest correlate to smoking was scholastic 

performance; those with the highest grades were found 

to smoke less than those with the lowest grades. This 

finding is consistent with Brunswickand Messeri’s (1984) 

research among young, urban black adolescents in 

Harlem, New York, as well as the Sussman et al. (1987) 

research with Hispanic and Asian adolescents in southem California. Students who disliked school and feared 

school failure were more likely to begin smoking in early 

adolescence than those who liked school and had expectations of school success (Ahlgren et al. 1982). In two 

well-designed studies, adolescents who had limited expectations of academic achievement increased their smoking levels over time (Gerber and Newman 1989; Chassin, 

Presson, Sherman 1990). Still, among inner-city black 

seventh-grade students, Botvin et al. (1992) found that 

academic achievement was not a significant predictor of 

current smoking or intentions to smoke. 

Conrad, Flay, and Hill (1992) found that 80 percent 

of the prospective studies on the onset of smoking indicated a positive relationship between low academic 

achievement (and other school-related factors) and smoking onset. In a longitudinal study of 739 junior high 

students (66 percent white, 15 percent black, 10 percent 

Hispanic) in Los Angeles, the research team of Newcomb, 

McCarthy, and Bentler (1989) concluded that an 

adolescent’s “academic lifestyle orientation” (measured 

by grades, educational aspirations, personal and profession plans, and expectations) was the central organizing 

influence on teenage smoking behavior, teenage emotional well-being, social relationships with smokers, and 

adult smoking behavior. This centrality emerged even 

when emotional well-being, self-efficacy, personal ambition, and friends’ smoking behavior were considered. 

Other Adolescent Behaviors 

The association between smoking and other adolescent behaviors has been examined as an extension of 

Jessor and Jessox’s (1977) concept of the covariation of 

problem behaviors, including both unconventional behaviors (such as alcohol and drug use) and conventional 

behaviors (such as academic achievement and church 

attendance). Cigarette use among adolescents has been 

studied as “problem” behavior; that is, studies have examined its association with alcohol and drug use, risktaking behaviors, proneness to deviance, early antisocial 

behavior, and group membership, as well as its association with constructive or health-enhancing behaviors. 

Some adolescents see problem behaviors as a way to 

PsychosociaI Risk Factors 99 
Surgeon General’s Report 

achieve--and signal to others-the precocious transition 

to independence and autonomy. 

The association .of cigarette smoking and illegal 

drug use suggests that cigarettes may be an entry-level 

or gateway drug in a sequence of progressive drug use 

(see “Smoking as a Risk Factor for Other Drug Use” in 

Chapter 2 and “Smoking and Other Drug Use” in Chap 

ter 3). The suggestion here is not that smoking causes 

illegal drug use, but that those who use illegal drugs 

have most likely smoked cigarettes previously. In the 

following studies, smoking is considered a gateway drug, 

since the decision to smoke appears to facilitate the decision to use other drugs. 

Scheier and Newcomb (1991) studied 717 junior 

high school students in northern California. They concluded that early cigarette use predicted illegal drug use 

during the two-year study period. This finding complements the work of Fleming et al. (1989) and Newcomb 

and Bentler (19861, who emphasized the crucial role of 

cigarette smoking in the progression to marijuana and 

hard drug use, even without the mediating impact of 

alcohol use. Those authors concluded that these substances are reciprocally influential over time, with increased use of cigarettes associated with increased use of 

illegal drugs. By young adulthood, a clear correlation 

seems to exist between cigarette smoking and illegal 

drug use. For example, in Brunswick and Messeri’s 

(1983) 6- to &year prospective study of 536 blacks aged 

11 through 13 in Harlem, New York, at followup (aged 18 through 23), 56 percent of males and 59 

percent of females who had used illegal drugs smoked 

cigarettes, whereas 24 percent of males and .35 percent 

of females who had not used illegal drugs smoked 

cigarettes. 

Risk Taking, Rebelliousness, and Deviant Behaviors 

Risk taking, rebelliousness, and deviant behaviors 

are generally those behaviors that are considered unconventional, antisocial, or alienated from traditional institutions. The research literature has repeatedly 

characterized adolescent drug use as one manifestation 

of rebelliousness and deviance fJessor and Jessor 1977; 

Chassin, Presson, Sherman 1989). By testing Jessor and 

lessor’s (1977) model, Chassin et al. (1984) found that 

proneness to deviance significantly predicted smoking 

onset in a longitudinal study of secondary students, although not for. those who had already experimented 

with cigarettes. In a subsequent study of high school 

students, Chassin, Presson, and Sherman (1989) found 

that in some instances, deviance was associated with 

independence and personal control; whether psychologically constructive or not, however, deviance was a 

significant predictor of cigarette smoking. A risk-taking 

orientation (that is, an inclination toward excitement and 

chance taking) was similarly associated with trying a 

cigarette for the first or second time (Leventhal, Fleming 

Glynn 1988). Risk taking was also a significant predictor 

of smoking initiation in the Colhns et al. (1987) study of 

1 l- and 1Zyearolds in Los Angeles. In the Sussman et 

al. (1987) study of southern California adolescents, risk 

taking predicted smoking among blacks, but the association was not significant for whites, Hispanics, or Asians. 

Conrad, Flay, and Hill’s (1992) review of prospective 

research on smoking initiation cited five studies that 

associated rebelliousness, risk taking and proneness to 

deviance with smoking onset (see “Cigarette Smoking 

and Other Health-Related behaviors” in Chapter 3). 

Peer Groups 

During the past two decades, the relative irnportance of adolescent bonding with peers has increased, 

while the importance of bonding with parents has declined (Perry, Kelder, Komro 1993). This shift has allowed more time, opportunity, and social support for 

dysfunctional behaviors, such as cigarette use. Adolescent females who spent most of their free time with their 

families, for example, were less likely to begin smoking 

than those who spent little free time with their families 

(Brunswick and Messeri 1984). As Flay (19931 notes, 

“youth alienated from conventional culture have more 

opportunities than others to observe substance use and 

its positive functions. . . . They are also more likely to 

overestimate the proportion of their peers who use these 

substances--because they are likely to be associating 

with groups who actually do use . . . . [and] deviant cultures reinforce these youth when they do use, for example, by acceptance into groups” (p. 369). 

Leventhal et al. (1991) observe that parents, teachers, and other adults seldom discuss with youth the 

intense biological and social changes that occur in adolescence: ‘When such a dialogue is absent. . . the peer 

group becomes the predominant influence integrating 

and shaping the adolescents’ vague yet pressing internal 

states” (p. 586). 

Participation in Athletics and Other Health-Enhancing 

Behaviors 

Health-enhancing behaviors, such as sports involvement, might moderate a high-risk environment 

(Rantakallio 1983). Swan, Creeser, and Murray (19901 

found that girls were significantly less likely to begin 

smoking if they were involved in an organized sport, but 

were significantly more likely to begin smoking if they 

participated in organized social activities. Involvement 

in sports did not appear to affect boys’ rate of smoking 

100 Psychosocial Risk Factors 
p,n,&kg Tobacco Use Among Young People 

onset in this study. McCaul et al. (1982) found no association between boys’ smoking and participation in extracurricular activities. Among urban black femrales in 

~~wic?k and Messeri’s (1984) study, those who re 

p~ecl minimal concern about their health & those 

who reported a larger appetite were more likely ho begin 

sm&j.ng; in contrast, black males who had the greatest 

number of health-related activities and were of normal 

body weight were more likely to begin smoking than 

other black males (Brunswick and Messerr 1983). 

Sussman et al. (1993) found that among you& at the 

h$vst risk of smoking, those who did not smoke rep&d that they valued their health. Finally, in Kelder’s 

(19%) longitudmal study of secondary school ,-dents 

~JI the north-centi United States, cigarette smoking was 

found to be related to poor food choices and less exercise 

after the eighth grade; the correlation betwm these 

behaviors was stronger with increasing age. 

Behaviord Skih 

The final set of behavioral factors comprises the 

tj&avion3l skills that are necessary to begin smoking 

tfme that are necessary to resist influences to smoke, 

and those that are necessary to cope with other social 

situations that might indirectly encourage cigarette use. 

Hahn et al. (1990) found that 42 percent of smoking 

expairnent~ had asked for their first cigarette- In the 

Sussman et al. (1987) study in southern California, difficulty in refusing offers to smoke predicted onset for all 

four ethnic groups, particularly for whites and blacks, 

for whom it was the strongest predictive factor found in 

the study. This difficulty in refusing an offered cigarette 

appears to be strongly influenced by the offering friend’s 

attitudes and behaviors (e.g., being persistent or critical if 

refused), particularly for high-risk adolescents (Saiomon 

et al. 1984; Lawrance and Rubinson 1986; Reardon, 

Sussrnan, Flay 1989). Conrad, Flay, and Hill (1992) reviewed three prospective studies and found that 

refusal or resistance skills against smoking were 

associated with lower rates of onset. 

Generally, cigarette use can be viewed as a coping 

mechanism-a skilled response designed to close the 

gap between an adolescent’s current position and goals 

(Leventhal et al. 1991). Smoking serves as a coping 

response if it brings the adolescent closer to a valued 

goal, such as acceptance in a peer group. Smoking may 

also serve as a coping response to stress or &tress Wrlls 

and Shiffman 1985; Castro et al. 1987). These studies 

suggest that youth need more general social skills, such 

as being able to cope with various kinds of stress or 

social pmssures, to help them manage the many developmental demands of adolescence (Franzkowiak 1987). 

A more comprehensive concept of skills that has been 

used in prevention efforts is discussed in Chapter 6 (see 

“lnstiUing Skills for Resisting Social Influences to Smoke” 

and “ExemplaryPmgrams for ResistingSocialInfluences”). 

Personal Factors in the Initiation 

of Smoking 

Personal factors are those that are inherent in the 

individual, they include cognitive processes, values, personality constructs, and psychological well-being. These 

factors can be considered the personal filters through 

which so&demographic and environmental factors pass 

as they influence behavior. Personal risk factors also 

explain differences in behavior among individuals exposed to the same or simiIar environments. The personal factors that have been examined in the research 

literature include levels of knowledge about the health 

consequences of smoking, the functions or meanings of 

cigarette use among adolescents, the subjective expected 

utility C3ELJl of smoking self-esteem, self-image, selfefficacy in refusing offers of cigarettes, personality variables, and emotional well-being. 

Knowledge of Long-Term Health Consequences 

Knowledge of the long-term health consequences 

of smoking has not been a strong predictor of adolescent 

onset (Collins et al. 1987; Krohn, Naughton, tiuer 1987; 

Sussman et al. 1987; Conrad, Play, Hill 1992; Royal College of Physicians of London 1992), perhaps because 

virtually all U.S. adolescents--smokers and nonsmokers 

alike-are aware of the long-term health effects of smoking and because many adolescents feel inherently invulnerable in their characteristically short-term view (Gerber 

and Newman 1989). Belief that smoking has short-term 

effects on health appears to be a more powerful influence 

than knowledge of long-term health effects (Krohn, 

Naughton, Lauer 1987; McNeill et al. 1988). Similarly, 

belief in personally relevant nega live social consequences 

of smoking has been associated with a dechne in smoking prevalence among secondary school students 

(Chassin et al. 1987). Botvin et al. (1992) found that lack 

of concern about the harmful effeds of smoking was 

associated with intentions to smoke among young, 

inner-city black adolescents. Similarly, dismissing or 

rnhimizing the health consequences of smoking has been 

associated with both initiation of cigarette use and adult 

smoking levels Wittelmark et al. 1987; Swan, Creeser, 

Murray 1990). Krohn, Naughton, and Lauer (1987) found 

that smoking behavior predict& beliefs about the health 

effects of smoking more than beliefs predicted future 

cigarette use. Knowledge of the health consequences of 

smoking may or may not deter some adolescents from 

begiming to smoke; beginning to smoke appears to accentuate adolescents’ denial of the health consequences. 

Psychosocial Risk Factors 101 
Surgeon General’s Report 

Functional Meanings of Adolescent Smoking 

The question of why adolescents begin to smoke 

has led to multiple examinations of the meanings of 

cigarette use, the utility of smoking, and the functions 

that smoking serves in an adolescent’s life (Leventhal 

and Clear-y 1980; Perry, Murray, Klepp 1987). Examining smoking from the perspective of the adolescent is a 

departure from viewing the onset of smoking exclusively as a response to the social environment or as 

capricious, arbitrary behavior. Since knowledge of the 

harmful consequences of cigarettes does not appear to 

deter onset, researchers are examining the social reasons 

and purposes of smoking. 

Adolescents who begin to smoke perceive a more 

functional purpose of smoking than those who are 

nonsmokers (Gerber and Newman 1989). Adolescent 

smokers are more likely to view smoking as a way to act 

mature, be accepted by a peer group, have fun, cope with 

personal problems and boredom, or be rebellious (Perry, 

Murray, Klepp 1987). Cigarette smoking has also been 

shown to be a coping behavior for adolescents who are 

dealing with disruptive and stressful family events 

(Castro et al. 1987). Hunter et al. (1987) found that 

adolescent smokers were significantly more likely than 

nonsmokers to believe that smoking has psychological 

and physiological benefits. They were also less likely to 

believe that others smoked for negative reasons, such as 

to “show off.” 

In the research of Hahn et al. (1990), regular smokers were asked why they first had tried cigarettes arrd 

why they had most recently smoked. Sixty percent re 

ported that curiosity was the reason for their first try, 13 

percent said that they wanted to fit in with a group, and 

10 percent reported that they were pressured into it. For 

most recent use, 27 percent reported that they smoked 

for pleasure, 20 percent out of dependence, 17 percent 

because they were curious, and 10 percent to fit in with 

the group. These findings are consistent with Chassin et 

al. (19841, who suggest that positive attitudes toward 

smoking, such as the idea that smoking is fun or pleasurabIe, are a better predictor of the transition to regular 

smoking than they are for first experimentation. In general, these investigators found that positive attitudes toward smoking may increase as a function of age. Botvin, 

Botvin, and Baker (1983) found that independent of the 

smoking status of friends, students in the eighth grade 

(13- and 14-year-olds) were more likely to have a positive social image of smoking than students in the seventh 

grade (ll- and 12-year-olds). 

Subjective Expected Utility 

Carolina. SEU is defined as the extent to which an 

individual expects the overall consequences of a behavior, such as smoking, to be positive or negative. Fishbein 

(1980) found that behavioral intentions to smoke were 

related to whether more positive or negative conse 

quences were expected from smoking. SEU was found 

to be predictive of the onset of smoking over a one-year 

interval and of increased smoking levels among baseline 

smokers (Bauman et al. 1984). In a second study, SEU 

was found to be mediated by the adolescent’s perception 

of personal control; current smokers with the highest 

scores for internal locus of control (that is, the belief that 

they have control over what occurs to them) were more 

likely to have been influenced by SEU Wunan and 

Fisher 1985). Therefore, regular smoking appears more 

likely to be motivated by internal processes than are 

initiation and trying, which may primarily be products 

of exposure to a high-risk social environment. 

Self-Esteem 

The process of individuation and identity formation is inherent to adolescence. The adolescent’s sense of 

self evolves as she or he interacts with parents, school, 

and peers and considers options for the future. Selfesteem, or an individual’s qualitative self-evaluation, 

emerges from these contexts (Young and Werch 1990). 

In several studies, the onset of smoking has been associated with lower self-esteem. Young and Wench (1990) 

found that young nonsmokers and those with no intention of smoking in the future had higher self-esteem 

relative to family, school, and peers than frequent users 

or those who intended to use in the future. Ahlgren et al. 

(1982) found that low self-esteem within family or school 

contexts was associated with initiation and continuance 

of smoking. Self-esteem concerning school predicted 

intentions to smoke among young, inner-city black adolescents (Botvin et al. 1992) but did not predict actual 

smoking. Stacy et al. (1992) found that general low selfesteem directly predicted smoking onset in a multiracial, 

southern California sample yet did not significantly 

mediate friends’ social influences. In their review of 

prospective research, Conrad, Flay, and Hill (1992) 

conclude, “Self-esteem received fairly consistent support 

[as a predictor of initiation] from the reviewed longitudinal studies. This is better than we would have expected from our reading of previous cross-sectional 

studies” (p. 20). 

Self-Image 

Some adolescents may smoke cigarettes to enhance 

their low self-esteem by improving their external imBauman et al. (1984) have examined the SEU of 

smoking for adolescents in a longitudinal study in North 

d I 

age-that is, by appearing mature & “cool.” Smoking 

onset was seen as a way to improve self-image among 

102 Psychosocial Risk Factors 
preventing Tobacco Use Among Young People 

whites, blacks, and Hispanics in southern California 

(Sussman et al. 1987). Role models who smoke am 

frequently seen to have socially desirable attributesthey seem tough, sociable, and sexually attractive 

(Chassin, Presson, Sherman 1990). Adolescents who 

believe that smoking bestows these attributes may see 

smoking as a powerful mechanism for self-enhancement. 

These young people may experiment with smoking to 

try to adopt a perceived positive social image and thereby 

improve the way others, particularly peers, view them 

(Chassin, Presson, Sherman 1990; Leventhal et al. 1991). 

If peers respond favorably to this strategy, these new 

young smokers may continue to smoke, since the behavior has proved functional for them in creating an acceptable self-image. 

Self-Efficacy 

An individual’s efficacy (or confidence) in performing specified skills and behaviors is a significant mediator of peer influences to smoke (Bandura 1986). Ellickson 

and Hays (1990-91) found that low self-efficacy, as measured on a scale of having little or much confidence in 

resisting offers of drugs, was associated with drug use, 

including smoking. DeVries, Kok, and Dijkstra (1990) 

found that self-efficacy in resisting offers to smoke was 

the best predictor of smoking among adolescents in the 

Netherlands over a oneyear interval. Similarly, Lawrance 

and Rubinson (1986) found that young adolescents’ perceptions of their ability to resist cigarette smoking corresponded to their self-reported smoking. Finally, Stacy et 

al. (1992) found in their cross-sectional study of high 

school students not only that low self-efficacy in resisting 

social influence was a significant predictor of smoking 

but also that high self-efficacy was the only significant 

mediator of friends’ social influences on smoking. There 

fore, self-efficacy, a personal factor, appears to act as a 

buffer that protects adolescents from potent peer influences to smoke (Conrad, Flay, Hill 1992). 

Personality Factors 

The research on personal factors has also examined 

many personality factors for their association with onset, 

in part to assess whether underlying emotional or psychological problems predict adolescent smoking. Personality 

characteristics that are related to deficiencies in selfcontrol, such as impulsiveness and sensation-seeking 

tendencies, are important and were discussed earlier in 

this chapter in connection with behavioral factors. 

Psychological Well-Being 

Several studies have associated cigarette smoking 

and symptoms of depression among adolescents. Covey 

and Tam (1990) showed an independent relation of 

depressive mood, friends’ smoking behavior, and living 

in a single-parent home with cigarette smoking among 

205 urban 11th~grade males and females. Depression 

scores correlated with the number of cigarettes smoked. 

Malkin and Allen (1980) found a significant association 

between smoking and depression among males in a 

study of 229 rural Bth- and 11 th-grade students, a 

fmding that was replicated for both genders by Kaplan 

et al. (1984). 

Stein, Newcomb, and Bentler (unpublished data) 

found that cigarette use was positively associated with 

being extroverted and negatively associated with having 

symptoms of depression among junior high school students in Los Angeles. Cigarette use, however, significantly predicted symptoms of depression in these young 

people four and eight years later (Newcomb, McCarthy, 

Bentler 1989). These findings may reflect the addictive 

quality of tobacco use beyond the earliest experimental 

states and the relationship between smoking and depression, since depression is a personality factor that 

usually persists over time. Smoking might be a shortterm, self-medicating response to symptoms associated 

with depression. In the long-term, however, this effect 

would diminis h; as tolerance to nicotine increases, the 

possible antidepressant effects of smoking (such as alertness, euphoria, and calm) dissipate (Newcomb, 

M&Whey, Bentler 1989). Similarly, Leventhal, Fleming, 

and Glynn (1988) found that reported feelings of help 

lessness were associated with more rapid movement to a 

second and third experiment with smoking; however, 

these feelings were not related to the initial experimentation. The association of smoking and suicide attempts, 

another clearly serious symptom of depression, is presented in Chapter 3 (see “Cigarette Smoking and Other 

Health-Related Behaviors”). 

Flay (1993) suggests that symptoms of depression 

may be a response to distress associated with stress and 

poor family bonding. He points out that stress and 

distress have been associated with drug use, including 

tobacco use (Wills and Shiffman 1985). The research of 

Kellam, Ensminger, and Simon (1980) suggests that this 

cycle may begin early in life. In their study of first-graders 

(aged five through seven) in Chicago, they found that 

males rated by observers as aggressive or as alternately 

shy and aggressive had the highest rate of drug use, 

including cigarette use, 10 years later; no long-term psychological predictors were found for females. In another 

study (Brunswick and Messeri 19841, adolescent males 

were more likely to begin smoking if they were peSSMSbc about the likelihood of the world becoming any better 

or if they held low expectations for their own future; for 

adolescent females, a shortened time perspective (i.e., a 

Psychosocial Risk Factors 103 
Surgeon General’s Rep-t 

limited ability to conceptualize their future) was the most 

important psychogenic predictor of initiation. 

Adolescent Smoking Behavior as a Risk 

Factor for Subsequent Smoking 

Intentions to Smoke 

Since intentions are viewed as proximal to performance, the research on smoking behavior as a predictive 

factor of smoking includes behavioral intentions to smoke. 

In several studies, intentions to smoke have been associated with both the onset and continuation of smoking. 

Sussman et al. (1987) found in their longitudinal study in 

southern California that the intention to start smoking 

was one of 0nIy three factors that predicted onset among 

all ethnic groups. McNeill et al. (3988) found that future 

intentions to smoke increased the odds of starting to 

smoke by a factor of 244 and was the strongest predictor. 

of change in smoking status after current behavior (having tried smoking) and gender were entered into the 

analysis. In the Chassin et al. (1984) longitudinal study, 

behavioral intentions were “significant predictors of future smoking transition in all subgroups, accounting for 

between 1.9 percent and 10.2 percent of the variance in 

transition. . . . In fact, behavioral intentions were typically the most important single predictor of future transition” (p. 237). 

Intentions to smoke appear to be a particularly 

strong predictor of future smoking for those who have 

already tried smoking. Shean (1991) found that inten-’ 

tions to smoke a “next cigarette” among 14-year-old 

Western Australians predicted smoking eight years later. 

Conrad, Flay, and Hill (1992) found that in eight of nine 

prospective studies of young adolescents, the intention 

to smoke was significantly associated with onset. Be 

cause of the strength of this association, severat reseamhers have used intentions to smoke as an outcome measure 

in their studies, especially in populations (such as p* 

adolescents) where smoking prevalence is low relative 

to adolescents’ intentions to smoke. Intentions to begin 

smoking seem a much more reliable predictor of future 

behavior than do intentions to quit smoking 

(see “Adult Implications of Adolescent Smoking” in 

Chapter 3). 

Present Smoking Status 

Any cigarette use places an adolescent at higher 

risk for subsequent use and for further progression 

through the stages of smoking behavior. Conrad, Flay, 

and Hill (1992) document seven prospective studies in 

which prior experience with, or exposure to, smoking 

predicted tobacco use. McNeill et al. (1988) found that 

the act of having tried smoking was the most predictive 

factor in initiation and that it more than quadrupled their 

study participants’ odds of taking up smoking. Collins 

et al. (1987) found that prior smoking behavior was the 

most important predictor of future smoking over a 2.5- 

year interval. Even though the physiological effects of 

the fust tries are mostly adverse (unpleasant taste, coughing headache, nausea, dizziness) (Hahn et al. 19901, those 

who persist report incmasingiy positive reactions (pleasant taste, euphoria, alertness, relaxation, curbing of ap 

petite) and develop tolerance (experience fewer 

unpleasant sensations) (Flay 1993). Stein, Newcomb, 

and Bentler (unpublished data) reported a more established pattern of cigarette use among young adults than 

among adolescents. In their study, the standardized 

regression coefficient of prior smoking for smoking behavior between Year 1 and Year 5 (youth in junior high 

and high school age groups) was 0.43, yet from Year 9 to 

Year 13 (young adulthood) it was 0.82. The authors 

suggest that in early adolescence, some cigarette triers 

never fully develop a pattern of smoking but by late 

adolescence, the addictive properties of cigarette use 

figure prominently in behavior formation. These findings underscore the need for antismoking efforts to focus 

on preventing initial tries, on discouraging transitions to 

more regular smoking, and on encouraging early cessation (Leventhal, Fleming, Glynn 1988; Kelder 1992). 

Summary of Psychosocial Risk Factors for 

Cigarette Smoking 

Some clear convergence of research findings 

emerges from this review, a summary of which is highlighted in Table 1. Table 3 provides a second summary 

of supportive and unsupportive findings from the 

Conrad, Play, and Hill (1992) review of 27 prospective 

studies; for the most part, this summary table is consistent with Table 1. Among the so&demographic factors, 

age is the risk factor consistently linked with onset in 

early adolescence; ages 11 through 15 (seventh through 

ninth grades) am the peak age group for first trial and 

experimentation. Cigarette smoking clearly has social 

meanings that are attractive to many young and vuhterable identityseeking adolescents. This age factor is even 

more pronounced when linked with SES, another important so&demographic risk factor for smoking onset. 

Altema tive health-enhancing avenues for independence 

and identity may be less readily available to adolescents 

from lower SES families, especially those adolescents 

who live in a single-parent home. Limited by fewer 

opportunities for healthy development and parental supervision, lower-SES youth are generally at greater risk 

to begin smoking. The gender difference, another major 

factor, is no longer evident, although the meanings of 

104 Psychosocial Risk Factors 
preventing Tobacco Use Among Young People 

cigarette use and the pathways to regular use may vary 

by gender. Finally, differences by ethnic group do not 

appear to show a consistent pattern across communities, 

particularly when income level and cigarette availability 

are considered. The review of so&demographic factors 

thus concludes that a young adolescent from a low-SES 

family is at highest risk to begin smoking. 

Proximal environmental factors, such as the influence of peers, friends, and siblings, play a powerful role 

in the initiation of adolescent smoking. Smoking initiation appears to be a component of peer associations and 

peer bonding in adolescence, as peer groups establish 

shared behaviors to differentiate themselves from other 

adolescents and from adults. Adolescents usually try 

their first cigarettes with their peers; peer groups may 

subsequently provide expectations, reinforcement, and 

opportunities for continuation. The influence of peers 

seems to be particularly potent in the stages of smoking 

that precede regular use; in later stages, personal and 

pharmacological factors appear to predominate. 

Data on the influence of parental smoking are not 

as compelling as those on peer influence; only about half 

of the prospective studies show a clear predictive relationship. The influence of parental smoking appears to 

be strongest for whites and females, particularly in the 

early stages of smoking onset. This review suggests that 

parental influence might include other important factors, such as parents’ approval or disapproval of smoking, their involvement in freetime supervision, their 

manner and extent of communication on health-related 

matters, or their promotion or nonpromotion of academic achievement for their children. Lastly, young 

people are exposed not only to role models but also to 

the consequences of the behavior of these role models; 

having a parent who smokes might even serve to deter 

an adolescent from smoking if the parent is struggling 

with cessation or displays the health consequences of 

tobacco use. 

How adolescents perceive their social environment 

also influences their smoking behavior. Adolescents 

overestimate the number of young people and adults 

who smoke, and those with the highest estimates are 

more likely to become smokers. In addition, young 

people are more likely to smoke if they feel that their 

peers approve of smoking, and particularly if adults do 

not seem to disapprove. In each of these cases, the 

perceived environment could accurately reflect the actual environment. Those who begin to smoke may actually be exposed to more role models who smoke, more 

peers who approve of smoking, and fewer adults who 

disapprove than those who never begin to smoke. 

Families in which parents are considered to be 

generally concerned and supportive, or in which the 

children are involved in family decisions, are home 

environments in which adolescents are less at risk for 

smoking initiation. Parental strictness and parental 

approval or disapproval of smoking have indirectly 

and inconsistently predicted initiation and are therefore less influential on adolescent smoking behavior 

than the general family environment. The research on 

parental skills in coping with adolescent smoking is 

limited and warrants further investigation. 

The behavioral factors examined were consistently 

associated with the initiation of cigarette smoking. Patterns of behavior that are associated with smoking include alcohol and drug use, risk-taking and rebellious 

actions, and involvement in peer groups in early adolescence. Patterns of behavior that are associated with les‘s 

risk of smoking include academic achievement, involvement in sports (for females), hea$hy eating and physical 

activity patterns, and the ability to resist offers of cigarettes. Thus, encouraging and providing opportunities 

for health-enhancing activities and academic achievement might, by fulfilling some of the needs that smoking 

apparently meets for adolescents, prevent some young 

people from trying their first cigarette. 

The personal factors-those most proximal to the 

individual and to the immediate decision to smoke a 

cigarette-reflect, in part, the adolescent’s intemalization of the social environment. An adolescent’s knowledge of the health consequences of smoking is a poor 

predictor of subsequent cigarette use, although smoking 

risks that are personalized appear to be important. More 

significant predictors include the meanings, the perceived 

positive functions, and the expected utility of cigarette 

use. These aspects are linked to having a positive social 

image, bonding with peers, and being “mature’‘-all of 

which are particularly socially relevant for adolescents. 

Compared with nonsmoking adolescents, those who 

begin to smoke appear to have lower self-images and 

lower self-esteem; for them, smoking becomes a selfenhancement mechanism. Similarly, self-efficacy toward 

avoiding cigarettes seems particularly linked with the 

ability to resist cigarette offers from peers. Of the personality variables, symptoms of depression, helplessness, 

aggression, pessimism, and a limited ability to conceptualize the future were all found to be smoking-predictive 

in a small number of studies. The most predictive personal factors were those linked to the social environment, to peers, and to the meanings of cigarette smoking 

learned in youth. 

Intentions to smoke and prior experimentation with 

cigarettes strongly predict subsequent smoking. The 

adverse physiological reactions to first tries at smoking 

wane with repetition, and tolerance levels to nicotine 

increase. Adolescents who smoke are more likely than 

nonsmokers to discount the negative health consequences 

of smoking, report positive functions of smoking, and 

Psychosocial Risk Factors 105 
Surgeon General’s Report 

perceive that their peers are smokers. The shift from 

social to more personaI reasons for smoking is associated 

with increasing nicotine dependence and addiction. 

Several other factors that influence smoking 

initiation are not covered in this chapter. First, the combined influence of tobacco advertising and promotion 

represents a powerful environmental risk factor (see 

Chapter 5). Second, cultural or community-level research on the causes of smoking onset is decidedly limited. In particular, the effect of taxation, of restrictions to 

public smoking, of vending machine regulations, and of 

limiting access to tobacco for underage buyers needs to 

be addressed prospectively (Chapman and Bloch 1992; 

Sweanor et al. 1992; see Chapter 6). Third, even at the 

school level, smoking prevalence rates have been shown 

to be partly attributable to attendance at a particular 

school and to school smoking policies (Best et al. 1984; 

Semmer, Lippert, et al. 1987; Penk et al. 1989; Santi et al. 

Initiation of Smokeless Tobacco Use 

1990-91; see “Smoking Restrictions in the School” in 

Chapter 6). Still, which aspects of schools contribute to 

smoking onset-whether their rules, consistency of rule 

enforcement, grade structure, or discipline proceduresneed to be studied. These distal environmental factors 

partly determine the meaning for, and acceptability of, 

cigarette use at a community level, determine the ease or 

difficulty with -which adolescents can obtain tobacco, 

and reinforce or inhibit the continuation of use into adulthood. Proximal factors are strong determinants of use 

once the meaning of-smoking is established and access 

to cigarettes is possible. Therefore, the more distal risk 

factors might be considered the proper targets of intervention research efforts, which should test the potency of these factors and provide the clear 

community-level message that cigarette smoking among 

the young is unacceptable. 

Compared with the research literature on smoking 

initiation, the knowledge base on smokeless 

tobacco initiation is modest. Far fewer longitudinal studies have been conducted. For the most part, research 

efforts on smokeless tobacco have been crosssectional; a 

few have also been guided by behavioral theory. Nonetheless, a number of methodologically sound studies 

provide knowledgeabout the risk factors associated with 

the initiation of smokeless tobacco use. In parallel with 

the research on cigarette smoking among young people, 

sociodemographic, environmental, behavioral, and personal factors have all been explored as correlates of smoke 

less tobacco use. With only a few exceptions, the 

consistency of the findings with those found for cigarette 

smoking suggests that both smoking and the use of 

smokeless tobacco products share a common causality 

as well as similar fmctions and meanings for young 

people. 

Sociodemographic Factors in the Initiation of 

Smokeless Tobacco Use 

National survey data on the demographics of 

smokeless tobacco Use are presented in detail in Chapter 

3 (see “Recent Patterns of Smokeless Tobacco Use”) and 

are only summa rind here. These data clearly indicate 

that smokeless tobacco use among young people is particularly prevalent among non-Hispanic white males. 

The three youth surveys that assessed smokeless tobacco 

prevalence (that is, use during the month preceding the 

survey) also found that males were 10 to 15 times more 

likely than females to use smokeless tobacco. Although 

nationally representative data on American Indian and 

Alaskan Native youth are not available, communitylevel studies of these populations have xqorted high 

rates of weekly smokeless tobacco use among both males 

(43 percent) and females (34 percent), even at very young 

ages (Schinke et al. 1987,1989; Bruerd 1990). 

The Monitoring the Future Project survey, a national survey of high school seniors, indiated that 54 

percent of males had used smokeless tobacco. Among 

those, 23 percent first used smokeless tobacco before or 

during the sixth grade, and over 53 percent first used it 

before or during the eighth grade (see “Grade When 

Smokeless Tobacco Use Beg%&’ in Chapter 3). Data 

from a number of other recent surveys suggest that early 

adolescence is the peak age for first using smokeless 

tobacco (Schaefer et al. 1985; US Department of Health 

and Human Services IUSDHHSI 1986; Ary, Lichtenstein, 

Severson 1987; Ary et al. 1989; Riley, Barenie, Myers 

1989; Brownson et aL 1990; Riley et al. 1990,1991). 

Limited evidence suggests that the following 

so&demographic factors may also be related to higher 

rates of smokeless tobacco use among youth: one or no 

parenk in the household (Jones and Moberg 1988; Murray 

et al. 1988; see “So&demographic Risk Factors for 

106 Psychosocial Risk Factors 
Prevedng Tobacco Use Among Young People 

Smokeless Tobacco Use” in Chapter 3); lower parental 

education (Bauman, Koch, Lenk 1989; Botvin, Baker, 

To&u 1989); blue-collar parental occupation (Burke et al. 

1989; Elder, Molgaard, Gresham 1988; Novotny et al. 

1989); and rural environment (Olds 1988; botvin, baker, 

Tortu 1989; Rouse 1989; Lisnerski et al. 1991; see 

“So&demographic Risk Factors for Smokeless Tobacco 

Use” in Chapter 3). As is reported in Chapter 3 (see 

“Current Use of Smokeless Tobacco”), prevalence varies 

among regions and is somewhat lower in the Northeast 

than in other regions. 

Environmental Factors in the Initiation of 

Smokeless Tobacco Use 

Factors That Influence Acceptability and Availability 

Ease of access to smokeless tobacco appears to be 

an important factor in initiation, and young people 

seem to have little trouble obtaining smokeless tobacco 

(USDHHS 1992a, CDC 1993). In interviews conducted 

by the Office of Inspector General WSDHHS 1986),90 

percent of smokeless tobacco users in junior and senior 

high school reported that they purchased their own 

smokeless tobacco; 94 percent reported that although 

they were minors, it was either never or only rarely 

difficult for them to purchase smokeless tobacco. Convenience stores were the most frequent purchase site (55 

percent); supermarkets and grocery stores accounted for 

an additional 33 percent of sales. barovich et al. W9.l) 

found that 50 percent of store personnel were willing to 

sell to minors. In another study (Leopardi et al. 19891, 

junior high school students reported that their leading 

sources of smokeless tobacco were friends (43 percent) 

and direct store purchase (30 percent); senior high school 

students’ chief sources were direct purchase (62 percent) 

and friends (25 percent). In a recent study in Texas, 

minors successfully purchased smokeless tobacco in 59 

percent of stores selling the product (CDC 1993). 

Interpersonal Factors 

Parental Use 

As in the research on cigarette smoking, the evidence depicts either a modestly positive or no significant 

association between parental use of smokeless tobacco 

and adolescent use. The only prospective study that 

examined parental use found no link to onset or continued use of smokeless tobacco among youth (Ary, 

Lichtenstein, Severson 1987). However, several crosssectional studies have reported significant relationships 

between concurrent use by parents and youth (Cohen et 

al. 1987; Hall and Dexter 1988; Colbom, Cummings, 

Michalek 1989; Glover et al. 1989; Brownson et al. 1990). 

Bauman, Koch, and Lentz (1989) found that an adolescent was more likely to use smokeless tobacco if the 

father did, although there was an interaction with the 

level of the father’s education. Two cross-sectional studies found no significant association between concurrent use of.smokeless tobacco by parents and adolescent offspring (Chassin et al. 1985; Ary, Lichtenstein, 

Severson 1987). 

Sibling Use 

The evidence from cross-sectional studies generally supports a relationship between a sibling’s use of 

smokeless tobacco and an adolescent’s use. However, 

one prospective study did not fjnd significant sibling 

relationships (Ary, Lichtenstein, Severson 1987), and another study found no effect for “older family members” 

(Chassin et al. 1985). The sole longitudinal study did not 

find that sibling use was related to adolescent onset (Ary, 

Lichtenstein, Severson 1987). 

Peer Use 

Although a substantial amount of cross-sectional 

research has examined the use of smokeless tobacco by 

peers, only two longitudinal studies have been pub 

lished. Every cross-sectional study found that peer use 

was significantly related to adolescent use (Cohen et al. 

1987; Hall and Dexter 1988; Lucas and Christen 1988; 

Glover et al. 1989; Leopardi et al. 1989; Riley, Barenie, 

Myers 1989; Brownson et al. 1990, Hunter, Vizelberg, 

berenson 1991). Peer use of smokeless tobacco was 

related to the onset of adolescent use at the 9-month 

follow-up in one longitudinal study (Ary et al. 1989) but 

not in another study (Ary 1989) at the 6- and K&month 

follow-up times. However, peer use was found to be 

related to continued use among initial daily users of 

smokeless tobacco at 6, 9-, and 12-month follow-ups 

(Ax-y, Lichtenstein, Severson 1987; Ary 1989). 

Perceived Environmental Factors 

Norms 

Current evidence indicates that most adolescents 

who use smokeless tobacco perceive that this behavior is 

socially acceptable. The Office of Inspector General 

(USDHHS 1986) reported the following findings from a 

survey of male adolescents who used smokeless tobacco: 

l 86 percent perceived that most or some students at 

their school approved of smokeless tobacco use. 

Psychosocial Risk Factors 107 
l 98 percent said their best male friends either approved 

of, or were neutral toward, their smokeless tobacco 

use. 

l 93 percent said their parents knew of their smokeless 

tobacco use. 

l 68 percent said their fathers and 45 percent said their 

mothers approved of, or were neutral toward, their 

smokeless tobacco use; 

l 91 percent said their brothers and 71 percent said their 

sisiers either approved of, or were neutral toward, 

their smokeless tobacco use. 

87 percent listed their home as a setting where they 

regularly used smokeless tobacco. 

43 percent whose dentist knew of their use were not 

advised by that professional to quit. 

51 percent said their coaches either approved of, or 

were neutral toward, their smokeless tobacco use. 

These findings were replicated in the 1992 Office of 

the Inspector General study on Spit Tobacco and Youth 

(USDHHS 1992b). The adolescents in this study who 

used smokeless tobacco said that the greatest influences 

on their trying smokeless tobacco were peer pressure 

and other family members’ use. The majority of these 

young users felt their parents would agree that their 

using smokeless tobacco was preferable to smoking cigarettes (USDHHS 1992b). 

In another study, only 14 percent of smokeless 

tobacco users reported that their father disapproved of 

their smokeless tobacco use, whereas 60 percent said 

their mother disapproved (Marty, McDermott, Williams 

1986). WilIiams et al. (1986) found that 55 percent of 

smokeless tobacco users indicated that their parents disapproved of their use. in a study by Ary et al. (19891, 

only 13 percent of daily smokeless tobacco users reported that their dentist had said anything to them 

about their use. Brubaker and Loftin (1987) found that 

smokeless tobacco users reported greater peer acceptance of, and less parental opposition to, their use than 

did nonusers. 

Social Support 

Chassin, Presson, and Sherman (1988) examined the 

relationship between family social support and current 

use of smokeless tobacco. Three cross-sectional analyses 

found no pattern of relationships between smokeless tobacco use and perceived parental expectations (for success 

or academic accomplishment), parental supportiveness, 

Surgeon Generals Repott 

parental strictness, agreement between parents, parentpeer agreement, or the adolescent’s reported motivation 

to comply with parents. Similarly, two sets of analyses 

examining one-year prediction of smokeless tobacco onset found no statistically significant effects for the same set 

of factors, although the statisti& Rower to detect such 

effects was minimal because the sample contained few 

cases of smokeless tobacco onset. 

Parental Reaction to Smokeless Tobacco Use 

Parents appear to be more accepting of smokeless 

tobacco use than of cigarette smoking. About 40 percent 

of high school smokers reported that their parents knew 

about their smoking, whereas smokeless tobacco users 

reported that 71 percent of their iarents knew of their 

use (Chassin et al. 1985). Similarly, young people who 

did not use tobacco reported that their parents and peers 

were more accepting of smokeless tobacco use than of 

smoking (Chassin et al. 1985; Ary et al. 1989). These 

findings suggest that adolescents may begin using smokeless tobacco partly because they perceive that it is less 

deviant than smoking or other drug use and therefore is 

more likely to be accepted by their peers and parents 

(Hahn et al. 1990). 

Some research evidence indicates that the anticipated parental response to an adolescent’s use of smoke 

less tobacco is related to that youth’s likelihood of using 

smokeless tobacco. Riley, Barenie, and Myers (1989) 

found that high school students’ anticipation of their 

parents’ response was highly predictive of the first trial 

of smokeless tobacco and of the level of continued 

use. Brubaker and Loftin (1987) found that adolescents 

who did not currently use smokeless tobacco but who 

intended to become users reported that it would be 

unlikely that their parents would respond by taking 

away their privileges, reprimanding them, becoming angry, expressing disappointment, or prohibiting them from 

continued use. These youth also reported that it was 

likely that their parents would ignore their smokeless 

tobacco use. 

Behavioral Factors in the Initiation of 

Smokeless Tobacco Use 

Academic Achievement 

For males, smokeless tobacco use was related to 

poor academic performance (Jones and Moberg 1988) 

and to a low grade point average (Brownson et al. 1990). 

The NIDA national household survey indicated that for 

males, the prevalence of daily use of smokeless tobacco 

was highest among school dropouts (13 percent) and 

lowest among college students (6 percent) (Rouse 1989). 

108 Psychosocial Risk Factors 
Proven ting Tobacco Use Among Young People 

Smoking as a Risk Factor for Smokeless Tobacco 

Five longitudinal studies examined the prospective relationships between cigarette smoking and the 

onset or continued use of smokeless tobacco Wy, 

Lichtenstein, Severson 1987; Dent et al. 1987; Murray et 

al. 1988; Ary 1989; Sussman et al. 1989). (The relationship between smokeless tobacco use and subsequent 

cigarette smoking is reviewed later in this chapter.) In a 

longitudinal study of eighth graders, Dent et al. (1987) 

reported that smoking status at baseline predicted the 

onset of smokeless tobacco use one year later. Twentynine percent of regular smokers at baseline-but only 6 

percent of those who had never smoked-reported 

smokeless tobacco onset at follow-up. Ary, Lichtenstein, 

and Severson (1987) used disaiminant analysis to identify predictors of the onset of smokeless tobacco use nine 

months after smoking onset among 7th,9th, and 10th 

graders. The disaim&nt function accounted for .11 

percent of the variance, and having tied smoking was 

an important predictor, correlating at 0.64 with the disaiminant function. Jn a similar study using a separate 

sample of 7th, 9th, and 10th graders in Oregon, smoking 

did not significantly predict smokeless tobacco onset at 

6-month or 12-month follow-ups (Ary 1989). Another 

longitudinal study found general support for the influence of smoking on seventh graders who had tried smoke 

less tobacco (Murray et al. 1988). Longitudinal analysis 

of one-year follow-up data from two other samples of 

seventh graders indicated that both males and females 

exhibited a fairly consistent relationship between, the 

onset of smokeless tobacco use and pretest smoking 

thsman et al. 1989). 

Three of the longitudinal studies cited above also 

examined the prospective relationship between cigarette 

smoking and continued use of smokeless tobacco among 

adolescents. Ary, Lichtenstein, and Severson (1987) found 

that baseline smoking did not predict frequency of later 

smokeless tobacco use at nine-month foIlow-up. In a 

separate study, Ary (1989) examined these relationships 

and found that frequency of smoking was related to 

continued daily smokeless tobacco use at 1Zmonth 

follow-up but not at 6month follow-up. A 24month 

follow-up study of ninth graders also found general 

support for the infhrence of smoking on later use of 

smokeless tobacco (Murray et al. 1988). Although the 

findings from these thr& prospective studies are inconclusive, numerous studies ‘&port significant concurrent 

relationships between smoking and smokeless tobacco 

use. The degree of statistical power exhibited by these 

relationships varied widely, but every study found at 

least one significant association between smokeless tobacco use and smoking. 

Other Adolescent Behaviors 

Twelve studies fairly consistently indicated that 

smokeless tobacco use is related to concurrent use of 

alcohol and marijuana Whtenstein et al. 1984; Ary, 

Lichtenstein, Severson 1987; Burke et al. 1988,1989; Jones 

and Moberg 1988; Murray et al. 1988; Ary 1989; Riley, 

Barenie, Myers 1989; Rouse 1989; Sussman et al. 1989; 

Riley et al. 1991; Stevens et al. 1991). One of these studies 

CGssman et al. 1989) found that seventh- and eighthgrade females showed no relationship between having 

tried smokeless tobacco and concurrently using alcohol, 

but two of four samples with male subjects showed 

significant relationships. Only three studies examined 

the prospective relationships between smokeless tobacco use and the use of alcohol and marijuana. In one 

study, the onset of smokeless tobacco use among those 

who had not used at baseline was related to marijuana 

use but not to alcohol use (Ary, Lichtenstein, Sever-son 

1987). In a separate study, initial use of alcohol or marijrtana did not predict onset of smokeless tobacco use at 6- 

month follow-up, but initial alcohol use predicted 

smokeless tobacco use at 12-month follow-up (Ary 1989). 

In another 1Zmonth longitudinal study, onset of smoke 

less tobacco use among those who at baseline had never 

used smokeless tobacco was predicted by initial alcohol 

use in one of two samples of seventh-grade females but 

not in two samples of males (Sussrnan et al. 1989). Taken 

together, there is some evidence that prior use of either 

alcohol or marijuana is related to subsequent onset of 

smokeless tobacco use and to continued useof smokeless 

tobacco among daily users. 

Several studies suggest that adolescents who use 

smokeless tobacco are more likely to use multiple drugs 

than are adolescents who do not use smokeless tobacco. 

Ary, Lichtenstein, and Severson (1987) found that among 

male adolescents who reported use of smokeless to 

bacco, cigarettes, alcohol, or marijuana in the week preceding the survey, 43 percent (47 percent in Arfs separate 

study [19891) indicated that they used more than one of 

these substances during that week The percentage of 

daily users of smokeless tobacco who reported use of 

alcohol during the preceding week was particulariy high 

(76 percent in Ary, Lichtenstein, and Severson’s study 

[1987J and 74 percent in Ary’s separate study 119891). 

Among daily smokeless tobacco users, 83 percent in Ary, 

Lichtenstein, and Severson’s study (1987) (80 percent 

in Ary’s 1989 study) also reported using a drug other 

than alcohol, a fact suggesting that daily smokeless tobacco users are particularly likely to be multiple drug 

users. 

Psychosocial Risk Factors 109 
Surgeon Gem-al’s Report 

Smokeless Tobacco Use as a Risk Factor for Smoking, 

Alcohol, and Other Drug Use 

Although the known Literature indicates that the 

use of cigarettes and other drugs. is a risk factor for 

smokeless tobacco use, several studies also indicate that 

the converse is true; that is, smokeless tobacco use is a 

risk factor for the onset and maintenance of cigarette 

smoking and for the use of alcohol and marijuana (see 

“Smokeless Tobacco Use and Other Drug Use” in Chap 

ter 3). Ary, Lichtenstein, and Severson (1987) examined 

the prospective relationship between smokeless tobacco 

use and the onset of the use of cigarettes, alcohol, and 

marijuana at nine-month follow-up. Smokeless tobacco 

users were found to be more likely than nonusers to 

begin using cigarettes (22 percent vs. 7 percent), alcohol 

(18 percent vs. 7 percent), and marijuana (37 percent vs. 

18 percent). These findings were replicated in Ary’s. 

(1989) 12-month follow-up study of a separate sample. 

Smokeless tobacco users were significantly more likely 

than nonusers to report smoking cigarettes (6 percent vs. 

0.5 percent), drinking alcohol (29 percent vs. 12 percent), 

and smoking marijuana (12 percent vs. 2 percent). 

Similarly, smokeless tobacco users were more likely 

than nonusers to increase their use of other drugs. A 

greater proportion of smokeless tobacco users than of 

nonusers reported increased use (in the week preceding 

the survey) of cigarettes (18 percent vs. 8 percent), alcohol (34 percent vs. 20 percent), and marijuana (20 percent 

vs. 8 percent) (Ary, Lichtenstein, Severson 1987). The 

1989 study replicated these findings for each substance: 

cigarettes (7 percent vs. 2 percent), alcohol (25 percent vs. 

13 percent), and marijuana (15 percent vs. 2 percent) 

(Ary 1989). 

Several studies provide additional evidence for the 

progression from smokeless tobacco to other drugs. In 

one, decreases in smokeless tobacco use were 

accompanied by increases in cigarette smoking (Hunter 

et al. 1986). In a different longitudinal study, smokeless 

tobacco users were more likely to report cigarette smoking at a two-year follow-up (67 percent) than were nonusers (14 percent) (Schinke et al. 1986). A study of 

undergraduates found that switching from smokeless 

tobacco to cigarettes was a more Likely progression than 

the converse (Glover, I.&in, Edwards 1989). 

Risk Taking and Rebelliousness 

Although smoking is associated with rebelliousness and unconventionality, several studies have found 

no such association for smokeless tobacco use. A significant but modest relationship has been found between 

smokeless tobacco use and risk taking. In one of the few 

longitudinal studies of smokeless tobacco use, Dent et al. 

(1987) found that among eighth graders, current risk 

taking predicted the onset of smokeless tobacco use one 

year later. In another study, a significant relationship 

was reported between seventh-grade students’ smokeless tobacco use and risk taking (Botvin, Baker, Tortu 

1989). Studies with high school students found that risk 

taking was related to trying smokeless tobacco but not to 

the level of smokeless tobacco use (Riley, Barenie, Myers 

1989; Riley et al. 1991). In two of eight replication samples 

in another study, risk taking was a significant correlate of 

trying smokeless tobacco (Sussman et al. 1989). 

Participation in Athletics 

Given the number of professional athletes who use 

smokeless tobacco, and given the associated advertising 

efforts by smokeless tobacco companies, youth who participate in athletics would seem likely to be at greater risk 

of using smokeless tobacco than nonparticipants. Current studies have mixed findings about this possible 

relationship. Although 28 percent of predorninantLy white 

Little League baseball players (aged 12 or less, N = 1,141) 

in southeast Texas believed that more than half of professional baseball players use smokeless tobacco, this belief 

was not strongly associated with use of smokeless tobacco among these youth (Evans, Raines, Getz 1992). 

Similar findings on a stratified random sample of rumI 

and urban youth in grades one, three, five, and seven 

were reported in North Carolina (Lisnerski et al. 1991). 

In a one-year longitudinal study of seventh graders, 

sports participation did not predict onset of smokeless 

tobacco use in two samples of males and in one of two 

samples of females (Sussman et al. 1989); for the other 

sample of seventh-grade females, the relationship was 

positive but modest. Sussman et al. (1990) reported that 

self-identified “dirts” (i.e., “heavy metal” music enthusiasts and marijuana users) and “skaters” (i.e., skateboarders and surfers) were more likely to be currently using 

smokeless tobacco than were “jocks/athletes.” Another 

study of high school students yielded inconclusive results (Riley, Barenie, Myers 1989). On the other hand, 

Ringwalt (1989) found that llth- and 12th~grade athletes 

(students who played on school teams) were more likely 

than nonathletes to have used smokeless tobacco, to 

have used smokeless tobacco in the preceding 30 days, 

and to perceive fewer (if any) health risks for smokeless 

tobacco use. Jones and Moberg (1988) found that fre 

quency of smokeless tobacco use was related to participation in team sports. Glover et al. (1989) found that 

smokeless tobacco use among U.S. college students was 

related to participation in organized sports. Taken together, the current evidence is inconclusive and warrants further investigation that might consider team rules 

regarding smokeless tobacco use, coaches’ use of smokeless tobacco or attitude toward team members’ use, and 

parents’ degree of involvement in the team. 

110 Psychosocial Risk Factors 
preventing Tobacco Use Among Young People 

Personal Factors in the Initiation of 

Smokeless Tobacco Use 

Knowledge of Long-Term Health Consequences 

Because the long-term health consequences of 

smokeless tobacco use have not been as widely communicated as those of smoking, knowledge of these conse 

quences is potentially an important predictive factor for 

smokeless tobacco use. ‘Most youth appear to be aware 

that smokeless tobacco use can be harmful to health, but 

most smokeless tobacco users do not perceive their own 

risk to be great. In interviews with smokeless tobacco 

users, 80 percent of junior high school and 92 percent of 

senior high school users acknowledged that smokeless 

tobacco use can be harmful, but about 60 percent of the 

junior high users and 40 percent of the senior high users 

believed that there was no risk or only slight risk in 

regular smokeless tobacco use KJSDHHS 1986). A study 

of 7th- through 10th~graders found that 31 percent of 

daily users of smokeless tobacco believed that there was 

very little health risk associated with this use (Ary, 

Lichtenstein, Severson 1987). Similarly, only 40 percent 

of 7th- through 12th-grade students in another sample 

perceived smokeless tobacco use as very harmful 

(Schaefer et al. 1985). Marty, McDermott, and Williams 

(1986) reported that 35 percent of high school students 

who use smokeless tobacco believed that such use had 

little or no effect on their health. 

Many youth appear to believe that smokeless tobacco use is much safer than cigarette use. Schaefer et 

al. (1985) found that 77 percent of smokeless tobacco 

users perceived smoking to be very harmful, whereas 

only 40 percent perceived smokeless tobacco use as 

very harmful. Another study reported that 86 percent 

of fifth- and sixth-grade smokeless tobacco users believed that smoking would hurt their health, but only 

33 percent believed this of smokeless tobacco use 

(Schinke et al. 1986). Ary et al. (1989) found that when 

smokeless tobacco users were asked why they preferred smokeless tobacco to cigarettes, they most often 

gave “lower health risk” as the reason. Users of smokeless tobacco are more likely than nonusers to perceive 

that smokeless tobacco is a comparatively safe altemative to cigarette use (Chassin et al. 1985; McDermott 

and Marty 1986; Boyle 1989; Glover, Laflin, Edwards 

1989; Brownson, DiLorenzo, Van Tuinen 1990; 

Brownson et al. 1990; Lisnerski et al. 1991). 

A number of studies have examined the relationship between concurrent smokeless tobacco use and 

health knowledge and beliefs about smokeless tobacco, 

but none of these studies have examined the prospective 

relationship. Most of these studies show that youth with 

more health knowledge of, or greater beliefs in, the risks 

of smokeless tobacco use are indeed less likely to use 

smokeless tobacco. Three studies reported that having 

tried smokeless tobacco was related to lack of health 

knowledge and beliefs (Cohen et al. 1987; Riley, Barenie, 

Myers 1989; Riley et al. 1991); only one study that examined this possible link failed to find such a relationship, 

and that study involved very young subjects (first 

through seventh graders) (Lisnerski et al. 1991). Multiple studies have reported that health knowledge and 

beliefs were significantly related to various categories of 

smokeless tobacco use (Boyle 1989; Polcyn et al. 1991), 

current smokeless tobacco use (Chassin et al. 1985; 

Colbom, Cummings, Michalek 1989; Glover, Laflin, 

Edwards 1989; Marty, McDermott, Williams 19861, level 

or amount of smokeless tobacco use (Riley, Barenie, Myers 

1989; Riley et al. 1991), or daily smokeless tobacco use 

(Ary, Lichtenstein, Severson 1987). In only two studies 

was no relationship found between health knowledge 

and beliefs and smokeless tobacco use (Brownson et al. 

1990; Lisnerski et al. 1991). 

Functional Meanings 

In a study of seventh- and eighth-grade students, 

favorable personal attitudes toward smokeless tobacco 

use were significantly related to concurrent use of smoke 

less tobacco <Polcyn et al. 1991). In another study, Bththrough 11th~grade students’ expectancy and beliefs 

about the positive attributes of smokeless tobacco use 

(e.g., tastes good, is relaxing, helps concentration) were 

related to current smokeless tobacco use (Colbom, 

Cummings, Michalek 1989). Negative attributes of 

smokeless tobacco use (i.e.,gives bad breath, stains teeth) 

were negatively related to current smokeless tobacco use 

(Colbom, Cummings, Michalek 1989). No prospective 

studies were found. 

Social Image 

Other research suggests that smokeless tobacco use 

has a more positive social image than smoking (Chassin 

et al. 1985; Chassin and Presson 1988). One study of high 

school students found that students were more likely to 

have used smokeless tobacco during the past month and 

that nonusers were more likely to have intentions of using 

if the students’ real and ideal self-concepts were similar to 

their perceived image of smokeless tobaccousers Oassin 

et al. 1985). This finding suggests that youth may take up 

smokeless tobacco as a method of attaining a valued social 

image. Positive social attributes expected from smokeless 

tobacco use (e.g., increases attractiveness, brings more 

friends, makes one become more “macho”) were also 

shown to be significantly related to concurrent use of 

smokeless tobacco (Colbom, Cummings, Michalek 19891. 

No prospective research was found. 

Psychosocial Risk Factors 111 
Surgeon Generd’s Report 

Personality Traits 

Some studies have examined relationships between 

smokeless tobacco use and a number of personality trans. 

A positive association was found with anger (Jacobs et 

al. 1988), anxiety (Jacobs et al. 1988), assertiveness (Botvin, 

Baker, Tortu 19891, depression (Tones and Moberg 1988; 

Rouse 1989), and locus of control (Dignan et al. 1986). A 

negative association was found with anxiety, curiosity 

(Jacobs et al. 19881, and self-concept O&nan et al. 1985). 

Smokeless Tobacco Use as a Risk Factor for 

Continued Use 

Intentions to Use Smokeless Tobacco 

Consistent with data on youth smoking, the research indicates a strong relationship between concurrent smokeless tobacco use and intention to use in the’ 

future. Brubaker and Loftin (1987) found that reported 

intention to use smokeless tobacco in the week after the 

survey was strongly related to current smokeless tobacco use in a small sample of fifth- through eighthgrade males. Intention to use in the next two weeks was 

also related to current-use status Gerber, Newman, Martin 1988). No studies were found, however, that examined the prospective relationship between intention to 

use smokeless tobacco and the initiation or continuation 

of use. 

Current Use of Smokeless Tobacco 

Ary, Lichtenstein, and Severson (1987). prospectively examined the predictors of frequency of smokeless tobacco use at a nine-month follow-up for their 

sample of daily users of smokeless tobacco. Current 

use of smokeless tobacco was the best predictor of later 

use; the initial rate of use was highly correlated with the 

rate of use nine months later and accounted for 33 

percent of the variance. This finding suggests that the 

successful reduction of smokeless tobacco use will require early intervention before the development of physiological addiction. 

Summary of Psychosocial RiskFactors for 

Smokeless Tobacco Use 

The major factors associated with the initiation 

and development of smokeless tobacco use found in 

this review are shown in Table 1. With the exception of 

adequate knowledge of the health consequences of 

smokeless tobacco use and the social acceptance afforded by smokeless tobacco use, these factors are nearly 

identical to those found for the onset of smoking. Although most youth perceive that smokeless tobacco use 

can be harmful to health, most smokeless tobacco users 

do not perceive the risk to be great, particularly to 

themselves, and particularly compared with the hea& 

risk of cigarette smoking. Peer modeling of smokeless 

tobacco use seems to be strongly and consistently I+ 

lated to the onset and continued use of smokeless to 

bacco. Smokeless tobacco use serves social functions 

within the peer group that may support experimental 

and continued use. The evidence is less conclusive for 

modeling by parents and siblings. Peer and, notably, 

parental acceptance of smokeless tobacco use is much 

higher than for cigarette smoking. 

Fairly consistent evidence indicates that smokeless 

tobacco use is related to concurrent use of cigarettes, 

alcohol, and marijuana. Emdings from prospective studies suggest that the use of smoke&s tobacco may precede the use of these other substances and occurs early in 

a sequence of drug use by some adolescents. Prospective 

evidence shows that smoking and the use of alcohol and 

marijuana are also related to the onset and continued use 

of smokeless tobacco. Engaging in risk-taking behavior 

and having poor academic performance also appear to 

be reIated to smokeIess tobacco use (see “Smokeless 

Tobacco Use and Other Health-Related Behaviors” and 

“So&demographic Risk Factors for Smokeless Tobacco 

Use” in Chapter 3). There is mixed evidence that smoke 

less tobacco use is associated with youthful athletic participation; nonetheless, some professional athletes have 

promoted its use both indirectly (through visible personal use) and directly Ohrough advertising). 

Finally, there is evidence of concurrent relationships (but no prospective evidence) between smokeless 

tobacco use and health beliefs/knowledge, attitudes, expectancies, and social image. The perception that smokeless tobacco use may be a healthier choice than cigarette 

smoking consistently emerges in the data and indicates 

the need for prevention programs that stress the health 

consequences of smokeless tobacco use. 

Smokeless tobacco use, then, appears to be a 

function of the so&I worId of young people, who see 

this “adult” behavior as an aid-a generally accessible 

one-in improving their individual social image. Moreover, perhaps because even among adults the health 

consequences of smokeless tobacco use am not widely 

understood, adults lack consensus on whether smoke 

less tobacco use should be actively discouraged. Peer 

use of smokeless tobacco thus becomes a strong motivator for initiation and continued use. 

These misperceptions on the part of adolescents 

and adults alike are of serious concern, given the healthcompromising, addictive aspects of smokeless tobacco 

use. More strikingly, smokeless tobacco use is associated 

strongly with other drug use and may serve as an entry 

behavior to the use of cigarettes, alcohol, and illegal 

substances. 

112 Psychosocial Risk Factors 
p~exnting Tobacco Use Among Young People 

Implications of Research for Preventing Tobacco Use: Modifying Psychosocial Risk 

Although substantial research has examined the 

onset of tobacco use for individual adolescents, there is 

clearly a need to examine how change in community and 

cultural factors may modify onset rates. This review of 

the literature strongly suggests that the onset of tobacco use is socially learned and is a social behavior for 

adolescents, with socially relevant meanings, images, 

and functions. Therefore, rather than focusing only on 

individuals and families as the primary targets of prevention efforts, attention should also be directed to the 

social environment of adolescents. These efforts should 

consistently and persuasively promote the prevention 

and cessation of tobacco use and should demonstrate 

that the meanings of tobacco use are negative. Prevention efforts should portray tobacco use as a behavior that 

is nonnormative, unattractive, addictive, and immature. 

Although the meanings of tobacco use are learned 

in childhood, early to middle adolescence appears to be 

the time of greatest need for direct intervention. This 

idea is not only supported epidemiologically by the occurrence of highest onset rates during this time, but also 

developmentally, in that the challenges of adolescence 

can expose youth to the perceived utility of tobacco use. 

The meanings of tobacco use that have been established 

in our society become personally relevant during adolescence. Tobacco use becomes a mechanism to establish 

social relationships, display independence, and create a 

new, mature identity. Moreover, because many adolescents believe themselves to be all but invulnerable, have 

a short perspective on their future, have limited abstract 

cognitive abilities, and highly value their associations 

with same-age peers, adolescents may view tobacco use 

as particularly functional to them and not potentially 

harmful. Adolescence is clearly a vulnerable time when 

adult involvement and protection is still warranted and 

required. Adults should see the prevention of adolescent tobacco use as an important part of their responsibility in the healthful socialization of the young. 

The onset of tobacco use is strongly associated with 

peer influences, peer smoking, and peer approval of 

smoking. Programs that prevent tobacco use should 

systematically seek peer-group involvement and enlist 

peer role models who do not use tobacco. The emphasis 

of this involvement should be to affect peer-related norms 

and to persuade adolescents that most people their age 

do not use tobacco, that tobacco use has negative social 

consequences, and that tobacco use projects an image 

that, instead of being “cool,” is unattractive, unpopular, 

and immature. Parents should also pay attention to the 

amount of time adolescents spend with peers, to peers’ 

behavior, and to unsupervised peer-group activities. 

The increased need for social competencies during 

adolescence (i.e., the ability of young people to decipher, 

cope with, and deal with the social environment) should 

be a critical focus of comprehensive efforts to prevent 

tobacco use. Adolescents need skills to help them identify, resist, and refute environmental influences-whether 

from the media, adults, or peers-to use tobacco. 

Similarly, adolescents may need to be taught how to 

cope better with difficult, stressful situations at home or 

at school. Without such ski& many youth may continue to use tobacco as a mechanism to deal with low 

self-esteem, depression, and the feelings of helplessness that can result from the ordinary challenges of 

growing up. 

Positive social bonding with family and schools and 

health-enhancing behavior, such as physical activity, 

should be encouraged among youth as protective factors 

against tobacco use. Students who perform poorly in 

school should be offered tutoring and academic counseling; besides being personally motivating, such support 

can increase students’ affiliation with school and decrease 

their involvement in tobacco use. Encouraging sports 

participation (and countering the negative role models of 

some professional athletes by providing explicit messages about the health consequences of smokeless tobacco 

use), regular physical activity, and a healthy diet may 

increase adolescents’ valuation of, and attachment to, 

health and a healthy body that might becompromised by 

tobacco use. Parents may also need to demonstrate their 

support for academic achievement, health activities, and 

a greater link between home and school. 

Finally, to substantially modify tobacco use and to 

provide adolescents with consistent messages against 

tobacco use, the community (and society on the whole) 

should embrace the prevention of tobacco use. A focus 

on individuals, families, or peer groups is necessary but 

not sufficient to address the origins of tobacco’s appeal to 

young people. Limiting the acceptability of tobacco use 

through restrictive policies, such as legislation supporting clean indoor air and school policies banning tobacco 

use, provides a clear message to adolescents that tobacco 

use is not acceptable as a public behavior. Severely 

limiting adolescents’ access to tobacco products makes it 

clear that cigarettes and smokeless products are dangerous substances. Mandating tobacco-use prevention programs in schools signals the importance of this topic 

through the use of explicit, earmarked resources. These 

Psychosocial Risk Factors 113 
Surgeon General’s Report 

community actions provide external support for par- home. Above all, community action at multiple levels 

ents, teachers, and adolescents to assert their beliefs of the social environment directly and consistently reabout the health hazards of tobacco use and to assist futes the notion that tobacco use is an attractive adult 

their demand for tobacco-free environments. Such clear, behavior. Community intervention should be a top 

normative messages emanating from the community priority in poorer communities, where the need for 

level reinforce those messages given at school or at action is especially great. 

Conclusions 

1. The initiation and development of tobacco use among 

children and adolescents progresses in five stages: 

from forming attitudes and beliefs about tobacco, to 

trying, experimenting with, and regularly using tobacco, to being addicted. This process generally 

takes about three years. 

2. So&demographic factors associated with the onset 

of tobacco use include being an adolescent from a 

family with low socioeconomic status. 

3. Environmental risk factors for tobacco use include 

accessibility and availability of tobacco products, 

perceptions by ado1 escents that tobacco use is normative, peers’ and siblings’ use and approval of 

tobacco use, and lack of parental support and involvement as adolescents face the challenges of 

growing up. 

4. behavioral risk factors for tobacco use include low 

levels of academic achievement and school involvement, lack of skills required to resist influences to 

use tobacco, and experimentation with any tobacco 

product. 

5. Personal risk factors for tobacco use include a lower 

self-image and lower self-esteem than peers, the belief that tobacco use is functional, and lack of selfefficacy in the ability to refuse offers to use tobacco. 

For smokeless tobacco use, insufficient knowledge 

of the health consequences is also a factor. 

114 Psychosocial Risk Factors 
Preventing Tobacco Use Among Young People 

Chapter 5: Efforts to Prevent Tobacco Use Among Young People 

Introduction 

This chapter examines the range and effectiveness and communitywide programs. The third set of sections 

of efforts to prevent tobacco use among young people. examines the impact of social conditions and public poliThe first section provides data on recent public opinion ties, including the effects of mass media programming 

of strategies to reduce tobacco use among young people. legal restrictions, warning labels, and tobacco taxation 

The second set of sections focuses on educational efforts Together, these efforts can inoculate against the 

to reduce cigarette smoking and smokeless tobacco use psychosocial risk factors discussed in Chapters 4and 5, as 

among young people, including school-based, clinic, shown in Figure 1. 

Figure 1. Efforts to prevent tobacco use among young people, by stage of initiation 

Never Smoker 

Mass media programming 

Counteradvertising 

Communitywide programs 

Social influences programs 

1 iFZE!Zt~ZE~o minors ) Nonsmoker 

Experimentation 

Source: Adapted from U.S. Department of Health and Human Services (1991). 

Pmen tion I15 
Surgeon General’s Report 

Public Opinion About Preventing Tobacco Use Among Young People 

Introduction 

The information in this section is derived from 

several different sources, including national surveys conducted by the federal government and by private organizations (e.g., the Gallup Organization, Louis Harris and 

Associates), statewide su veys conducted by government 

agencies or private organizations (e.g., the American 

Cancer Society [ACSI), and community-based surveys. 

A remarkably consistent pattern emerges regarding public 

opinion of tobacco-control policies. Fit, both smokers 

and nonsmokers express much greater support for policies to prevent youth from smoking than for policies to 

discourage adult smoking. A second finding is that 

nonsmokers are consistently more supportive of govemment efforts to regulate tobacco than are smokers. 

Public Opinion About Tobacco Education 

Historically, public support for efforts to keep children from smoking has been stronger than support for 

efforts to reduce smoking among adults. During the first 

half of this century, most states instituted laws that prohib 

ited the sale or gift of cigarettes to minors (Hawkins 19641, 

since tobacco use was viewed as an adult behavior and 

children were seen as a group to be protected from potentially harmful substances. However, as the health dangers 

of smoking became known, the public looked to schools to 

do more to educate children about the hazards of tobacco 

use. For example, a 1957 national survey of adults (N = 

1,541) conducted by the Gallup Organization (1957) found 

that 68 percent of respondents believed that the danger 

from smoking was great enough to warrant literature 

being distributed to schoolchildren to warn them of these 

dangers. Fifty-three percent of the respondents also felt 

that the danger was sufficient to warrant an announ~ 

ment from the federal government (presumably, to adult 

smokers) regarding the danger of smoking. 

Traditionally, public and private efforts to reduce 

the initiation of smoking by children have involved 

schools (U.S. Department of Health and Human Services 

[USDHHSI 1989). A number of states have enacted laws 

that mandate education about smoking and health in 

schools. In part, the emphasis on school-based education 

reflects a belief that education is the most effective way to 

discourage children from smoking. A 1984 national 

survey of adults sponsored by the American board of 

Family Practice (Research and Forecasts, Inc. 1985) asked 

respondents to indicate what approaches they believed 

were effective in discouraging smoking. The highestrated approach, mentioned by 81 percent of those 

surveyed (N = 1,007), was providing smoking-related 

education to children in grade school. The use of public 

service campaigns, television shows, and other media to 

motivate teenagers not to smoke was mentioned by 66 

percent of respondents. Twenty-one percent felt that 

legally banning the use of tobacco would be effective. 

There is strong public support for tobacco education efforts in the schools. The 1989 Smoking Activity 

Volunteer-Executed Survey (SAVES), which was administered to adults in four states (Arizona, Michigan, Pennsylvania, and Texas), collected information on a wide 

range of issues relevant to policies concerning smoking 

(Marcus et al., in press). Trained and supervised ACS 

volunteers used standardized questionnaires to conduct 

telephone interviews of the sampled adults. Data collected in this survey found that a high proportion of the 

respondents (87 to 91 percent) agreed with the statement, 

‘There should be a strong tobacco education program in 

the school system” (Marcus et al., in press). Only a 

minority of these respondents (13 to 33 percent) agreed 

with the statement, “Currently, schools are doing enough 

to prevent children from starting to use tobacco.” This 

finding is consistent with the results of a 1990 telephone 

survey of California adults, in which 74 percent of respondents felt that antitobacco education in schools 

should be increased (California Department of Health 

services 1991). 

Restrictions on Smoking in Schools 

Traditionally, even secondary schools that prohibit 

smoking by students have allowed teachers and staff to 

smoke in designated areas away from students KJSDHHS 

1989). This double standard &l&s public opinion about 

restricting smoking in school settings. A 1987 telephone 

survey of adults in Ivlinnesota CForster et al. 1991) found 

strong support (93 percent) for a policy prohibiting students from smoking in school, and a smaller percentage 

(77 percent) favored a ban on smoking among teachers 

and staff. S&WI smoking policies, like those for other 

workplaces, have become more restrictive in recent years. 

Several states and many communities have enacted laws 

that completely ban or severely restrict smoking in schools 

and on school property (Coalition on Smoking OR Health 

1992). These laws are discussed later in this chapter. 

The 1989 Surgeon General’s report on smoking and 

health (USDHHS 1989) clearly documented the trend of 

Americans to increasingly support r&rictions on smoking in a wide range of public locations, such as restaurants, worksites, and schools. In general, surveys that 

116 Prevention 
proven ting Tobacco Use Among Young People 

ask about limiting smoking in various settings have found 

that support for such restrictions in schools is usually 

stronger than for other locations. For example, findings 

from a telephone survey for the 1989 National Cancer 

Institute (NC11 Community Intervention Trial for Smoking Cessation (COMMIT) (Centers for Disease Control 

[CDCI 1991al revealed that fewer than onequarter of 

adult respondents in 10 U.S. intervention communities 

supported a complete ban on smoking in private worksites 

and restaurants, whereas over haIf endorsed a ban on 

smoking on school grounds. Support for banning smoking in secondary schoois possibly reflects the broad societal belief that schools have an important role to play in 

discouraging tobacco use by children. 

Restrictions on Tobacco Advertising 

and Promotion 

Numerous national, state, and local surveys have 

tried to assess public opinion about restrictions on tobacco product advertising. In a series of national GaUup 

surveys (Gallup Organ&&ion 1978, 1987, 1988, 1991, 

1993) conducted between 1977 and 1993, support for a 

complete ban on cigarette advertising increased from 36 

to 53 percent. The 1989 COMMIT survey (CDC 1991a) 

of a representative sample of 300 to 400 adults 25 to 64 

years old in each of 10 intervention communities in 9 

states found that between one-half and three-quarters 

agreed with the statement, “AII tobacco advertising 

should be eliminated.” 

Some surveys have asked about limiting specific 

types of tobacco advertising (e.g., biIIboards, newspapers, magazines) and promotional practices (e.g., distribution of free tobacco samples, tobacco company 

sponsorship of sporting and cuIturaI events) (Table 1). A 

1987 telephone survey (Forster et aI. 1991) of 821 adults 

from seven Minnesota communities asked respondents 

to indicate their support for restrictions on various forms 

of advertising. Seventy-three pemnt of respondents 

favored a ban on tobacco signs and billboards; 70 percent 

supported a ban on tobacco advertising in newspapers 

and magazines. The ACSsponsored 1989 SAVES 

survey of four states found that support for a ban on 

cigarette advertising in newspapers, in magazines, and 

on billboards ranged from 61 to 69 percent Wu-cus et al., 

in press). Over three-quarters of respondents in this 

survey agreed with the statement, ‘Tobacco companies 

should be prohibited from distributing free tobacco 

samples on public property or through the mail.” Comparable results were obtained in a 1990 telephone survey 

of adults in California (Cahfornia Department of Health 

Services 1991). Fifty-four percent of respondents in this 

survey supported a ban on tobacco ads on outdoor biIIboards; 49 percent supported a ban on tobacco ads in 

newspapers and magazines; 67 percent supported a ban 

on the distribution of free tobacco samples or coupons 

to obtain free samples by mail; and 75 percent supportt~I 

a ban on the distribution of free tobacco samples on 

public property. 

Three surveys (Cahfomia Department of Health 

Services 1991; CDC 1991a; Marcus et al., in press) have 

measured public opinion about tobacco company sponsorship of sporting and cuIturaI events (Table 11. In the 

1989 COMMIT survey (CDC 1991a) of 10 communities, 

from one-third to more than one-half of respondents 

supported a ban on such sponsorship. The 1989 SAVES 

survey (Marcus et al., in press) found that about one&If 

of respondents agreed with the statement, ‘Tobacco companies should be prohibited from sponsoring sports 

events or advertising their products at these events.” 

Fe-two percent of respondents in the aforementioned 

1990 California survey (C&forma Department of Health 

Services 1991) believed that sponsorship of sporting or 

cultural events by tobacco companies should be banned. 

In all three surveys, support for a ban on tobacco company sponsorship of sporting and cultural events was 

about twice as strong among nonsmokers as it was 

among smokers. 

The function and eff& of tobacco advertising have 

been the subjj of much controversy and debate among 

scientists and within the tobacco industry. The tobacco 

industry has argued that advertising targets adults only 

and encourages regular smokers to switch brands or to 

maintain brand loyalty (Tobaclrx, Institute 1964; see ‘The 

‘Maturity’ of the Cigarette Market” in Chapter 5). Many 

health experts assert that tobacco advertising targets chiIdren to encourage them to start using tobacco Crye 1987; 

DiFranza et al. 1991; Fischer et al. 1991; Pierce et aI. 1991; 

CDC 1992a). In fact, a major newspaper, the Seattle Times, 

voluntariIy discontinued tobacco advertising in June 1993, 

citing “growing medical evidence on the dangers of smoking, as weII as tobacco advertisers’ recent targeting of 

youth and racial minorities” (Nogaki and Gupta 1993, 

p. El). LegisIative proposals to restrict or prohibit tobacco advertising are often presented as a means of 

protecting children (Myers and HoIIar 19891. In 1986, 

about haIf of the respondents to the Adult Use of Tobacco 

Survey (AU’IS) (USDHHS 199OcI agreed with the statement, “If cigarettes were not advertised anywhere, fewer 

young people would start smoking.” In July 1990, a 

national Gallup survey (Gallup Organization 199Oc) of 

adults found that more respondents (49 percent) thought 

that advertising and promotion paid for by the tobacco 

companies represented an active attempt to get teenagers and young people to start smoking than believed that 

such efforts were to encourage brand switching among 

people who already smoke (38 percent). 

Prevention 227 
Surgeon General’s Report 

Table 1. Public opinion about restricting or banning different types of tobacco advertising and promotions, 

United States, 1987-1991 

Source and 

year of survey Description of survey _ Questions or statements Responses 

American Cancer 

Society 1989 

(Marcus et al., in 

press) 

Telephone survey of a 

random sample of adults 

(aged > 18 years) in four 

states: Arizona (N = 294), 

Pennsylvania (N = 2911, 

Texas (N = 3031, and 

Michigan (N = 98) 

Advertising of cigarettes should be 

banned in newspapers, magazines, 

and outdoor posters or billboards. 

Tobacco companies should be 

prohibited from distributing free 

tobacco samples on public property 

or through the mail. 

Agreement across the 

four states sampled: 

61%-69% 

73%-81% 

Tobacco companies should be 

prohibited from sponsoring sports 

events or advertising their products 

at these events. 

49%59% 

California 

Department 

of Health 

Services 1990 

(California 

Department 

of Health 

Services 1991) 

Telephone survey of a 

random sample of adults 

(aged Z 18 years) in 

California (N = 6,600) 

Do you think advertising of tobacco 

products on outdoor billboards 

should be allowed or banned? 

Do you think advertising of tobacco 

products through newspapers and 

magazines should be allowed or 

banned? 

54% favored a ban 

(42% smokers; 62% 

nonsmokers) 

49% favored a ban 

(38% smokers; 57% 

nonsmokers) 

Do you think sponsorship of sporting 52% favored a ban 

or cultural events by tobacco companies (39% smokers; 61% 

should be allowed or banned? nonsmokers) 

Do you think that distribution of free 

cigarettes and tobacco products on 

public property should be allowed 

or banned? 

75% favored a ban 

(62% smokers; 84% 

nonsmokers1 

Do you think that distribution of free 

tobacco samples or coupons to obtain 

free samples by mail should be 

allowed or banned? 

67% favored a ban 

(52% smokers; 78% 

nonsmokers) 

*COMMIT = Community Intervention Trial for Smoking Cessation. 

128 Prevention 
preventing Tobacco Use Among Young People 

Data collected in a 1992 national telephone poll 

(N = 1,200) of adults (Louis Harris and Associates 1992) 

suggest that a predominant belief in the individual’s 

fight to smoke coexists with a less predominant concern 

about the persuasive power of tobacco advertising. An 

overwhelming majority (87 percent) of respondents 

agreed with the proposition that “to smoke or not to 

smoke is a personal decision that adults should be free to 

make for themselves.” On the other hand, 68 percent 

favored a ban on tobacco ads in newspapers, in magazines, and on billboards; 73 percent said they would 

support an initiative to require stronger warning labels 

on cigarette packages; and 83 percent would favor legislation banning tobacco ads targeted at teenagers. Three 

quarters of smokers themselves supported a ban on 

tobacco ads targeted at teenagers. The survey report 

concludes that “even smokers see smoking as something 

to be discouraged, especially where teenagers are 

concerned” (p. 39). 

Restrictions on the Sale of Tobacco Products 

to Minors 

Public opinion strongly favors measures to discourage tobacco sales to minors (persons under the age of 18). 

A 1962 national Gallup personal interview survey (Gallup 

Organization 1962) found that 79 percent of adults sup 

ported the idea that there should be a law against selling 

cigarettes to people under 16 years old. According to the 

1964 AU’IS (U.S. Department of Health, Education, and 

Welfare JLJSDHEWJ 1%9), only 9 percent of adults thought 

that sales of cigarettes to young people under a certain age 

should not be against the law. Today, all states have laws 

prohibiting the sale of cigarettes to persons under 18 years 

old (CDC, OSH, unpublished data). 

On July 10, 1992, Congress passed Public Law 

102-321, the Alcohol, Drug Abuse, and Mental Health 

Administration (ADAMHA) Reorganization Act, which 

contained Section 1926, providing for the enforcement of 

minors’ access legislation in all states receiving funding 

for the prevention and treatment of substance abuse. 

These provisions required funded states to enforce legislation prohibiting the sale or distribution of tobacco products to individuals under the age of 18. Enforcement 

included yearly random, unannounced inspections as 

well as annual reports to the Secretary of Health and 

Human Services describing the state’s enforcement activities for that year, the extent of success in reducing the 

availability of tobacco to children under 18, and enforce 

ment strategies to be used in the next year for which 

funding was being sought. By June 1993,49 states and 

the District of Columbia had passed legislation in compliance with Section 1926, prohibiting the sales and 

distribution of tobacco products to children under the 

age of 18. (Virginia restrictions applied only to sales of 

tobacco products.) 

Most people do not believe that laws prohibiting 

the sale of tobacco to minors are adequately enforced, 

and the overwhelming majority of both smokers and 

nonsmokers support stronger measures to limit minors’ 

access to tobacco. The 1989 SAVES (Marcus et al., in 

press) found that 8 out of 10 adults felt it was “very easy” 

or “somewhat easy’ for teenagers to buy cigarettes near 

where they live (see ‘Factors That Influence Tobacco 

Acceptability and Availability’ in Chapter 4). The overwhelming majority of respondents to this survey (86 to 

92 percent) felt that there should be better enforcement of 

existing laws banning the sale of tobacco to minors, and 

most (83 to 88 percent) endorsed the idea that the laws 

should be strengthened. Results of a 1990 survey of 

California adults (California Department of Health Services 1991)provideasimilarpicture;76percentresponded 

negatively when asked, ‘Do you think the laws banning 

the sale of tobacco products to minors have been adequately enforced?” 

Several different surveys have tried to assess 

public opinion regarding specific types of legislative 

actions (e.g., licensing retailers and banning cigarette 

vending machines) to prevent minors’ access to tobacco 

(Table 2). A 1987 survey of adults in Minnesota (Forster 

etal.l991)foundthat75percentfavoredapolicywhereby 

retailers would lose their tobacco licenses if they sold 

cigarettes to minors. Two-thirds of adult participants in 

the 1989 COMMlT survey (CDC 1991a) agreed with the 

statement, ‘Tobacco products should be as strictly controlled as alcohol products.” The majority of respondents in this survey (from 77 to 93 percent) also agreed 

with the statement, ‘Merchants who sell tobacco to minors should be fined.” 

The 1989 SAVES (Marcus et al., in press) asked 

respondents in four states if they thought the sale of 

cigarettes through vending machines should be banned. 

Overall, between 60 and 68 percent of respondents favored a ban on cigarette vending machines; smokers 

were much less likely than nonsmokers to support a ban 

(42 to 58 percent vs. 66 to 72 percent). The 1987 Minne 

sota survey (Forster et al. 1991) found that 57 percent of 

adults supported a policy eliminating all cigarette vending machines; 80 percent favored a policy banning vending machines in locations where teenagers gather. In the 

1990 California survey (California Department of Health 

Services 19911, a majority of both smokers (74 percent) 

and nonsmokers (87 percent) favored the idea of banning cigarette vending machines that are accessible to 

minors. A similar result was found in the 1989 COMMIT 

survey (CDC 1991a), wherebetween 76 and 89 percent of 

adults agreed with the statement, “Cigarette vending 

Prevention 129 
Surgeon General’s Report 

Table 2. Public opinion about different legislative actions to prevent minors’ access to tobacco, United 

States, 1987- 1991 

Source and 

year of survey Description of survey Questions or statements Responses 

American Cancer 

Society 1989 

(Marcus et al., in press) 

Telephone survey of a 

random sample of adults 

(aged 2 18 years) in four 

states: Arizona (N = 294L 

Pennsylvania fN = 2911, 

Texas (N = 3031, and 

Michigan (N = 98) 

Do you think there should 

be laws to ban the sale of 

cigarettes through vending 

machines? 

Support for a ban across 

the four states sampled: 

60%-68% 

California 

Department of Health 

Services (California 

Department of Health 

SeNiCes 1991) 

Telephone survey of a 

random sample of adults 

(aged 2 18 years) in 

California (N = 6,600) 

Do you think cigarette 

vending machines that are 

accessible to minors should 

be allowed or banned? 

82% favored a ban (74%. 

smokers; 87% nonsmokers) 

‘COMMIT = Community Intervention Trial for Smoking Cessation. 

machines should be eliminated in places where teens 

gather.” 

Taxes on Tobacco Products 

Public opinion surveys consistently show that most 

people would support an increase in tobacco taxes over 

other taxes (such as income tax, sales tax, or gasoline tax) 

(Gallup Organization 1989,1990a, 1993; Hart Research 

Associates and Robert Teeter 199Oa, b, c; Yankelovich, 

Clancy, Shulman WOa, b; ACS 1992; Kleine 1993). Surveys conducted between 1989 and 1993 show strong 

support for raising taxes on tobacco and alcohol as a way 

of nzducing the federal budget deficit or to pay for health 

care reform (‘Toner 19931 (Table 3). 

Support for raising tobacco taxes tends to increase 

when tax revenue is earmarked for specific purposes, 

120 Prevention 
Preventing Tobacco Use Among Young Peopie 

especially for health and educational programs (Gallup cigarettes to pay for an expanded federal antidrug pro- 

&ganization 1993), such as those aimed at preventing gram. The same questions asked in 1990 found that 77 

children from smoking or from using drugs. A 1989 percent supported raising cigarette taxes (Associated 

national survey sponsored by the Associated Press (Asso- Press/Media General 1990). The 1989 SAVES (Marcus et 

&ted Press/Media General 1989) found that 75 percent of al., in press) found that about twc&irds of adults favored 

adults supported increasing the federal excise tax on using an extra tax on tobacco to cover the cost of 

Table 3. Public opinion about increasing tobacco taxes, United States, 1989-1990 

- 

Source and 

year of survey Description of survey Questions Responses 

Gallup Organization 

1989 

National personal Taking into account 64% favored raising cigainterview survey with the amount each (tax) rette taxes by 16 cents per 

2,048 adults (aged 2 18 would raise, and your pack; the only other tax 

years) opinion about these measure mentioned more 

taxes, which, if any, frequently was raising the 

would you favor as a tax on alcohol (69%) 

means of reducing the 

federal budget deficit? 

Hart Research 

Associates and 

Robert Teeter 

1990a, b, c 

National telephone 

survey of a random 

sample of registered 

voters (January survey 

N = 1,510; May survey 

N = 1,007; July survey 

N = 1,555) 

* ‘,. ,.‘.*;z,‘:- ^ _ .- 

Let us suppose the January 1990: 78% favor 

government needed to May 1990: 83% favor 

raise taxes. Do you July 1990: 78% favor 

favor or oppose 

raising alcohol and 

tobacco taxes? 

Associated Press/ 

Media General 

1989,199O 

National telephone 

survey of adults (aged 

2 18 years) (September 

1989 survey N = 1,071; 

May 1990 survey 

N = 1,143) 

..,i. .;I “:-22i :b& 

To pay for a bigger September 1989: 75% favor 

federal antidrug May 1990: 77% favor 

program, would you 

support or oppose 

higher federal taxes on 

cigarettes? 

Preuen tion 121 
Surgeon General ‘3 Report 

campaigns to reduce smoking. A 1987 national survey 

sponsored by the American Medical Association (Harvey 

and Shubat 1987) found that 79 percent of adults favored 

an increase in the tax on tobacco products if the money 

from the increase went to Medicare. A 1992 survey of 

Michigan adults (ACS 1992) found that 72 percent would 

support raising the state’s cigarette excise tax if the additional revenue would be targeted for health care and 

education. Interestingly, 58 percent of respondents to 

this survey claimed that they would vote for a candidate 

who supported the tobacco tax increase, whereas 27 

percent would vote for a candidate who opposed the tax 

increase. 

Some relevant information on public opinion re 

garding tobacco taxes comes from a survey conducted in 

Canada, where tobacco taxes have increased sharply in 

the past decade. A December 1990 poll conducted for the 

Council for Tobacco-Free Ontario (Council for a Tobacco 

Free Ontario/Non-Smokers’ Rights Association 1992) 

questioned Ontarians about their support for a substantial increase in the tobacco tax. Overall, 58 percent of 

Ontarians supported a Went per pack increase in the 

cigarette tax; this support did not change when respondents were informed that taxes currently accounted for 

60 percent of the retail price of cigarettes. However, 

when respondents were told that higher tobacco prices 

could prevent children from starting to smoke, support 

for the tax increase climbed to 67 percent. Support was 

even higher when respondents were told of different 

ways to use revenues raised by the new tax, such as 

reducing the budget deficit (70 percent support), helping 

people quit smoking (78 percent support), and estabhshing a fund to help prevent smoking among young people 

(84 percent support; 77 percent among smokers). 

Educational Efforts to Prevent Tobacco Use Among Young People 

School-Based Smoking-Prevention Programs 

Introduction 

Since the 1964 publication of the first Surgeon 

General’s report on smoking and health (public Health 

Service [R-IS] 1964), smoking prevention has been recognized as a primary strategy for controlling smoking in the 

general population. The first report identified the difficulty that long-term adult smokers typically experience 

in their attempts to quit. The report thus advocated 

programs directed at educating high school and college 

students about the health hazards of smoking; in theory, 

school-based programs would interfere with the development of smoking behavior before smoking became 

firmly established. 

When the term “prevention” was applied to healthrelated issues in the 196Os, however, the concept referred 

not exclusively to school curricula but also to efforts to 

disseminate warnings about products and practices that 

public health professionals considered potential health 

hazards (Schwartz 1969). The approach to prevention 

research at that .time consisted of biomedical research to 

establish physiological mechanisms of smoking-related 

diseases, coupled with epidemiologic research to identify etiologic characteristics of smokers. This research 

led, when appropriate, to the dissemination of findings 

and recommendations to the public. A proclamation and 

direct warning from the U.S. Surgeon General about the 

life-threatening characteristics of cigarette smoking was 

expected to convince smokers to quit and nonsmokers to 

avoid taking up the practice. Had this effect been the 

case, the concept of smoking prevention might never 

have amounted to mom than “spreading the word” to 

those segments of the population who had not yet received it. Unfortunately, nearly three decades later and 

despite monumental efforts to disseminate warnings, 

cigarette smoking remains the single most preventable 

cause of death and disease in our society WSDHHS 

1989). 

This section reviews the evolution of the concept of 

smoking prevention since the 1960s and identifies avenues for future progress in this area. 

Early Approaches to Smoking Education and 

Prevention 

In the 1960s and early 197Os, strategies to prevent 

the onset of cigarette smoking were often based on the 

premise that adolescents who engaged in smoking behavior had failed to comprehend the Surgeon General’s 

warnings on the health hazards of smoking (Thompson 

1978). The assumption was that these young people had 

a deficit of information that could be addressed by pre 

senting them with health messages in a manner that 

caught their attention and provided them with sufficient 

justification not to smoke. Improvements in knowledge 

levels, or cognitive factors, would thus lead directly to 

changes in behavior. 

122 Prevention 
Preventing Tobucco Use Among Young People 

fnformation Deficit Model 

Early prevention programs based on this information deficit model tried to heighten young people’s aware 

ness and comprehension of the negative consequences of 

smoking. Programs based on this model used various 

educationaI methods to convey information, including 

books, pamphlets, posters, films, and lectures Chomp 

son 1978). Through images and messages often intended 

to arouse fear, these programs were designed to convince the adolescent audience that persons who smoke 

risk a variety of serious physical consequences throughout their lives, including an increased likelihood of premature death in adulthood from cardiovascular disease 

or cancer. 

The underlying assumption of these informationfocused programs proved to have limited grounding. 

Although expanded educational efforts in schools 

throughout the 1970s provided adolescents with various 

kinds of smoking-related information, this information 

alone did not deter them from beghming to smoke. Comprehensive reviews published at that time concluded 

that smoking-prevention programs based on the information deficit approach were not effective (Thompson 

1978;Goodstadt 1978). providing knowledgeof the health 

consequences of smoking is still an important task for 

public health, but this single strategy is not sufficient to 

change most young people’s behavior. 

Affective Education Model 

The information deficit model did not take into 

account the complex relationship between knowledge 

acquisition and subsequent behavior (nor, as will be 

discus& later, did it consider the addictive nature of 

tobacco use). For example, cognitive factors are mediated by different personal variables, including changes 

in attitudes, beliefs, intentions, and perceived norms 

(M&rim 1%4; Fishbem 1%7J. To rectify the shortcomings of information-focused interventions, alternative 

smoking-prevention approaches that evolved during the 

1970s tried various forms of motivational or affective 

education. These approaches, which came to be referred 

to collectively as the affective education model, were 

based on the assumption that adolescents smoke cigarettes because their self-perceptions are somehow compatible with a health-compromising behavior like 

smoking Khrell and Btioski 1984). Interventions based 

on the affectke model sought to increase adolescents’ 

Perceptions of self-worth and to establish or clarify a 

health-related value system that would support a young 

Person’s decision not to smoke. 

Another assumption typicalIy made by prevention 

Programs based on the affective education approach 

was that information specific to tobacco was neither 

necessary nor sufficient for reducing the onset of cigamttesmoking among adolescents (Goodstadt 1978). These 

affective approaches evolved out of the direct experiences of educators and counselors who had begun to 

associate cigarette smoking among adolescents with various problem behaviors, including school absenteeism, 

low achievement motivation, and antiso&l behavior. 

The intervention programs suggested that adolescents 

who experienced such problems could rectify them 

through changes in their attitudes toward school, family, 

or community, if sufficiently motivated to do so. 

Reviews based on more than a decade of research 

have concluded that interventions based on the affective 

education model were no more,, effective in reducing 

adolescent smoking than those based on the information 

deficit model. Some studies have even suggested (that is, 

without conclusive findings) that these programs may 

have had the untoward effect of eliciting interest in the 

behaviors they attempted to discourage (Kinder, rape, 

Walfish 1980; Schaps et al. 1981; Hansen et al. 1988). 

Nonetheless, affective education programs marked the 

begiming of an era during which enormous effort was 

expended to design smoking-prevention interventions 

that were more directly related to the factors believed to 

cause smoking among adolescents. 

Correlates of Adolescent Smoking Behavior 

Evaluations of interventions before the mid-1970s 

suggested that these approaches were insufficient for 

several reasons. For example, although high school and 

college students were the intended targets of smokingprevention programs in the 1940s and 197Os, the development of smoking behavior follows a series of stages 

that typically begin earlier in life, when students are in 

the sixth or seventh grade (Lever&al and Cleary 1980). 

Such findings suggest that smoking-prevention interventions need to be initiated earlier than high school and 

that attention should be given to the various stages that 

adolescent smokers moved through as they developed 

from nonsmokers into regular smokers (Chassin, I’resson, 

Sherman 1985). 

As opposed to the narrow focus of prevention models based solely on information or affective factors, a 

broader focus and a more diverse set of correlates or 

antecedents began to emerge as important determinants 

of adolescent cigarette smoking. As reviewed by Evans 

(19841, these factors have been studied categorically as 

so&demographic, environmental, behavioral, and personal variables. Throughout the 198Os, using data from 

both longitudinal (McAlister, Krosnick, Milbum 1984) 

and cmss+e&onal (Chassin, presson, Sherman 1984) 

surveys, researchers developed a clearer understanding 

of the etiology of smoking behavior. 

Prezwntion 123 
Surgeon General’s Report 

This research showed that prevention strategies in 

the 1960s and 1970s had greatly underestimated the extent to which adolescent smoking was determined by 

social environmental variables. An exception was the 

early work of the proactive physicians group Doctors 

Ought to Care (DOC), which argued that tobacco advertising and promotional activities strongly influence the 

social environment of adolescents (Blum 1980). A detailed overview of the relationships of social environmental variables to .the acquisition of smoking behavior 

is found in Chapter 4 of this report (see “Environmental 

Factors in the Initiation of Smoking”). 

As the major risk factors associated with smoking 

onset were identified, they were translated into new 

intervention methods, and the programs that resulted 

were substantially different from the approaches that 

had preceded them. 

Instilling Skills for Resisting Social Influences 

to Smoke 

Prevention research grants from the National Institute on Drug Abuse @JIDA) and the National Institutes 

of Health (Bell and Levy 1984; USDHHS 1984; Stone 

1985; Glynn 1989) were largely responsible for creating a 

wave of prevention program development from the late 

1970s throughout the 1980s. These efforts fundamentally redefined the concept of primary prevention in 

several ways. 

First, programs began to make better use of social, 

psychological, and behavioral theories as a basis for understanding what approaches might work to modify 

patterns of smoking onset among adolescents. Program 

design became far more data driven, as researchers began to design intervention components based directly on 

findings from theory-based etiologic research on adolescent smoking. This orientation led to an improved understanding and targeting of the determinants and 

correlates of smoking behavior among adolescents. Much 

information was published about the characteristics and 

components of successful smoking-prevention programs. 

Much of what has been learned focuses particularly on 

social infhrences, norms, and skills training and has the 

objective of attaining behavioral abilities, methods, skills, 

and techniques (rather than knowledge, beliefs, or motivation) that make it easier to adopt and maintain healthenhancing behavior patterns, such as not smoking. Lastly, 

the research methodology used to evaluate the efficacy 

of preventive interventions became far more sophisticated and considerably more rigorous. 

Intervention Objectives 

This prevention intervention approach recognizes the social environment as the most important 

determinant of smoking onset and focuses on the development of norms and skills to identify and resist social 

influences to smoke. Underlying this approach is the 

assumption that adolescents who smoke may lack specific skills to deal successfully with various social influences that support smoking. Such influences include the 

misperception that most people smoke, the perceived 

desirable social image of smoking, the appeal of cigarette 

advertising and promotional activities, and the persuasive effects of sibling and peer smoking. Although considerable variation can be found across curricula, 

programs that instill the skills needed to resist such social 

influences have included a fairly consistent group of 

components that include training in resisting social pressures (e.g., marketing) and peer pressures to smoke and 

training that fosters general assertiveness, decision making, and communication skills (Botvin and Wills 1985). 

These programs also promote healthful normative expectations and particularly correct the misperception that 

most adolescents smoke. 

Earlier programs for adolescents designed their 

messages to generate fear and anxiety about long-term 

disease risk. Approaches that teach skills to guard against 

social influences have assumed that scare tactics based 

on long-term health risk are not pertinent to the shortterm perspective of many adolescents. The principal 

messages of skills-based intervention have thus focused 

on the negative, short-term social consequences of smoking, on the techniques of tobacco advertising that may be 

falsely appealing to adolescents, and on the socially salient advantages of being a nonsmoker. 

Overall Program Structure 

In 1987, the NCI convened a panel of experts to 

establish consensus regarding the essential structural 

elements of effective smoking-prevention programs 

(USDHHS 1991). The panel agreed that eight features 

could be considered both necessary and sufficient for 

effective school-based smoking-prevention programs 

(Glynn 1989) (Table 4). In a recent meta-analysis (Mooney 

1992) of outcomes of research studies conducted from 

1974 through 1989 on school-based smoking prevention, 

the essential elements of the NCI expert panel were 

examined and mostly supported. This meta-analysis 

will be discuss& later in this chapter. 

Most of the successful programs that provide skills 

for resisting social influences share several major curriculum components. One of these is to convey the shortterm negative consequences of cigarette smoking, 

including social undesirability and physiological impairment. Another component is to have students explore 

inaccurate normative expectations; students thus learn 

that cigarette smoking is not a normative behavior for 

124 Prevention 
preventing Tobacco Use Among Young People 

adolescents their age and that the majority of persons in 

any age group are nonsmokers. Students examine the 

reasons that adolescents say they smoke, including to be 

accepted by peers, to appear mature, or to help cope with 

difficult situations. The factors that affect adolescent 

smoking can also be explored, including the influence of 

parents, peers, and mass media; for example, students 

can learn how role modeling and advertising can falsely 

establish positive cultural meanings for smoking (see 

“Research on the Effects of Cigarette Advertising and 

Promotional Activities on Young People” in Chapter 5). 

A related component is to engage students in training, 

modeling, rehearsing, and reinforcing methods that 

counter these influences and to coach students to communicate these techniques to others. Some approaches 

also include generic personal and social skills training to 

promote overall competence and reduce motivations to 

smoke (Botvin and Wills 1985). 

Curriculm Format 

Among the numerous approaches to teaching skills 

to resist sociai influences to smoke, the format variations 

are in most cases minor (Best et al. 1988). For example, a 

number of these approaches rely on classroom teachers 

to deliver the smoking-prevention program. The sixsession program designed by Colquhoun and Cullen 

(1981) focused on refusal skills training provided by 

classroom teachers with the help of local physicians. 

Biglan, Glasgow, et al. (1987), on the other hand, trained 

health and science teachers to deliver intervention sessions on four consecutive days, followed by a booster 

session two weeks later. 

Other intervention variations have used a combination of trained staff or teachers plus student peer leaders. 

Pa~y,IQepp,andSillas(1989),forscample,usedsame-age 

pees in a smoking-prevention program that promoted 

cardiovasda.r health. Ellickson and Bell (19901, on the 

other hand, employed trained health educators to deliver 

their intervention to seventh gradexs and contrasted this 

approach by delivering the intervention through students’ 

mgulartea&rsa&tedbyteenleademSiily,Arkinet 

al. (1981) organ&d seventh-grade student nominations of 

classmates who students felt would be effective peer leaders Those selected then served as discussion leadem and 

helped students rehearse and n&play appropriate responsestosituatiomthatsimuIatedsociaI~. 

In Project SHOUT (Students Helping Others Understand Tobacco), college undergraduate students in 

psychology, health sciences, and other majors worked 

for college credit toward their degrees by serving as peer 

leaders to young adolescents. The college students were 

mature and reliable enough to deliver interventions (both 

in the classroom and over the telephone, in booster calls) 

yet sufficiently youthful to be acceptable to an adultwary audience (Young et al. 1988; Young et al. 1990; 

Elder et al. 1993). 

Table 4. Essential elements of school-based smoking-prevention programs 

1. Classroom sessions should be delivered at least five times per year in each of two years in the sixth 

through eighth grades. 

2. The program should emphasize the social factors that influence smoking onset, short-term 

consequences, and refusal skills. 

3. The program should be incorporated into the existing school curricula. 

4. The program should be introduced during the transition from elementary school to junior high or 

middle school (sixth or seventh grades). 

5. Students should be involved in the presentation and delivery of the program. 

6. Parental involvement should be encouraged. 

7. Teachers should be adequately trained. 

8. The program should be socially and culturally acceptable to each community. 

Source: Glynn (1989). 

Praention 125 
Surgeon General’s Report 

Other variations in intervention approaches have 

used media supplements and involved students’ parents. Flay et al. (1987), for example, used a five-day 

smoking-prevention curriculum in junior high school 

classrooms and coordinated it with five different fiveminute video segments aired on a local television station. 

The focus of these television segments was smoking prevention, and they were followed the next week by five 

more segments dealing- with smoking cessation (Flay et 

al. 1987). 

Pentz et al. have trained health, science, and social 

studies teachers to deliver a social influences program 

that was reinforced by 10 homework activity sessions 

involving parents and other family members in role playing and other forms of behavioral rehearsal (Penk, Dwyer, 

et al. 1989). In a related project, this group has developed 

a component that asks parents to attend organizational 

meetings, support school activities, and participate in an 

educational workshop (Penk, MacKinnon, Flay, et al. 

1989). The results of these studies are discussed later in 

this chapter, along with other community programs. 

Biglan, Glasgow, et al. (1987), have also designed a 

component that tries to enlist direct parental support of 

their standard classroom curriculum. The component 

relies on a set of four mailed messages for parents of 

participating students. These messages reinforce classroom activities, encourage family discussions of smoking 

in general, and urge parents to establish family policies 

regarding smoking. 

Walter, Vaughan, and Wynder (1989) embedded 

smoking education in a comprehensive school health 

education program, the Know Your Body Program, with 

fourth- through eighth-grade students in New York. This 

more comprehensive program had a significant impact 

on multiple risk-related behaviors, including cigarette 

smoking. 

Finally, Cain, Dudley, and Wilkerson’s (1992) 

“Tar Wars” program has used health professionals 

to deliver antitobacco messages with the help of 

fourth-, fifth-, and sixth-grade children. The students 

participate in a poster contest to counter the messages of 

tobacco advertising, and a communitywide media campaign complements the school program. Originating in 

1977, this program is based on the DOC program 

Superhealth 2000, which similarly emphasized 

counteradvertising skills among 7th- through 10th~grade 

students (Blum 1980). 

A number of recent reviews have closely examined 

issues related to program design and content (Botvin and 

Wills 1985; Flay 1985; Glasgow and McCaull985; Hansen 

1992). Rather than replicate these efforts here, the next 

section will provide examples of the range of programs 

that can teach adolescents the skills needed to resist social 

influences to smoke. 

Exemplary Programs for Resisting Social 

Influences 

Social Inoculation 

In the mid-1970s Evans et al. developed the first 

prevention program that instilled adolescent skills to 

resist social influences to smoke. The program, described 

as “social inoculation,” taught students methods for recognizing and coping with pressures to smoke from peers, 

family, and the media fMcGui.re 1964). The program’s 

hypothesis was that if young adolescents received classroom “inoculations” of “peer pressure,” for example, 

and learned how to deal with it, they would be more 

prepared to resist actual social pressure from peers. 

Additional emphasis was placed on the immediate physiological impairments that smoking produces, rather than 

on long-term consequences (Evans et al. 1979). The 

program used videotapes of nonsmoking peers to impart information and to teach skills needed to resist social 

influences. In the pilot study involving 750 seventhgrade students, the proportion of nonsmokers in the 

experimental group who 10 weeks earlier had reported 

smoking at least one cigarette was approximately half 

that of those in the control group. 

This research group introduced a notable procedure for enhancing the validity of self-reported smoking 

behavior among study subjects. Students were shown a 

film indicating that their smoking status could be verified biochemically by analyzing a sample of their saliva. 

The perception that the samples could be examined led 

to more truthful reporting by students and thereby decreased misclassification bias due to inaccurate self-reports (see “Validity of Measures of Smoking,” Appendix 

2, in Chapter 3). 

Although interpretations of results from this early 

work were complicated by a variety of methodological 

flaws (Flay 19851, Evans’ work provided the foundation 

for much of the smoking-prevention research that followed over the next decade. 

Project CLASP 

Later in the 197Os, McAlister et al. (1980) developed 

anintervention&ledCounselingLeadershipAboutSmoking Pressure CLASP), during which peer leaders from 

high school were trained to help junior high school students develop the skills needed to resist social pressures to 

smoke. The students learned to identify social pressures 

and then rehearsed and modeled strategies for coping 

with them McAlister et al. 1980). 

Besides this use of older students as peer leaders, 

the use of behavioral rehearsal methods and strategies to 

enhance commitment to nonsmoking was an innovation 

126 Prevention 
preventing Tobacco Use Among Young People 

that has been incorporated into many of the prevention 

programs developed later. The intervention consisted of 

three sessions delivered on consecutive days, followed 

by four booster sessions delivered over the remainder of 

the seventh-grade school year. Nine months after pretest, 5.6 percent of the treatment group and 9.9 percent of 

the control group reported smoking during the previous 

week-a statistically significant 56 percent difference be 

tween the groups. These reductions in smoking prevalence were observed up to the 10th grade. 

Life Skills Training 

botvin (1986) has developed another variation of 

the social influences approach that includes resistance 

skills, behavioral rehearsal, role playing, self-control, decision making, problem solving, and self-reward, as well 

as components devoted to increasing self-esteem, selfconfidence, autonomy, and assertiveness. The program,’ 

called Life Skills Training, includes various aspects of 

cognitive-behavioral psychological training. The program consists of 15 to 20 sessions for seventh-grade 

students; booster sessions are given in the eighth and 

ninth grades. The specific objectives of the program are 

to teach skills that help students resist direct pressures to 

smoke; to enhance students’ self-esteem, self-mastery, 

and self-confidence in order to decrease their susceptibility to indirect social pressures to smoke; to prepare students to cope with anxiety induced by social situations; 

to enhance students’ knowledge of the actual prevalence 

of smoking among adolescents and adults; and to promote attitudes and beliefs consistent with nonsmoking. 

This program has been evaluated extensively in 

progressively larger studies over the past decade; the 

encouraging results have ranged from 40 to 80 percent 

reductions in smoking prevalence, and long-term effects 

havelasteduptofouryears(BotvinandDusenbury1989). 

In the most comprehensive evaluation of the Life Skills 

Training program to date, 56 schools in three different 

geographic regions were randomly assigned to three 

study conditions: Life Skills plus one-day teacher training, Life Skills plus video training for teachers, and a 

control condition. Significant positive effects were reported for cigarette use (see Table 5) and for smokingrelatedknowledge,attitudes,andnormativeexpectations. 

In most cases, the two treatment conditions had similar 

results; students in both groups demonstrated more positive effects than students in the control group (Botvin et al. 

1990). The effects of the Life Skills Training program have 

been demonstrated when the program hasbeen delivered 

by project staff, older peers, or regular classroom teachers. 

These effects have also been demonstrated on inner-city 

Table 5. Outcomes of the Life Skills Training (LST) program: adjusted third-year follow-up mean for 

smoking-related knowledge, expectations, personality measures, and behavior 

Adjusted mean scores* 

LST LST 

(with (with 

Smoking variable teacher training) video training) 

Knowledge 

Smoking prevalence 1.10* 1.16+ 

Smoking consequences 4.W 4.60A 

Smoking acceptability 1.495 1 .52A 

Normative expectations 

Adult smoking 3.92+ 3.95+ 

Peer smoking 3.80’ 3.77+ 

Personality measures 

Self-esteem 34.25+ 34.07 

Self-efficacy 19.27 19.20 

Social anxiety 28.71t 29.36 

Smoking behavior 1.46” 1.50$ 

Source: Botvin et al. (1990). 

‘Means for LST groups differ from control group at + p < .05, fp -C .Ol, §p < .OOl, and “p < .OOOl. 

Control 

.93 

4.13 

1.37 

4.22 

3.92 

33.65 

19.26 

29.92 

1.63 

Prevention 127 

161-235 95-5 
Surgeon General’s Report 

populations of predominantly Hispanic (Botvin et al. 

1992) and black (Botvin et al. 1989; Botvin and Cardwell 

1992) adolescents. 

The SODAS Model 

Several researchers have developed a variation of 

the social skills training approach that adds to the basic 

components of resistance skills, behavioral rehearsal, and 

role playing. The additional components focus on selfcontrol, decision making, problem solving, and selfreward. Using a problem-solving approach called Stop, 

Options, Decide, Act, and Self-Praise (SODAS), students 

are taught self-control skills for smoking prevention 

coupled with self-reward for personal successes (S&i&e 

et al. 1986; Gilchrist et al. 1986). 

This research group has conducted a variety of 

studies evaluating this intervention model in different 

settings and using varied delivery modalities. The results 

of these studies have consistently demonstrated that treatment students reduce their smoking prevalence more 

than control students and that treatment students have 

greater positive changes in smoking-related knowledge and attitudinal factors (Schinke and Gilchrist 1984, 

1985,1986). 

The Waterloo Smoking-Prevention Program 

Investigators at the University of Waterloo (Ontario, 

Canada) have carried out a series of largescale, long& 

dinal studies evaluating the efficacy of an intervention 

that teaches sixth-grade students the skills they need to 

resist social influences to smoke. This intervention is 

based on an integrative model of attitude and behavior 

changes surrounding health issues that suggests that if 

information is attended to, comprehended, and accepted, 

it may lead to changes in beliefs. Beliefs, however, will 

not necessarily lead to changes in attitudes, and attitudes 

will not necessarily lead to changes in intentions unless 

values, expectancies, and social influences are considered. Lastly, intentions will not necessarily lead to changes 

in behavior unless the individual has the requisite control and coping skills (Flay 1986). 

The intervention program has three main components that are delivered to sixth graders in six one-hour 

weekly sessions. The first component provides information on the consequences of smoking and the reasons 

that adolescents smoke. The second component examines social influences-including family, friends, other 

peers, and the media-that promote smoking; students 

then learn specific skills to resist these pressures. In the 

third component, the students are asked to integrate 

information learned in all previous sessions in order to 

make a decision about their future smoking behavior 

and to publicly commit to nonsmoking, if that is their 

decision. 

In the first large-scale randomized trial of this pro 

gram, 22 schools were randomly assigned to treatment 

and control conditions. Sixth-grade students in the 11 

treatment schools received the curriculum plus booster 

sessions in seventh and eighth grade. Initial evaluation 

results indicated that although the intervention did not 

reduce levels of regular smoking or significantly increase 

the probability of remaining a nonsmoker, it prevented 

the onset of experimental smoking through the end of the 

eighth grade. The results were particularly encouraging 

for students who were at highest risk of becoming regular 

smokers because they had tried smoking in grade six or 

because their parents, siblings,‘or friends were smokers 

(Best et al. 1988). 

The University of Waterloo research group has 

reported six-year follow-up data for the same cohort of 

students studied earlier through the eighth grade. Ninety 

percent of the students were located for this follow-up 

study, and data were obtained from over 80 percent of 

them. These students had not received any additional 

intervention after the eighth grade. The significant intervention effects observed in this cohort after the eighth 

grade had begun to disappear by the fifth year after the 

intervention; by the sixth year, there was no longer a 

significant difference between treatment and control students (Flay et al. 1989). These results (see Figure 2) 

suggest that the initial positive impacts of such interventions may dissipate over time (Kozlowski et al. 1989), 

particularly if intervention activities and booster sessions 

do not extend throughout middle school, junior high, 

and high school (botvin and Botvin 1992). School-based 

programs may also be strengthened by supplementary 

intervention activities that extend beyond the school context into the community (Perry, Klepp, Shulk 1988; Perry 

et al. 1992). 

The Minnesota Smoking-Prevention Program 

The Minnesota Heart Health Program is a 

community-based cardiovascular disease prevention program that has been carried out in selected Minnesota 

study communities during the past decade (Blackburn et 

al. 1984). As a part of this program, the Minnesota 

Smoking-Prevention Program (MSPP) has addressed the 

prevention of tobacco use by influencing the social and 

psychological factors known to promote the onset 

of smoking. 

The activities in MSPP are often led by peer (sarneage) leaders who are trained to communicate the social 

and psychological messages embodied in the program. 

The students first form small groups to discuss 

the short-term, social consequences of smoking. By 

128 Prevention 
prtwrz ting Tobacco Use Among Young People 

Pxarninirtg actual data and discussing young people’s 

tendency to overestimate smoking prevalence, students 

lenm that smoking is not a normative behavior in our 

++ety. After exploring why adolescentssmoke, students 

J~SS positive alternatives to smoking. Students then 

learn how these misperceptions about smoking are establish& in our culture through advertising and role modeling by peers and adults. Students practice the skills to 

resist the social influences that promote smoking, in- 

&ding peer influences and advertising techniques. 

gear the end of the program, students state a goal to 

remain nonsmokers 

In evaluating the effects of the MSPP in eight junior 

high schools, Murray et al. (1988) reported that after four 

irears, the peer-led social influences intervention reduced 

;he incidence of daily and weekly smoking by 35 to 50 

percent. In contrast, no reduction was observed in an 

adult-led group that was taught the health consequences 

of smoking or in a comparison group enrolled in an 

existing curricuhun covering general health topics. These 

differences, however, were no longer statistically significant at the five- and six-year follow-ups (Murray 

et al. 1988). 

As part of this overall research program, the Class 

of 1989 Study was established to test the efficacy of the 

MSPP approach when introduced as part of a broader, 

community-based health promotion effort (Perry et al. 

1992). Researchers hypothesized that the school-based 

intervention program would have longer-lasting effects 

if it was introduced in communities where adults were 

involved in communitywide smoking-cessation programs, where antismoking ordinances in the schools and 

public community spaces were being considered, and 

where integrated school and community intervention 

Figure 2. Six-year follow-up of the first Waterloo School Smoking Prevention Trial: proportion of 

subjects smoking regularly and experimentally at each wave of the study 

45 

40 

35 

q Experimental 

n Regular 

- r 

Control -Program Control Program Control Program Control Program Control Program Control Program Control Program 

(End of Trial) Wear 1 (Year 2 (Year 3 (Year 4 (Year 5 (Year 6 

follow-up) follow-up) follow-up) follow-up) follow-up) follow-up) 

Study condition 

Sauce: Flay et al. (1989). 

Prmention 129 
Surgeon General’s Report 

activities were offered. Throughout junior and senior 

high school, smoking prevalence was significantly lower 

among students in the intervention community than 

among students in the control community. The results of 

this study are discussed later in this chapter, along with 

other communitywide programs. 

International Research on SmokingPrevention Programs 

Intervention studies reported in the Englishlanguage literature outside the United States concentrate 

primarily on school-based interventions directed at secondary school students (persons aged 11 years or older). 

In many cases, these intervention programs have adopted 

some elements of U.S. school programs in order to reflect 

different local conditions. This section reviews several of 

the more rigorously evaluated programs and pays particular attention to programs that have been followed up 

for two or more years after intervention. 

Western Australia 

Armstrong et al. (1990) conducted a large randomized trial evaluating peer- and teacher-led social influence programs among 12- and 13-year-old students in 

Western Australia. The authors used the MSPP program 

(Arkin et al. 1981) and resurveyed the students one year 

and two years after the intervention. Although the effects of the program were not strong, at the two-year 

follow-up, the smoking prevalence in the control group 

was 6.6 percent higher than in the teacher-led intervention group and 8.1 percent higher than in the peer-led 

intervention group. 

North Karelia Youth Project 

The North Karelia Youth Project in Finland (part of 

the International Know Your Body study) was a twoyear controlled trial that targeted schoolchildren in grade 

seven (12 and 13 years old) and included components on 

smoking prevention, physical activity, and reduction of 

dietary fat and alcohol consumption (Puska et al. 1981, 

1982). The smoking intervention program was peer-led 

and involved three 45-minute sessions for grade seven; 

these students received seven shorter sessions the following year (a schedule similar to that of Project CLASP). 

The program included sessions on social pressures to 

smoke, ways to resist such pressures, ways to cope with 

social anxiety, the short- and long-term health effects of 

both active and passive smoking, and the impact tobacco 

growing has on the environment. 

Health educators from the project team delivered a 

direct, intensive intervention (intervention A) in two 

schools (one urban and one rural). A less intensive, 

countywide intervention (intervention B) provided materials and training to local youth and temperance workers. The evaluation involved the two intervention A 

schools, tie matched intervention B schools selectd 

from the county, and two matched reference schools 

selected from another county that did not receive an 

organized intervention. h&a et al. (1982) found that 

among boys, the prevalence of occasional smoking (one 

or two times per month) had increased by 30 percent in 

the reference group, by 8 percent in the A group, and by 

13 percent in the B group. Among girls, the prevalence of 

occasional smoking had increased by 20 percent in the 

reference group, by 18 percent in the A group, and by 9 

percent in the B group. Vartiainen et al. (1990) reported 

the results of an eight-year follow-up and found that the 

prevalence of “any smoking” in the reference group was 

10 percent higher than in the A group and 16 percent 

higher than in the B group. 

United Kingdom 

In the United Kingdom, Nutbeam et al. (1993) conducted a controlled trial of two school-based interventions. The Family Smoking Education Project was derived 

from a program first developed in Norway (Aam et al. 

1983). Directed toward lO- through 12-year-olds, the 

project consisted of five lessons on the immediate health 

effects of smoking and on the wider environmental impact of tobacco growing and use. A notable feature was 

a leaflet sent to parents to encourage their support for 

school-based smoking education. The Smoking and Me 

project was the United Kingdom adaptation of the MSPP. 

Directed toward lO- through 12-year-olds, the program 

consisted of six sessions highlighting a range of social 

influences and equipping students with skills to manage 

these social pressures. At the first-year and second-year 

follow-ups, no differences were observed between the 

intervention population and the control population for 

either smoking uptake or personal skills. 

Overall, school-based smoking education programs 

that have been evaluated internationally have met with 

limited success in the past decade. In general, these 

programs were brief and were not continued through the 

high school years. Many countries are taking more comprehensive approaches to smoking control among young 

people; such approaches include community action, further restrictions on tobacco advertising and promotion, 

and substantially higher tobacco tax rates than are found 

in the United States. 

130 Prevention 
preventing Tobacco Use Among Young People 

Meta-Analyses of School-Based Smoking 

. prevention 

Extensive discussions of the methodological issues 

inherent in research on smoking prevention have been 

thoroughly discussed elsewhere (Cook and Campbell 

1979; Flay 1985; Biglan, Severson, et al. 1987; Murray and 

Hannan 1990). The primary issues have included questions of mixed units of analysis, attrition of the subject 

(student) population, integrity of implementation, and 

homogeneity of the subject population. These issues 

have been partly accounted for in four important metaanalytic studies published since 1980. 

Tobler (1986) examined 143 studies of drug-use 

prevention programs for 6th- through 12thgrade students and found that these programs had an overall 

significant impact on behavior, skills, and knowledge. 

The study also found that peer-led programs and pro 

grams dealing with social influences were more effective 

than other modalities. Tobler (1992) later confirmed 

these findings with more rigorous analytic methods. The 

Rundall and Bruvold (1988) meta-analysis of 40 studies 

of school-based programs to prevent smoking examined 

knowledge, attitude, and behavioral outcomes of social 

influence programs versus traditional programs; the so 

cial influence programs were more likely to affect 

attitudes and behavior. Rooney (1992) examined 90 

school-based tobacco-use prevention programs conducted from 1974 through 1989 that sought to develop 

skills to resist social influences. The meta-analysis took 

into account the clustering of students in schools and 

used the school as the unit of analysis. Results mdicated 

that smoking prevalence was 4.5 percent lower among 

students in the social influence programs than among 

students in control conditions. The social influence programs that were most effective at one-year follow-up 

were those that were delivered to sixth-grade students, 

that used booster sessions, that concentrated the program in a short time period, and that used an untrained 

peer to present the program. Under these more optimal 

conditions, long-term smoking prevalence was reduced 

by about 25 percent. 

Bruvold’s meta-analysis (1993) included 94 separate interventions from the 1970s and 1980s. The intervention programs were categorized as rational Qxoviding 

factual information), developmental (increasing selfesteem and decision-making skills), social-normsoriented (providing alternatives and reducing alienation), 

and social-reinforcement-oriented (developing skills to 

deal with social pressures to smoke). The me&analysis 

showed that the rational approach had very little impact 

on smoking behavior, that the developmental and social 

norms approaches had equivalent and intermediate 

impact on smoking behavior, and that the social reinforcement approach had the greatest impact on smoking 

behavior (Bruvold 1993). 

Discussion 

In retrospect, research on smoking prevention has 

by its very nature had to contend with various threats to 

validity posed by factors such as mixed units of analysis, 

differential attrition, and inconsistent implementation. 

To a large extent, the most recent research studies have 

been designed to deal with these methodological obstacles and have still found moderately strong prevention effects (Rooney 1992; Bruvold 1993). Therefore,mast 

reviews of the smoking-prevention reseamh literature cons& 

tidy have come to the same conclusions, which can be summarized under three general findings. 

First, a variety of individual msearch reports @c&in 

and Dusenbury 1989; Flay et al. 1989), severai comprehensive literature reviews @lay 1985; Best et al. 19881, and four 

meta-analyses Crobler 1986; Rundall and Bruvold 1988; 

Rooney 1992; Bruvold 1993) have all reported lower 

prevalences of smoking among students in social influence 

programs than among students in equivalent comparison 

groups or randomly assigned control groups. The difference between treatment and nontreatment groups ranges 

from 25 to 60 percent and persists from one to four years, 

Second, as Best et al. (1988) have underscored, given 

thenumberofresearchstudies,thevariabilityinprogramformat and scope, the various cofnmunties and cultures in 

whichthesestudiesw~undertaken,andthepotential~~ 

to internal and external validity in school-based research, 

the consistency of overall findings and reductions in 

smoking prevalence across all these studies is rather 

remarkable. 

Third, it has been observed repeatedly that the 

positive shorter-term intervention effects reported in 

adolescent smoking-prevention studies tend to dissipate over time (Murray et al. 1989; Pen& MacKinnon, 

Dwyer, et al. 1989; Flay et al. 1989; Ellickson, Bell, 

McGuigan 1993). This general trend has been particularly evident among school-based intervention studies 

that included little or no emphasis on booster sessions, 

few (if any) communitywide activities, or few (if any) 

mass-media-based components (Botvin, Renick, Baker 

1983; Perry, Klepp, Shultz 1988; Botvin and Botvin 1992). 

These interventions may be enhanced if they are embedded in a more comprehensive school health education program (AlIensworth and Kolbe 1987; Walter, 

Vaughan, Wynder 1989). The comprehensive school 

health approach needs further evaluation but is promising as an effective prevention tool. 

Only the social influence approaches have been 

scientifically demonstrated (through replicated research 

Prevention 131 
Surgeon General’s Report 

studies) to reduce or delay adolescent smoking. Still, 

the effects of these programs have not been sustained 

without additional educational interventions or community components. This experience suggests that programs grounded in school-based skills training are indeed 

important for preventing smoking, although more sustained and comprehensive efforts may be needed for 

long-term success. 

The concept of reciprocal determinism (Bandura 

1986) would argue that these complementary components should target the elements of the dynamic personenvironment interaction that school-based interventions 

may not be capable of reaching, much less influencing. 

These components would include the types of community, environmental, legislative, policy-based, and societal interventions described later in this chapter. 

Preventing Smokeless Tobacco Use 

Introduction 

The 1986 publication of the Advisory Committee‘s 

Report to the Surgeon General (USDHHS 1986b) on the 

health consequences of using smokeless tobacco (chewing tobacco and snuff) and subsequent reports of widespread use of smokeless tobacco among children and 

adolescents (Boyd et al. 1987; USDHHS 1992b) have 

called forth a wide range of written and media materials 

(including films, pamphlets, and video programs) on the 

risks of using smokeless tobacco (Wilson and Wilson 

1987; Laflin, Glover, McKenzie 1987). These materials, 

made available to school personnel and parents, have 

aimed at countering the perception that smokeless tobacco is a safe alternative to cigarettes. Materials have 

been produced by federal agencies (such as the NC1 and 

the National Institute of Dental Research), voluntary 

nonprofit groups (such as the ACS), and professional 

organizations (such as the American Dental Association 

and the American Academy of Otolaryngology). These 

materials have been distributed widely, but the degree of 

their diffusion has not been evaluated, nor has their effect 

on young people’s use of smokeless tobacco. 

Evaluation of School-Based Efforts 

or regular use and to promote or assist cessation for 

adolescent and young adult users. Nine research grams 

on smokeless tobacco use have been funded by the NQ 

since 1987; most are focused on adolescent populations 

(USDHHS 199Ob), and results are pending. Although 

most of these projects have been school-based prevention activities, some programs have targeted youth in 

non-school settings (e.g., 4-H clubs, Little League basebail clubs, and Native American community centers). 

The prevention programs that have been evaluated 

have targeted both smoking and smokeless tobacco use 

among middle and high school students. The primary 

focus has been on middle school (grades 6-8, ages 12-14). 

Smokeless tobacco prevention has also been included as 

part of more comprehensive‘curricula to prevent drug 

use, such as Here’s Looking at You,2ooO (Roberts, Fitzmahan 

& Associates, Inc., and Comprehensive Health Education Foundation 1986), or as part of community-based 

interventions to reduce drug use. Seldom have programs to prevent smokeless tobacco use been instituted 

independent of other substance-use prevention or of a 

more general tobaccouse prevention effort. Since smokeless tobacco products are used primarily by males, the 

overall prevalence of use is lower than that of smoking. 

There is also less concern about the health effects of 

smokeless tobacco than about those of illegal drugs and 

cigarettes. This logical inclusion, however, of smokeless 

tobacco prevention in the context of other prevention 

efforts makes the evaluation of the smokeless tobacco 

component problematic. 

A factor that more directly obscures the importance of smokeless tobacco prevention is the widespread 

acceptance of use by both young people and parents. 

Youth generally perceive that smokeless tobacco use is a 

safe alternative to cigarette smoking. For example, in one 

study, 77 percent of school-aged children believed that 

cigarette smoking was very harmful to one’s health, yet 

only 40 percent believed the same of smokeless tobacco 

use (Schaefer et al. 1985). Parents are also more likely to 

accept smokeless tobacco use than smoking among teens 

(Chassin, Presson, Sherman 1985; see ‘Tarental Reaction 

to Smokeless Tobacco Use” in Chapter 4). 

because the increased use of smokeless tobacco 

among youth is a relatively recent phenomenon, few programs for preventing adolescent use of these products 

have been evaluated for either short- or long-term efficacy. 

Those that have been evaluated have been but one component of a broad tobacco-prevention program. 

The Oregon Research Institute Program 

In several studies, young adolescents have received 

a preventive curriculum that targeted both smoking and 

smokeless tobacco use. In one such study (Severson et al. 

1991), a social influences program conducted by the Oregon Research Institute was delivered by regular classroom teachers and by same-age peer leaders to entire 

classrooms in randomly assigned schools. The brief 

seven-session program significantly reduced smokeless 

tobacco use among males in both seventh and (to a lesser 

In response to the emerging concern about the 

health risks of regular smokeless tobacco use, the National Institutes of Health has funded numerous research 

grants to develop interventions to prevent initiation 

132 Prevention 
Preventing Tobacco Use Among Young People 

extent) ninth grades. Parallel analysis failed to show that 

the intervention had any positive effect on cigarette 

smoking. The results for smokeless tobacco use, however, were particuIarly encouraging, since only two of 

the seven class periods of the intervention were devoted 

to smokeless tobacco. 

The intervention used in the Severson et al. (1991) 

study sought to make students sensitive to overt and 

covert pressures to use tobacco and taught effective ways 

to respond to these pr&sures. The students practiced 

how to refuse offers of tobacco. Besides using a structured curriculum with role-play activities, the teacher 

used videotapes to standardize instruction and maintain 

student interest. The program was taught by regular 

classroom teachers; same-age peer leaders assisted in 

role-playing activities for the seventh-grade students. A 

videotape titled Big Diper (Oregon Research Institute 

1986) was developed to highlight the physical and social 

consequences of smokeless tobacco. To involve parents, 

brief brochures were mailed to students’ homes. 

Toward No Tobacco Use 

A study by Sussman et al. (1993) reports positive 

results in their Toward No Tobacco Use (TNT) project for 

reducing smokeless tobacco use. The study compared 

four different prevention curricula developed to counteract three types of factors related to the onset of tobacco 

use that are typically addressed within a comprehensive 

social-skills program. These include peer approval for 

using tobacco, incorrect social information provided about 

tobacco use, and lack of knowledge about physical consequences of tobacco use. The development of these 

curricula is detailed in previous reports (Sussman 1991). 

Smokeless tobacco use was significantly less prevalent among students who had received the TNT intervention than among those who had not (Sussman et al. 

1993). The results of the evaluation of this lo-lesson 

curriculum intervention suggest that learning about the 

physical consequences of smokeless tobacco use can be 

as successful as a social influences program and that a 

combination of both is probably best for deterring use of 

smokeless tobacco. The Sussman et al. (1993) study in 

southern California and the Severson et al (1991) study 

in Oregon suggest that smokeless tobacco use can be 

reduced through school-based programs that try to pre 

vent all types of tobacco use among seventh- and ninthgrade studen& 

Project SHOUT 

Elder et al. (1993) developed Project SHOUT, a 

social influences program that has been evaluated in 

22 junior high schools in San Diego County, California. Based on an operant conditioning model of 

tobacco use (Elder and Stem 19861, the intervention 

was delivered in randomly assigned schools to 

seventh-grade students. Intervention and assessment 

continued for three years (through seventh, eighth, 

and ninth grades). Because of multiple school changes 

at the end of the eighth grade, Project SHOUT used 

telephone calls and programnewsletters for the ninthgrade intervention. 

At the three-year follow-up, the intervention 

had a significant effect on cigarette use, smokeless 

tobacco use, and combined cigarette and smokeless 

tobacco use. The intervention effect was particularly 

strong during the ninth grade (Elder et al. 19931. The 

three-year intervention and follow-up is a strength of 

this study; previous studies have been limited to a 

single intervention year and one-year follow-up. 

Programs for Native American Populations 

Smokeless tobacco use by Native American youth 

on reservations is higher than that of other groups (Schinke 

et al. 1989). There is evidence of early, frequent, and heavy 

use of snuff and chewing tobacco by Native American 

children and Alaskan Natives (S&i&e et al. 1987X Young 

people in these populations begin using smokeless tobacco at an early age, and girls use it at levels almost equal 

to boys &hinke et al. 1987). Current reservation-based 

interventions aimed at reducing this pattern of smokeless 

tobacco use have not yet been evaluated. These ongoing 

programs are sensitive to the unique aspects of tobacco 

use by Native Americans, since tobacco has traditionally 

played a role in sacred rites. The programs make extant 

materials appropriate for Native American children by 

creating a specific curriculum for the tribal group and 

having Native Americans provide the intervention in 

schools or other settings on their reservation. 

Smoking Cessation 

Introduction 

Few studies have examined adolescent smoking 

cessation. The four primary sources of information on 

adolescent cessation are national probability surveys on 

patterns of adolescent attempts to quit (see “Attempts to 

Quit Smoking” and “Self-Reported Indicators of 

Nicotine Addiction Among Smokers” in Chapter 3), convenience sample surveys of adolescents who have tried 

to quit on their own, reports from prevention projects on 

effects of treatment on youth who were smokers at 

baseline, and programs that explicitly try to recruit 

adolescent smokers into cessation programs. The relatively few intervention studies vary considerably in scientific quality; many are anecdotal or descriptive accounts 

of programs. 

Prevention 133 
Surgeon General’s Report 

Convenience Samples of Adolescents Who Try to 

Quit Smoking 

Although national surveys ask a great many respondents a few questions about quitting smoking, some 

smaller studies have more deeply probed the experience. 

The role of nicotine’s pharmacologic effects has received 

increasing attention, culminating in the 1988 Surgeon 

General’s report on nicotine addiction. The report demonstrated that cigarette smoking is characterized by the 

same addictive processes that have been observed with 

other drugs that are abused (USDHHS 1988). Recent 

observations of adolescents who have tried to quit smoking suggest that dependency or addiction has developed 

in many adolescent smokers and may play an important 

role in their attempts to quit. Data from both Great 

Britain (McNeill et al. 1986; McNeill1991) and the United 

States (Hansen 1983; Hansen et al. 1985; Brshler et al. 

1989) show that many adolescents who try to quit have 

withdrawal symptoms that parallel those reported by 

adult smokers (see “Nicotine Addiction in Adolescence” 

in Chapter 2). 

Inasurveyof116Britishschoolgirls(aged 11 through 

17) who had tried to quit smoking, 63 percent reported 

withdrawal effects. The degree of withdrawal effects was 

related positively to both self-report and biochemical measures of nicotine intake (McNeill et al. 1986). These f%dings were replicated, although without biochemical 

measures, in a study of American 6th through 12thgraders of both sexes (Brshler et al. 1989). Over half of the 

smokers in both of these studies reported attempts to quit, 

and most were unsuccessful. These observations, along 

with other data summarized in Chapters 2, 3, and 4, 

strongly suggest that adolescent smoking is more than 

socially driven and that addictive processes in adolescents 

are similar to those that characterize adult smoking. 

Effect of Smoking-Prevention Programs on Cessation 

Smoking-prevention programs have typically, and 

appropriately, targeted younger adolescents. In these 

populations, prevalence rates tend to be low, and those 

who smoke are mostly doing so infrequently. These 

studies, reviewed earlier in this chapter, focus on preventing onset or on preventing the progression from 

experimentation to regular smoking. The impact of 

smoking-prevention programs on students who are experimental or regular smokers appears to be small and 

inconsistent (Best et al. 1984; Johnson et al. 1986; Biglan, 

Severson, et al. 1987). However, the small number of 

regular smokers (that is, those who smoke every week) 

tends to preclude meaningful analyses of cessation resulting from these programs (Best et al. 1984). 

Cessation Interventions in the School 

Young people who smoke have been a persistent 

concern of both educators and voluntary health agencies. 

A number of materials and programs for adolescent 

smoking cessation have been developed and implemented, but evaluation typically has been anecdotal or 

descriptive (Hulbert 1978; Patterson 1984; Brink et al. 

1988). Many of the older programs are described by 

Thompson (19781, USDHEW (1979), and Seffrin and 

Bailey (1985). Cessation programs are sometimes led by 

peers, sometimes by teachers or volunteers. Participants 

are recruited through school channels such as newsletters, classes, and public address announcements. Evidence from these descriptive reports, as well as from 

some of the formal research programs described below, 

indicates that recruitment is difficult; adolescent smokers 

are hesitant to come forth. In some instances, the participants in the school cessation programs are referred 

by school authorities for infractions of school smoking 

policies and are thus not coming to these programs 

voluntarily. 

These issues are illustrated by a program evaluation reported by the American Lung Association (unpublished data). The program, developed by a Minnesota 

affiliate of the American Lung Association, was evaluated in 22 schools in four states. A total of 241 students 

(mean age = 16 years old) participated in eight 5Ominute 

sessions during school hours over a four-week period. 

Over half the students, however, were required to participate as a consequence of being caught smoking on 

school grounds. This inclusion of nonvoluntary participants may partly explain the program’s low success rate: 

at the end of the sessions, only 30 students (14 percent) 

reported that they were abstinent (program dropouts 

were counted as smokers). Low cessation rates like 

these, coupled with recent legislation such as the Oregon 

law forcing school authorities to take action against students caught smoking on school grounds, signal the 

need for more effective cessation approaches for student 

smokers. 

Lotecka and MacWhinney (1983) compared an intervention group focusing on cognitive behavioral skills 

(N = 53) with a group only receiving health information 

(N = 54). Less than 50 percent of the students in each 

group participated in the three-month follow-up. Of 

those assessed at that time, 78 percent of the students in 

the cognitive behavior group reported a decrease in smoking, and only 4 percent reported an increase; the comparable figures for the information-only group were 46 

percent and 31 percent. No information was provided 

on complete abstinence. Given that reported rates of 

smoking are relatively unreliable and that the program 

134 Prevention 
praenting Tobacco Use Among Young People 

did not report cessation rates, this study cannot be considered conclusive. 

Perry et al. (1980, 1983) conducted two schoolbased cessation interventions in California schools. hi 

the first, IOth-grade classes in three high schools 

(N = 477) received a special program that focused on immediate physiological effects of smoking and on social 

cues that influence the adoption of smoking. Classes in 

two control schools (N = 394) received standard information on long-term health effects. The program consisted of four consecutive 45minute sessions in regular 

health classes conducted in the fall. Posttest outcome 

data were obtained approximately five months later and 

included carbon monoxide measures of smoking. At the 

posttest, the experimental group, compared with the 

control group, had a significantly greater percentage of 

subjects who reported abstinence in the previous week 

(22 vs. 16 percent) and month (30 vs. 24 percent). Parallel 

significant differences were also found for carbon monoxide measures. 

In their second study, the Perry group (1983) tried 

to sort out the specific efficacious components within the 

intervention program by analyzing three kinds of programs-those that discussed long-term health effects (the 

control group), those that discussed immediate and longterm physiological effects, and those that discussed social consequences--and comparing programs taught by 

either teachers or college students. Twenty health classes 

and four high schools were randomized by using a factorial design. The study obtained three-month follow-up 

data that included self-reports and carbon monoxide 

breath tests. Using entire 10th~grade health classes solved 

the recruitment problem but yielded a limited number of 

current smokers; the relatively small number of pretest 

smokers in this study (N = 82) precluded finding any 

significant difference between the groups. Overall, 23 

percent of the pretest smokers reported not smoking at 

the three-month follow-up. Teachers tended to be more 

effective with the traditional curriculum covering longterm health effects, and college students seemed more 

effective with the social influences curriculum. 

The largest and most systematic school-based ado 

lescent cessation study has not yet been published. Burton et al. (unpublished data) worked with rural and 

suburban high schools in two states. Within each of the 

16 treatment schools, students volunteering to participate in a cessation clinic were randomly assigned to a 

clinic or to a control group of students told they were on 

a waiting list. Clinic students were further randomly 

assigned either to a clinic designed to address addiction 

or to one designed around psychosocial dependency. 

Clinics consisted of five sessions spaced over one month. 

A follow-up session was held three months after the fifth 

session. The control participants were also invited to the 

follow-up session, where smoking status was assessed 

both by self-report and measurement of saliva co&-tine. 

At the three-month follow-up, 8.4 percent of clinic 

participants and 10.5 percent of controls were abstinent. 

When corrected for biochemical verification, these figures 

become 6.8 and 7.9 percent, respectively. There was considerable attrition; students lost to follow-up were assumed to be smokers. The negative results in the study are 

especially sobering because the investigators had previously conducted 31 focus groups with adolescents to help 

inform the intervention’s reuuitment strategies and content (Sussman et al. 1991). 

Difficulty in recruiting adolescent smokers in school 

programs has been a pervasive problem for investigators. 

Adolescents may be concerned about parents or teachers 

learning that they smoke (since parental consent could be 

required for participation). Adolescents may also be less 

motivated thanadults to quit, since long-term health consequences carry less weight with the young. A simpler 

explanation of low recruitment is that prevalence rates are 

low; schools do not provide large populations of smokers 

from which to recruit. Multisite trials that pool subjects 

may be needed before rigorous and meaningful evaluations can take place. 

Cessation Interventions Based Outside the School 

Hollis et al. (in press) tried an unusual approach to 

recruit young smokers. Adolescents between 14 and 17 

years of age who were members of a large health maintenance organization (HMO) were mailed a screening questionnaire that asked about “health habits.” Those who 

reported that they had smoked in the past week were 

asked if they would participate in a twoyear study of 

adolescent health and were randomly assigned to either 

an intervention group that received help to quit smoking 

or a control group that received no such help. 

The focus of the intervention was an office visit 

with a nurse practitioner at a conveniently located HMO 

clinic. Incentives were offered for attending these sessions, each of which lasted about 60 minutes. The participants reviewed their health history, watched and 

discussed a video on adolescent smoking cessation, were 

encouraged to set a quit date, and were given tips and 

strategies for successful quitting. Those who wanted to 

quit smoking received a follow-up call one week later; 

additional calls were also made, depending on the 

adolescent’s continued interest in quitting. Participants 

who had quit smoking were eligible to participate in a 

lottery with chances to win $100. 

All participants were followed up at one year, at 

which time both self-report and biochemical (saliva 

cotinine, carbon monoxide) data were obtained. The 

Proven tion 135 
Surgeon General’s Report 

intervention and control groups had similar self-report 

measures of smoking (i.e., measured in number of cigarettes in the last month, week, day) and similar biochemical indicators of smoking. No relationship was found 

between the number of contacts with the HMO interventionist and either quitting rates or the number of cigarettes smoked. Similar interventions in health care settings 

with adult smokers have usually yielded positive results 

(e.g., Hohis et al. 1991), but this was clearly not the case 

for adolescent smokers. 

Discussion 

The data reviewed indicate consistently that adolescent smokers frequently try to quit but are usually 

unsuccessful, often have withdrawal reactions much like 

adult smokers, are difficult to recruit and retain in formal 

cessation programs, and are not responsive to programs 

thus far developed. Further basic research and new. 

directions for intervention are clearly needed. Data pre 

sented in Chapter 3 (see “Adult Implications of Adolescent Smoking”) from the Monitoring the Future Project 

show that well over 80 percent of adolescents who smoked 

half a pack a day or more as seniors in high school (over 

15 percent of the sample) were smoking five to six years 

later as young adults; over half of these were smoking a 

pack or more a day at follow-up. In the absence of 

intervention, adolescent smokers will most likely be 

come adult smokers. 

Smokeless Tobacco Cessation 

Introduction 

Of the estimated six million people who regularly 

use smokeless tobacco, half are under age 21 (USDHHS 

1986b). Data from several national surveys show an 

increase in the prevalence of smokeless tobacco use, specifically in the use of moist snuff among young males 

(Boyd and Glover 1989; Marcus et al. 1989; Novotny et al. 

1989; Rouse 1989; see “Current Use of Smokeless Tobacco” in Chapter 3). The high prevalence of smokeless 

tobacco use underscores the growing need to help young 

people quit. 

To date, there are few published studies of smokeless tobacco cessation. The withdrawal symptoms for 

smokeless tobacco are the same as those for smokingcravings for the substance, irritability, distractibility, and 

hunger (Hats&an&Gust, Keenan 1987)-althoughthese 

symptoms may be less intense and felt less frequently. 

Because of these similarities, most cessation programs for 

smokeless tobacco users are multicomponent treatments 

that use key elements from smoking-cessation programs 

that have been extensively evaluated in largescale studies 

(Sever-son 1993). 

Clinical Studies 

Clinical studies of smokeless tobacco cessation have 

been done with both adolescents and adults. The first 

published study of smokeless tobacco cessation was re 

ported by Glover (1986), who adapted the ACS’ Fresh 

Start Adult Smoking Cessation Program for use with 41 

adults who used smokeless tobacco. This pilot study 

resulted in a six-month self-reported abstinence rate of 

only 2 percent. However, these subjects had not vohmtarily sought assistance in quitting; they had been required to attend the program for violating school rules at 

a college that prohibited the use of tobacco products. 

Low success rates are not surprising in a nonvoluntary 

cessation program. 

Eakin, Severson, and Glasgow (1989) reported an 

intervention with adolescent male daily users, aged 14 

through 18, who were recruited from high schools in 

Eugene, Oregon. The study recruited 25 students, five of 

whom also smoked cigarettes concurrently. The program 

consisted of three small group meetings with counselors, 

each lasting approximately one hour, during which the 

focus was on developing coping skills for cessation. Of the 

21 subjects who completed treatment, two s&j&s had 

quit using smokeless tobacco by the end of treatment, and 

three subjects were abstinent at the six-month follow-up. 

Compared with the other students, however, these successful quitters had consumed a smaller amount of smoke 

lesstobaccoatbaselineandwerelessaddicted,asmeasured 

by an adapted Fagerstriim Tolerance Questionnaire 

(Fagerstrom 1978). They were also more involved 

in school athletics than those who did not succeed 

at quitting. 

School-Based Efforts 

Three recent studies of smokeless tobacco cessation 

are informative about school-based cessation and self-help 

approaches. Burton et aL (unpublished data) report msulk 

from a school-based cessation clinic model tested in 16 high 

schools in Illinois and California. Within each school, cigarette and smokeless tobacco users were recruited and either 

randomly (and vohmtarily) assigned to a cessation clinic or 

told the clinics were filled. Clinics consisted of five sessions 

over a one-month period. A sixth session was held three 

months later to assess the intervention and control groups. 

The attrition rate for the clinic group was higlx almost half 

the students did not complete the treatment. Of the 16 

smokeless tobacco users who completed five sessions, seven 

reported quitting at the end of the treatment; none of the 

five students in the control group reported quitting. 

However, when the clinic dropouts were included as 

the denominator and the results corrected for biochemical verification, the quit rate for students in the smokeless tobacco clinic was 15 percent; none of the control 

136 Prevention 
Proven ting Tobacco Use Among Young People 

subjects had quit at the three-month follow-up. The 

study suggests that a school-based multisession clinic 

can achieve small cessation rates for adolescent subjects 

who volunteer, although the volunteer rates for the study 

were notably low. 

Persons going through treatment for smokeless 

tobacco addiction often request an oral substitute to help 

them through withdrawal. Smokeless tobacco users re 

port using cinnamon sticks, gum, sunflower seeds, finely 

ground mint leaves, or other chewed foodstuffs to lessen 

the effects of withdrawal (Severson 1992). To evaluate 

the use of nonnicotine substitutes as aids for smokeless 

tobacco cessation, a recent study compared the use of a 

ground-up mint product, chewing gum, and no substitute (Chakravorty 1992). Subjects were recruited from 

six high schools in rural Illinois. Two schools each were 

randomly assigned to either the treatment group (mint 

snuff substitute), gum group, or lecture-only control 

group. Within schools, smokeless tobacco users were 

invited to volunteer for a two-session school-based cessation program. Eighty-three males were recruited to 

participate. Of the 70 students who completed the treatment, 30 were in the mint group, 15 in the gum group, 

and 25 in the lecture-0 nly group. At the end of the 

treatment period, all three groups had about the same 

quit rates. Eleven students reported quitting smokeless 

tobacco, but nine of these quitters also smoked cigarettes. 

The author reports that students using the mint snuff 

substitute significantly reduced their frequency and intensity of smokeless tobacco use, but the study had rio 

biochemical verification of use. The results suggest that 

adolescent males who use smokeless tobatico can be 

recruited to attend sessions at school and that nontobacco 

oral substitutes may be a helpful adjunct to quitting. 

Research with adults suggests that health care providers can motivate some adult users of smokeless tobacco to quit (Stevens et al., in press). The clinical 

opportunity to provide advice on quitting in the context 

of health care delivery has been referred to as a. “teachable moment” (vogt et al. 1989; Morosco 1986). The 

results are modest in terms of overall quit rates, but 

having dentists, hygienists, nurses, and physicians counse1 their patients to quit using smokeless tobacco could 

have a significant effect on prevalence. The Stevens et al. 

(in press) study provided the first examination of a largescale, low-cost intervention to encourage smokeless tobacco users to quit. This program, which was conducted 

in the context of regular hygiene visits, provided strong 

evidence of the effect of smokeless tobacco use on oral 

health: 73 percent of the adult users in this study had 

identifiable oral lesions (Little, Stevens, La Chance, et al. 

1992). Parallel studies with youth or studies of programs 

using physicians or other health care providers have not 

been conducted. 

Smokeless Tobacco and Cigarettes 

Young people who use smokeless tobacco may 

also smoke cigarettes. Studies have reported that from 

12 to 30 percent of all regular users of smokeless tobacco 

also use cigarettes (E&in, Severson, Glasgow 1989; Williams 1992; Stevens et al., in press; see “Use of Smokeless 

Tobacco and Cigarettes” in Chapter 3). This relationship 

is critical, since cessation programs may motivate smoke 

less tobacco users to quit using snuff or chewing tobacco, 

yet not affect their use of cigarettes-and thus not affect 

their addiction to nicotine. Moreover, deprivation of one 

substance may lead to a direct increase in the use of the 

other (Biglan, La Chance, Benowitz, unpublished data). 

Cessation rates among men who use both tobacco products are significantly lower than those among men who 

use smokeless tobacco exclusively (Stevens et al., in press). 

Research and Programmatic Challenges 

Certain peculiar aspects of smokeless tobacco use 

may present problems to those who plan or study cessation programs. The lack of public data on the nicotine 

content of smok&ss tobacco products is not only a 

research problem but a challenge to cessation efforts that 

might reduce the severity of nicotine withdrawal by 

gradually cutting back on nicotine ingestion. Such efforts are further hampered, as are studies or programs 

depending on self-monitoring of product consumption, 

by the nonuniform (bulk) packaging of most smokeless 

products and by the variation in the amount of product 

that constitutes a “pinch” (of chewing tobacco) or a 

“dip” (of moist snuff) (Severson et al. 1990.) External 

monitoring of use also has inherent limitations, since 

snuff (and to a lesser extent, chewing tobacco) can be 

used surreptitiously. On the other hand, the oral lesions 

frequently experienced by smokeless tobacco users 

readily indicate smokeless use--and provide direct physical evidence to the user that this behavior has detrimental health effects (Little, Stevens, Severson, et al. 1992). 

The relationship between smokeless tobacco use 

and cigarette smoking also presents problems for research and intervention. Because many adolescents perceive smokeless tobacco use to be a safe alternative to 

smoking, motivation to quit using smokeless tobacco 

products may be low. On the other hand, because as 

many as one-third of all smokeless tobacco users also 

smoke cigarettes, the possibility exists (as was discussed 

previously) that persons trying to quit using smokeless 

tobacco may continue to smoke-or even increase their 

smoking-to minimize nicotine cravings. 

Although the preliminary evidence is that cessation rates for smokeless tobacco are similar to those for 

smoking, the difficulty in recruitment, the small sample 

Prevention 137 
Surgeon General’s Report 

sizes, the limited number of studies, the lack of control 

groups, and the lack of long-term follow-up necessitate 

cautious interpretation. Further research on cessation 

must consider the effects of usage frequency and 

intensity and must focus on relapse rates, use of nicotine replacement in cessation, self-help attempts at 

quitting, effects of advice by physicians and other health 

professionals, and effects of taxation and environmental restrictions. 

Clinical Interventions to Prevent Tobacco Use 

Introduction 

Physicians, dentists, and other health care providers who take care of children are in a unique position to 

help their patients avoid the use of tobacco (Perry and 

Silvis 1987). Children perceive these professionals as 

credible health experts and thus may attend more to 

what they say than to what parents and other adults say. 

Health care providers can serve as powerful role models 

who can positively influence the health behavior of their 

young patients, especially where a long-term relationship has been formed with the child and the family. 

Lastly, health care providers should know when to provide specific health information at critical times in a 

child’s development. 

The medical office provides an important opportunity for physicians, dentists, and staff to communicate 

attitudes about smoking and smokeless tobacco use 

(Kottke et al. 1989; Richards 1992). By not smoking, 

health professionals can serve as positive role models, 

as the American Academy of Pediatrics @AI?) and the 

American Academy of Family Physicians (AAFP) have 

recommended. Smoking by physicians, other staff, 

adolescents, or parents should not be allowed in 

the physician’s office or reception area (AAP 1987; 

AAFr 1992). 

The AAP recommends that between birth and 21 

years of age, a child should make a minimum of 20 visits 

to the physician (AAP 1988). These visits offer opportunities to prevent and deter tobacco use. To be successful 

at preventing tobacco use, physicians and other health 

professionals must know what the risk factors are, how 

to identify children who are most vulnerable, and how to 

intervene effectively. 

Recommendations to Clinicians Who Care for 

Children and Adolescents 

Education about tobacco should begin in childhood, when family standards and values are developing 

(AAl’ and Center for Advanced Health Studies 1988). 

The child’s visit may also afford the opportunity for a 

health professional to advise young parents who smoke 

to stop (Perry, Griffin, Murray 1985). During infancy and 

early childhood, clinicians should emphasize to parents 

the relationship between environmental tobacco smoke 

and the infant’s health, particularly the association between environmental tobacco smoke and children’s pneumonia, bronchitis, asthma, middle ear disease, and sudden 

infant death syndrome WSDHHS 1986a, 1990a; U.S. Environmental Protection Agency [USEPA] 1992). Advice 

from a child’s physician can reinforce advice that parents 

may have received from their own doctors. Clinicians 

thus need to learn skills to promote antismoking behavior and encourage parents to stop smoking. 

The NC1 and the AAP have developed recommendations for health professionals to prevent their preadult 

patients from trying smoking /Epps and Manley 1991bI. 

These brief activities can be carried out during the periodic visits that the AAP recommends between birth and 

21 years of age, as well as at other visits. Five steps that 

begin with the letter “a’‘-anticipate, ask, advise, assist, 

and arrange follow-up-are recommended: 

l Anticipafe the risks for tobacco use associated with the 

child’s development stage. These risks include expo 

sure to environmental tobacco smoke, experimentation with tobacco, and nicotine addiction (Kandell975; 

Hawkins, Lishner, Catalan0 1985; Dent et al. 1987; 

AAP 1988). Children and adolescents are more likely 

to use tobacco if their siblings and friends use it and if 

tobacco use is perceived as normative or functional 

(IJSDHI-IS 1986a; see “Interpersonal Factors” and ‘Terceived Environmental Factors,” both for smoking and 

for smokeless tobacco use, in Chapter 4). Adolescents 

are vulnerable to tobacco use-especially those with 

fewer coping skilIs (Doueck et al. 1988), those susceptible to cigarette advertising (Blum 19801, and adolescent females concerned about their body weight. (Gritz 

1986). 

l Ask at each visit, about tobacco exposures and tobacco 

use (Richards 1992). Ask about tobacco use by the 

patient and by the patient’s friends and family. When 

seeing infants and young children, ask parents whether 

the patient has regular contact with anyone who 

smokes. Ask if tobacco use is being discussed among 

the child’s friends or in school and, if so, in what 

classes. Ask about the child’s school health education 

program. Ask the child about participation in sports 

and extracurricular activities that may be incompatible with smoking. In dental examinations, inspect 

the intraoral soft tissue. If changes are noted in the 

mucosa, ask about smokeless tobacco use. 

l Advise tobacco users to stop. Advise women of the 

adverse effects of smoking during pregnancy. Inform 

smoking parents of the health consequences that environmental tobacco smoke can have on their children. 

Advise children and adolescents who are using (or 

138 Prevention 
Preventing Tobacco Use Among Young People 

even trying) tobacco to stop. Advise smokers of the 

short-term adverse consequences of tobacco use, such 

as bad breath, other odors, and the cost of cigarettes. 

Advise smokeless tobacco users of the potential consequences of use, such as discoloration of teeth, de 

struction of soft tissue in the mouth, and potential 

early development of oral lesions and cancers. 

l Assist tobacco users in stopping. Encourage parents 

who are trying to quit smoking and help them choose 

effective strategies to help them quit (Richards 1991, 

1992). Assistance for parents or adolescents can include selecting a quit date, providing self-help materiaIs, and in some cases counseling on the use of nicotine 

replacement (transdennal nicotine patch or nicotine 

gum) (Glynn and Manley 1989). Help children and 

adolescents take additional responsibility for their 

health behaviors. Encourage participation in programs that develop skills for solving problems, setting 

goals, making decisions, and countering peer pressure (Bingham, Edmondson, Stryker 1984a, b). 

l Arrange follow-up visits as appropriate. Arrange more 

frequent follow-up visits for an adolescent who is 

experimenting with tobacco products. At the first 

follow-up visit, one to two weeks after a scheduled 

quit date, discuss progress and problems. Arrange a 

second visit in one to two months. 

The five steps described above should be commonplace in the medical setting. Richards (1992) notes that 

“the words that a physician chooses to discuss smoking 

with a patient should be considered no less a therapeutic 

agent than the pharmacologic agent that the physician 

prescribes” (p. 687). Yet Frank et al. (1991) found that 

only 14 percent of smokers aged 12 through 17 years who 

had seen a physician in the previous year had been 

advised to quit smoking. In contrast, over 50 percent of 

smokers aged 25 years and older were advised to quit. 

Clearly, more consistent advice, concern, and counsel 

from the medical profession is warranted. 

Role of Health Professionals in the School, in the 

Community, and in Policy Formation 

Physicians and other health professionals are often 

considered leaders in their communities and have the 

opportunity to mobilize schools and communities to 

develop tobacco-use prevention, cessation, and policy 

change strategies. Health professionals who have examined their roles in this larger context should encourage 

their colleagues to act as advocates for such programs 

and, if possible, participate in their development or implementation (Shank 1985; AAP 1987; Blum 1992). 

Health professionals play a powerful role as 

sources for nonsmoking advice and assistance, as role 

models of nonsmoking adults, as providers and supporters of a nonsmoking health care environment, and 

as agents who deliver nonsmoking programs in schools 

and communities (USDHHS 1991). Several medical 

organizations have adopted policies and developed 

programs to encourage member concern and involvement in preventing adolescent tobacco use. The AMA 

House of Delegates has adopted numerous policy resolutions that support local tobacco-control activities on 

behalf of children and others (AMA 1992b). The AAF’P 

(1987) has also published policies and a manual on 

how to encourage patients of all ages to stop smoking. 

The AMA Guidelines for Adolescent Preventive Services recently recommended that physicians actively 

screen and counsel adolescentpatients about tobacco 

use (AMA 1992a). The AAP, with the NCI, has drafted 

a set of age-specific recommendations for pediatric 

practice as part of their Tobacco Free Generation program to prevent adolescent tobacco use (Epps and 

Manley 1991a). The AAP also distributes Healthy 

Beginning kits developed by the American Lung Association for counseling parents on the harmful effects 

of smoking around children and distributes pamphlets 

for parents and adolescents regarding tobacco use (AAP 

1988, 1990a, b). The American Academy of Otolaryngology-Head and Neck Surgery, Inc., launched 

a major public service campaign titled Through with 

Chew in response to the problem of smokeless tobacco 

use by youth. The campaign includes a video, a physician volunteer kit to encourage and assist members in 

community outreach, and a variety of educational aids 

designed to persuade young men, especially athletes, 

not to use smokeless tobacco (American Academy of 

Otolaryngology-Head and Neck Surgery 1992). 

Community Programs to Discourage 

Tobacco Use 

Introduction 

Community-based strategies to prevent smoking 

are important adjuncts to school-based programs. Some 

studies have shown that classroom-based smokingprevention programs, by themselves, have produced only 

short-term effects (Lichtenstein et al. 1990; Pentz, 

MacKinnon, Flay, et al. 1989; Best et al. 1988). These 

limited outcomes suggest the need to mobilize parents 

and elements of the community outside the schools to 

produce lasting behavior change. 

Young people who have the highest rates of tobacco use are those least likely to be reached through 

school programs (Glynn, Anderson, Schwarz 1991). 

Messages concerning tobacco use will be more acceptable to high-risk adolescents if they are embedded in 

groups or programs to which these youth already 

Prevention 139 
belong, rather than in tobacco-use prevention programs 

that stand conspicuously apart (Glynn, Anderson, 

Schwarz 1991). Community organizations and groups, 

on the other hand, are associated with particular social 

networks and social groupings of adolescents-potential 

avenues of program entry to the various social contexts 

of adolescents’ lives. 

Such contacts with and through these groups are 

important, since a strong correlation has been observed 

between smoking behavior and social group membership among youth (Novick et al. 1985; La Greta and 

Fisher 1992). The social environment of youth may include strong cues to use tobacco, such as adult role 

models who smoke or social groups where tobacco use is 

viewed positively. Community programs can effectively 

address these environmental elements and disperse messages against tobacco use (Becker et al. 1989; USDHHS 

1991). Concerted use of multiple school and community 

channels for affecting adolescent tobacco-use behavior 

can produce a synergistic effect on the risk factors associated with adolescent tobacco use (USDHHS 1991). 

Information about the programs described in the 

following sections was obtained through national and 

regional organizations and published literature. Many 

other locally initiated programs have been carried out in 

individual communities throughout the United States, 

but information on them was not readily available. 

Communitywide Research Trials on Smoking 

Prevention 

In the last 15 years, several major community-based 

prevention trials that target youth smoking have been 

undertaken. Three of these, the Stanford Heart Disease 

Prevention Program, the Pawtucket Heart Health Pro 

gram,andtheMinnesotaHeartHealthProgram,address4 

several cardiovascular risk factors for all age groups and 

used a variety of community strategies and channels, 

including school-based programs for youth (Farquhar et 

al. 1985;Mittelmarketal. 1986;Carletonetal. 1987). Young 

people therefore received these interventions directlythrough school and home-based programs-and indirectly-through a communitywide attempt to structure 

the overall social and physical environment to support 

smoking cessation and to discourage young people from 

starting to smoke. In the Class of 1989 Study, which was 

part of the Minnesota Heart Health Program, all of the 

2,400 students in the graduation class of 1989 in two of 

the state program’s six communities took part in a longitudinal study of health behaviors from 1983 through 

1989. In one community, the students also participated 

in five years of school-based health education, including 

a peer-led prevention program that addressed social 

influences to smoke (Perry, Klepp, Sillers 1989). At each 

140 Prevention 

Surgeon General’s Report 

of the annual follow-up surveys from 1984 through 1989, 

youth from the intervention communities had significantly lower smoking prevalences and smoking intensities than youth from the reference communities (Figure 

3); at the end of 12th grade, the intervention group had 

reduced its smoking prevalence by 40 percent (Perry et 

al. 1992). 

Similar results a172 anticipated from COMMIT, which 

isacomprrhensive,,community-basedappIoachtosmoldng 

cessation Though COMMITS adolescent component is 

largely limited to the school-based efforts, the program is 

designed tochangethecommunityenvinmmentbymaking 

smoking a major public health issue and strengthening the 

social norms and values that support nonsmoking (T’homp 

son et al 1990-91). 

The Richmond Quits Smoking Program tested the 

communitywide approach in a predominantly black community. Program components, including youth 

programs, were integrated into existing communication 

channels and social structures, and the smoking issue 

was presented in ways relevant to the black community 

(Hunkeler et al. 1990). 

Trials that focus specifically on youth include the 

Midwestern Prevention Project (MPP), which tested the 

use of a home- and community-based program in addition to school curricula to prevent the onset of tobacco 

Figure 3. Smoking prevalence of the cohort 

sample, Class of 1989 Study 

~1*~~*~ Intervention community 

- Reference community 

6 7 a 9* 10 11 12 

Grade 

Source: Pen-y et al. (1992). 

*Smoking prevalence adjusted for false negatives in ninth 

grade. 
Preventing Tobacco Use Among Young People 

ug. The overall design of the h4PP included all commu- 

&ies within metropolitan Kansas City (Kansas and Missouri) and Indianapolis (Indiana). Within each of these 

two areas, cohorts of adolescents were assigned by school 

to intervention or delayed intervention (control) conditions. The intervention programs initiaIly targeted sixthor seventh-grade students and consisted of a IO-session, 

school-based social skills curriculum; 10 homework assignments to be completed with parents or guardians; 

mass media coverage using television, radio, and print; 

community organization; and policy change. In the first 

two years of the project, 22,500 adolescents participated 

in the school and community intervention. Analyses 

from students in 42 schools (N = 5,008) indicated a lower 

prevalence of past-month cigarette, alcohol, and marijuana use at one-year follow-up for those exposed to the 

school intervention than for the control group (17 percent vs. 24 percent for cigarette smoking, 11 percent vs. 16 

percent for alcohol use, and 7 percent vs. 10 percent for 

marijuana use) (Pen& Dwyer, et al. 1989). 

Similar results were observed after two years for a 

longitudinal panel of students from eight schools in Kansas City (N = 1,122) (Pentz, MacKinnon, Hay, et al. 1989) 

(Table 6). Third-year results demonstrated sustained 

impact only on tobacco and marijuana use, but reductions were equivalent for adolescents at lower or higher 

risk (Johnson et al. 1990). The MPP is particularly 

important because it demonstrates the feasibility of a 

large-scale, communitywide effort focused exclusively 

on youth. The program has also demonstrated impact 

on those at high risk, and it has considerable methodological strength. The MPP’s long-term impact on 

tobacco is still to be determined. 

The New England Research Institute has developed 

and tested a community program for smoking prevention 

among Hispanic (Puerto Rican) adolescents. The program 

includes a music video, buttons and T-shirts, a smoking 

cessation booklet, information booths and a traveling 

music show at area festivals, and a basketball tournament 

that includes a discussion about pressures to smoke 

(McGraw 1990). The prehminary results of the evaluation, 

however, indicate no differences between the intervention 

group (in Boston) and a comparison group (in Hartford) in 

reported smoking rates, attitudes toward smoking, or intentions to smoke. 

Currently under way is Project SixTeen, a community trial being conducted by the Oregon Research Institute from 1990 to 1995. In this project, experimental 

communities receive a school program combined with 

community intervention that includes parental involvement, media campaigns, efforts by health care providers, 

and changes in policies and regulations (Ary and Biglan, 

unpublished data). 

State and Federal Tobacco-Control Efforts at the 

Local Level 

A number of states have adopted tobacco-control 

programs that include community-based adolescent 

components. The Association of State and Territorial 

Health Officials (ASTHO) has recommended the development of statewide tobacco-control plans that include 

both school and nonschool activities for youth (ASTHO 

1989). At least 12 states have developed freestanding 

statewide tobaccocontrol plans, and another 22 states 

have incorporated them into plans for controlling chronic 

disease (CDC 19!Xb). All but 15 states have a specific 

budget devoted to tobacco-related activities. Examples 

of state-funded nonschool activities to prevent tobacco 

use include the K.I.D.S. Coalition, a Utah program that 

encourages youth to work with community leaders to 

Table 6. Outcomes of the Midwestern Prevention Project: adjusted net differences in the percentage of 

smokers in program and control groups, from baseline to 6-month, l-year, and 2-year follow-up 

Adjusted net difference* 

Smoking variable 6 months 

Lifetime use 2.3 

Past-month use -7.5$ 

Past-week use -6.43 

1 year 

1.2 

-10.25 

-7.9s 

2 years 

11.7+ 

-16.05 

-1l.F 

Source: Pentz, MacKinnon, Flay, et al. (1989). 

‘Analyses done with school as a unit of analysis, adjusted for race and grade. 

‘p c .lO (one-tailed test). 

tp < .05 (one-tailed test). 

“p < .Ol (one-tailed test). 

Preuen t ion 141 
Surgeon Generals Report 

create social change around the tobacco issue (Utah De 

partment of Health 1991), and the Body Guards campaign, a program sponsored by the Minnesota Department of Health that trains minority youth (aged 12 

through 14 years) to involve their families and others in 

the community in tobacco-free pledges and messages 

(ASTHO 1992). 

The Federal Comprehensive Smokeless Tobacco 

Health Education Act of 1986 (Public Law 99-2521, which 

included a mandate for health education programs and 

materials about risks of smokeless tobacco, coincided 

with an increase in state-funded community programs 

addressing smokeless tobacco. In Ohio, for example, the 

Department of Health has involved American Lung Association affiliates, Boys and Girls Clubs of America, Little 

League, the Cleveland Indians baseball team, 4-H Clubs, 

and juvenile detention centers in efforts to reach youth at 

high risk of using smokeless tobacco (Capwell 1990). 

The most comprehensive state tobacco-control program operates in California. Administered by the state’s 

Department of Health Services and Department of Education, the program has been funded since 1989 by a 

cigarette excise tax increase of 25 cents per pack (as a result 

of Proposition 991, one-fifth of which is dedicated to 

antitobacco education (Bal et al 1990). Communitybased prevention services are specifically directed to 

high-risk youth (i.e., those who have parents who smoke, 

those who have dropped out of school, or those who are 

economically disadvantaged) (Tobacco Education Oversight Committee 1991). During its first two years, this 

program created local tobacco-use prevention coalitions 

in all 61 local health jurisdictions, organized a youth 

summit called Kids Choose a Tobacco Free Future, held 

training workshops for county staff of the Child Health 

and Disability Prevention Program to introduce materials 

and techniques for counseling children and parents about 

tobacco use, and funded many projects targeting ethnic 

minority youthand theircommunities. CalifomiaSmokeFree Cities is a joint project sponscmd by the California 

Healthy Cities Project and funded by Proposition 99. This 

program encourages cities to strengthen local tobaccocontrol efforts through various activities, many of which 

include youth (California Smoke-Free Cities 1992). 

A community-based program that embraces multiple states and communities is the Planned Approach to 

Community Health (PATCH), a partnership of the CDC, 

state health departments, and local communities to plan, 

carry out, and evaluate programs to prevent chronic 

disease (IJSDHHS 1992a). Many of the 19 states and the 

more than 50 communities that have been involved in the 

PATCH program have carried out communitywide 

tobacco-use prevention efforts, 

The Center for Substance Abuse Prevention, part 

of the Substance Abuse and Mental Health Services 

Administration WMHSA), sponsors a program of Community Partnership Grants, in which communities address local drug-use prevention issues. Public Law 

102-321, the ADAMHA Reorganization Act, Section 114, 

provides that all projects funded as prevention, treatment, and rehabilitation model projects for high-risk 

youth are to include strategies for reducing both tobacco 

and alcohol use among minors. 

The NC1 has supported nearly 100 controlled intervention trials aimed at preventing young people from 

taking up tobacco and herping adult users quit. These 

trials have involved more than 10 miIlion people in 33 

states and over 200 communities in North America; 24 

trials specifically targeted adolescents, and 6 addressed 

the prevention of adolescent use of smokeless tobacco 

KJSDHHS 199Ob). 

The NCI’s American Stop Smoking Intervention 

Study for Cancer Prevention (ASSIST) is the largest 

tobacco-control project attempted in the United States. 

ASSIST is designed to demonstrate that a comprehensive, coordinated intervention effort can significantly reduce smoking and tobacco use. The scientific rationale 

for this approach was clearly detailed in Strategies to 

Control Tobacco Use in the United States: A Blueprint for 

Public Health Action in the 1990s (LJSDHHS 1991). 

ASSIST is predicated on a coalition model. During 

the planning phase, nearly 1,000 community health agencies, social service organizations, and voluntary heahh 

groups have joined state and local tobacccFcontro1 coalitions. This number will grow as the project enters its 

intervention phase, when these organizations are expected to begin carrying out interventions targeting youth 

and other high-risk populations served by these groups. 

A number of states, including Maine, Virginia, Michigan, 

Massachusetts, Colorado, and Minnesota, have supplemented their broader statewide coalitions with separate 

coalitions for controlling tobacco use among youth. Those 

ASSIST states that have high rates of smokeless tobacco 

use (West Virginia, Virginia, North Carolina, and South 

Carolina) specifically address such behavior among both 

adults and youth in their statewide comprehensive plans. 

ASSIST has the potential to save more than 

1.2 rnilhon lives, including over 4CKl,OC0 deaths averted 

from lung cancer alone. The majority of these lives saved 

would be the direct results of ASSIST’s primary 

prevention efforts among children, adolescent, and young 

adults. 

Community Organizations for Preventing 

Tobacco Use 

Many youth organizations include a programmatic focus on substance use. These program activities 

may or may not explicitly focus on tobacco separately 

142 Preuention 
Preventing Tobacco Use Among Young People 

from other drugs. In most cases, little or no evaluation 

has been done to measure the effect these programs 

have on tobacco use. 

Project California 4-Health focuses specific~y on 

tobacco and is a joint effort of the University of California at Davis and the University of California Cooperative Extension 4-H programs. The program, which 

teaches older teens to present a tobacco-use prevention 

program to youth aged 9 through 12 in settings outside 

of school, is currently being evaluated (Project California 4-Health 1992). 

Two programs are noteworthy because they have 

been designed to reach high-risk youth. Girls Inc. (formerly Girls Clubs of America) is a nationwide (120-&y) 

network of over 200 centers serving young girls aged 6 

through 18; over half of these girls belong to racial and 

ethnic minority groups. The organization’s Friendly 

PEERsuasion program focuses on avoiding substance 

abuse (Girls inc. 1991). Developed under a grant from 

the Office for Substance Abuse Prevention, Friendly 

PEERsuasion uses an older-to-younger peer leadership 

approach to encourage girls aged 11 through 14 to 

choose healthy alternatives to using illegal drugs, alcohol, and tobacco. The Boys and Girls Clubs of America, 

a nonprofit organization that provides programs in several areas, including health and physical education, has 

recently established clubs (built on the structures and 

supports of the Boys and Girls Clubs of America) in 

several housing developments around the country. 

Dubbed the SMART Moves (Self-Management and I+- 

sistance Training) program, these clubs aim to prevent 

substance abuse (including tobacco use) among highrisk youth by also targeting parents and the community 

(S&i&e, Orlandi, Cole 1992). 

To counter the association between baseball and 

smokeless tobacco use, Little League Baseball, Inc., with 

the support of the NC1 and NIDA, has developed for 

young players two pamphlets that emphasize the 

negative social consequences of smokeless tobacco. A 

more extensive program for preventing smokeless tobacco use among youth who are baseball players is 

currently being evaluated among Little League and 

Senior League teams in Harris and Galveston counties 

in Texas (Evans, Raines, Getz 1992). This intervention 

targets players and their parents and involves professional baseball players. 

In 1987, .a program developed and implemented 

in 72 of the 4-H clubs in 24 California counties targeted 

reduction of smoking and smokeless tobacco use 

(D’Onofrio, Moskowik, Braverman, unpublished data). 

Club members aged 10 through 14 years were involved 

in the study; 68 percent of the sample were retained at 

the tweyear follow-up. The program included five 

tobacco-related outcome variables-knowledge, attitudes, 

perceived social influences, intentions, and behaviorsand involved five sessions of tobacco education provided 

at the monthly club meetings by volunteers (41 adults and 

26 teens) trained to deliver the program. At the first 

follow-up (one year later), the program demonstrated a 

significant impact on participants’ knowledge of the harmful effects of smokeless tobacco use and on participants’ 

intentions to smoke, but the program had no effect on 

actual use of smokeless tobacco. The two-year follow-up 

showed no difference between members of clubs receiving treatment and members of control clubs. The authors 

concluded that providing a tobacco-prevention program 

through 4-H clubs was difficult to manage because of time 

constraints on club meetings, but the effort proved to be a 

useful complement to school-based programs to change 

social norms. 

Other youth organizations that incorporate tobaccouse prevention as part of a general emphasis on preventing substance abuse include the YWCA (Condas 1992), 

Camp Fiie Boys and Girls (Emerson 19921, the Boy Scouts 

of America (Grau 1992), and the Girl Scouts of the U.S.A. 

(Eubanks 1992). 

The National Parent Teacher Association (PTA) has 

adopted a number of resolutions that recognize the hazards of tobacco use and support educational programs 

and community policies to discourage tobacco use (National PTA 1984). However, the organization’s materials 

for parents about drugs do not discuss tobacco use. 

“Just Say No” International is an organization 

founded in the late 1980s to promote local clubs for youth 

aged 7 through 14 years. These clubs give children information, ski%, and support to help them resist drugs, 

including tobacco (“Just Say No” International 1992). The 

parent organization and the 11,000 local clubs are largely 

funded through private sources and are based in schools 

and community settings, including some public housing 

sites. Activities include education, recreation, outreach 

and peer-education, and community service. An evaluation of 12 local clubs that had been active for at least one 

year revealed that these clubs can offer young people a 

meaningful role in improving the community, strengthening community ties, helping community members commit to drug-use prevention, and coordinating other 

prevention efforts (Duper 1992). 

Prevention Programs Initiated by the Tobacco 

Industry 

Since 1984, the Tobacco Institute has distributed a 

series of publications intended to discoumge chilti fzvm 

smoking (National Association of State Boards of Education 

[NASBEI 1984,1987;TobaccoObserver1984). AlthoughalIof 

thesepublicationsemphasiz.edecision-makingskills,onlythe 

Praention 143 
Surgeon General’s Report 

most recent, Tobacco: Helping Youth Say No, actually focuses 

on tobacco use (Tobacco Institute 199Oa, b). The program’s 

cosponsor, The Family COURSE Consortium (Communication through Open minds, Understanding Respect and 

Self Esteem) has approached schools and worked with 

school districts in four major cities to determine the content 

of their program (8launstein 1991). Although promotional 

materials include testimonials and endorsements, no data 

concerning the effect of these programs are available. 

The first program sponsored by the Tobacco Institute was Helping Youth Decide (NASBE 1984). The 

program’s focus is on parentxhild communication 

skills and responsible decision making (NASBE 1984; 

Coulson 1985). The program acknowledges that young 

people should not smoke, but the program itself offers 

no specific advice on preventing tobacco use (NASBE 

1984). 

In 1987, Helping Youth Decide was supplanted by 

Helping Youth Say No (NASBE 1987). Both programs 

were published in conjunction with NASBE. Like its 

predecessor, Helping Youth Say No focuses on parentchild communication and on adolescents’ decisionmaking skiIls. NASBE was criticized by a number of 

individuals and organizations for its involvement with 

the Tobacco Institute and eventually ended its association with the program. 

The current version of Helping Youth Say No consists of a booklet entitled Tobacco: Helping Youth Say NoA Parent’s Guide to Helping Teenagers Cope with Peer 

Pressure. Provided at no charge, these booklets are designed “to increase communication between parents and 

children and to raise levels of mutual trust and respect.” 

The text discusses the role of peer pressure in yotmg 

peoples’ lives, helps parents talk with their child about 

not using tobacco, and includes practical exercises to 

increase parent-child communication. The booklet is 

likely to appeal to both smoking and nonsmoking parents, since smoking is described as an adult choice 

(DiFranza and McAfee 1992). This booklet would not 

likely affect adolescent behaviors because it is directed at 

parents, who rarely participate in such programs without an incentive (Perry et al. 1989). The materials also do 

not attempt to set new peer-group norms or encourage 

peer leadership. Although the program does not specify 

whether it is to be used as a school-based curriculum, it 

would not meet the recommended criteria established by 

the NC1 in conjunction with a panel of smoking prevention experts CGlynn 1989; see Table 4). 

Prevention Programs Sponsored by Health-Related 

Organizations 

Most of the programs developed by voluntary 

organizations to prevent smoking among youth are 

offered as part of a school cunicuhu-n. An exception is 

the American Cancer Society’s preschool smokingprevention program Starting Free--Good Air for Me, 

which includes various home activity sheets and group 

activities for preschool settings (ACS 1987). This program was tested among 86 families in four primary care 

medical settings. Results indicated that children exposed to the program were almost three times as likely 

as others to report that they intended to protect themselves from adult cigarette smoke W-riIips et al. 1990). 

The American Lung Association disseminates the 

Unpuffables, a four-week, home-based program designed to help parents and children aged 9 through 12 

years discuss the issue of preventing tobacco use. Pilot 

tests of the Unpuffables program in schools in Minnesota and Massachusetts and with Camp Fire and YWCA 

youth groups in Oklahoma showed that parents were 

aware of and approved of the program (Perry et al. 

1990; American Lung Association of Green Country 

Oklahoma, unpublished data). 

The American Lung Association has been active 

in the area of adolescent smoking cessation. In 1988, a 

technical advisory group on adolescent smoking cessation reported that demands in this area were unmet and 

research questions unanswered (Hitchcock 1991). Local affiliates of the American Lung Association have 

developed one of the few available programs for smoking cessation among adolescents-Tobacco Free Teens, 

which is used by schools and other organizations in 25 

states and 84 local affiliates (Terwedo 1992). A recent, 

limited evaluation showed lower cessation rates and 

higher dropout rates than were observed in American 

Lung Association programs targeting smoking cessation among adults (American Lung Association 1991). 

The American Cancer Society, American Heart 

Association, and American Lung Association joined 

together in 1988 to launch the Smoke-Free Class of 2000 

program. The goal of this education effort is to help the 

cohort of young people who were first graders in 1988 

remain tobacco-free when they graduate in the year 

2000. The project reaches about 2 miIIion students and 

135,000 teachers nationwide. As students enter junior 

and senior high school, learning activities will shift 

from information to community advocacy, creating 

“youth ambassadors” for a smoke-free society. 

Tobacco-Control Advocacy Organizations 

DOC, the organization for health professionals 

that has more than 150 chapters in 23 countries, encourages physicians to counteract the promotion of tobacco 

to young people (Blum 1980; DOC 1992). Proactive and 

prohealth strategies in the classroom, clinic, and community use humor and ridicule of tobacco products and 

144 Prevention 
Preventing Tobacco Use Among Young People 

tobacco industry messages to call attention to the marketing of tobacco to children. DOC chapters sponsor 

youth sports teams and leagues with an antitobacco 

message, support local minority organizations and events 

such as the Cincinnati Smoke-Free Jazz Festival, and 

make “housecalls” (protests) at youth-appealing events 

sponsored by tobacco companies. DOC has aIso established a program whereby medical students can teach in 

school-based smoking prevention efforts and become 

special&s in school and community health promotion 

(Shank 1985). DOC’s leadership in innovative activities 

has been noted nationally and internationally, and these 

activities have been replicated or have been the basis for 

many communitywide programs. 

Other tobacco-control advocacy organizations, 

such as Stop Teenage Addiction to Tobacco (STAT), 

SmokeFree Educational Services, Inc., and Americans 

for Nonsmokers’ Rights, sponsor many other creative 

and effective community-based events, chapters, and 

conferences. Although the results of these organizational efforts are not usually published in scientific journals, their contributions to smoking-prevention 

programs and policies in the United States are widely 

recognized. 

STAT, for example, is the only organization in 

the United States dedicated solely to issues of teenage 

access to tobacco. Public education and information 

form a major part of STAT’s activities. Central to this 

are the STAT newsletter, the Tobacco Free Youth Reporter, which appears quarterly and is sent to over 

100,000 persons worldwide. This newsletter, along 

with STAT-authored journal articles and press advisories and a STAT-sponsored annual conference, has 

been used to present and analyze the practices of the 

tobacco industry. Statewide and community projects 

to reduce sales of tobacco products to youth have also 

been central to STAT’s activities since its inception. 

Currently, STAT has a major grant from the Robert 

Wood Johnson Foundation to expand activities related to teenage access to tobacco in communities in 

four states and to demonstrate how other communities can take similar actions. 

The Teens as Teachers program has been created 

and disseminated by the American Nonsmokers’ Rights 

Foundation. Teens as Teachers reaches young people 

most vulnerable to tobacco addiction. Although many 

current smoking-prevention programs do a good job of 

teaching adolescents how to resist peer influence, Teens 

as Teachers also teaches them to think critically while 

examining both the nature of the tobacco industry’s strategies and their right to be protected from primary and 

secondhand smoke. Teens as Teachers has reached over 

1,000 high school students, who in turn have reached 

over 6,000 elementary and middle school students. 

Role of the Mass Media in Reducing Tobacco 

Use 

Introduction 

Mass media are particularly appropriate prohealth 

channels for tobacco education among yotig people, 

who are heavily exposed to-and often greatly interested in-the media (Minnesota Department of Health 

1989). However, although the general public has received many antismoking messages in one form or another since the 1964 Surgeon General’s report on smoking 

and health (Warner 1989), few messages have been designed specifically to prevent young people from trying 

tobacco. 

Programmatic Use of Mass Media to Reduce 

Adolescent Tobacco Use 

By the early 198Os, the Office on Smoking and 

Health had responded to the lack of media messages 

discouraging tobacco use among youth by developing 

a series of national public service announcements (see 

Table 7). The major voluntary health agencies have 

also produced a national broadcast message for youth. 

DOC began creating counteradvertising in 1977, 

often involving young people in designing parodies of 

tobacco advertisements. DOC purchased advertising 

space, used counterpromotions (e.g.; the Emphysema 

Slims Tennis Tournament) (Solberg 1992), and encountered occasional censorship (Fitzgerald 1990). DOC 

has maintained visibility by enlisting medical professionals, youth, and parents for innovative media- and 

community-based antismoking campaigns. The program has not been formally evaluated. 

Young people have also been a major (but not 

exclusive) target group of several important statewide 

tobacco-use prevention and cessation campaigns. At 

their onset in the late 1980s and early 199Os, campaigns in 

Minnesota, Michigan, and California used funds from 

dedicated cigarette taxes to fund multimedia promotions. The programs have received funding for several 

years. These states have employed sophisticated marketing techniques (i.e., they have used marketing experts, focus groups, pretesting, pilot campaigns, and 

ongoing evaluations) to increase their effectiveness and 

have arranged for extensive paid and donated advertising to ensure adequate reach and frequency of statewide 

coverage (Minnesota Department of Health 1991; Kizer 

and Honig 1990). Each of these campaigns also included 

an outdoor billboard or poster component that mirrored 

themes in the broadcast media. In 1989, the Michigan 

Legislature dedicated revenues from a tax on computer 

software (about $9 million per year) to health promotion, 

primarily for AIDS and smoking education (Moore & 

Prevention 145 
Surgeon General’s Report 

Table 7. Major mass-media campaigns to prevent tobacco use among young people, United States, 1983-1992 

Source and dates 

Year of survey Campaign description Representative spots 

Office on 

Smoking and 

Health 

(1983-1990) 

A series of W spots 

with attractive images of 

young people dancing or playing 

sports; the general theme is 

that living is positive and 

smoking is out of fashion 

Cigarette Mash 

Nit (A Teen) 

National Cancer Institute 

(1987) 

American Lung 

Association (1988) 

. . ‘- 

Radio campaign ‘1’ : 

. :_,,. . _ _, ,. -. .._,. ..“. 

1 : i 

feat$ngna&naIrac+ ‘:-:-. -: 

.: Smoking’s Out 

.‘I I .i ‘.< .- .- *-..v;; .~, 

personality Casey K&em 

i-,.‘,T ._ ‘4.. :. 4 

.- ., i 

. ,_ ..e -._ .~ 1 “_ . bi c_- 5 .*... I~_i -_ _ :-/... ___b ..t 

TV spot with awareness Cigarettes Are Drugs 

message 

1% Prevention 
Preventing Tobacco Use Among Young People 

Format and duration 

(in seconds) Content 

TV (60) Dancing girls stomp on cigarettes to model 

quitting; viewers invited to write in for poster 

TV (60) Cartoon of a “butthead” getting shunned by peers 

TV (30) A boy in a rundown neighborhood appears to 

be buying drugs, but it’s a pack of cigarettes 

TV 60) 

TV (30) 

TV (30) 

TV (15) 

Fast-paced music video: smoking’s not cool 

Cartoon: young kids are smart and don’t smoke 

Tobacco executives joke about “getting” smokers 

Disgusting look of a cigarette butt in the mouth 

TV (30) Three boys show disgust for a girl’s smoking 

Prmenfion 147 
Surgeon General’s Report 

Associates, Inc. 1990). The Michigan Department of Health 

invited representatives from television stations and newspapers to participate in the creative process; the multirnedia campaign has included paid and public-service 

broadcast time, as welI as space on television, radio, billboards, and buses. 

Several other state health departments have developed smaller campaigns. In 1986, Arizona created a 

smokeless-tobacco-prevention campaign that included a 

short television message (or “spot”), a series of peerinfluence radio spots, a poster, and a ballplayer spokesperson (Arizona Department of Health Services 1986). 

Indiana created a television spot to discourage smokeless 

tobacco use (Indiana State Board of Health 1992); a 

smoking-prevention campaign with monthly broadcast 

spots was conducted in Alabama (Alabama Department 

of Public Health 1992); and in Tennessee, a local television 

spot was used to support the Smoke-Free Class of 2000 

school program (Tennessee Department of Health 1992). 

State health departments often use advertising 

agencies and production companies to create their campaign messages. The campaign in Vermont, however, 

used materials developed previously by other states 

and by a research grant from the University of Vermont 

(Flynn et al. 1992). Using focus groups of Vermont 

children, the Vermont Department of Health pretested 

the existing materials (including 15-second messages 

titled “Girl Mouth” and “Boy Mouth”) borrowed from 

Michigan and the “Smoking Is Real Gross” spot produced by the ACS. The spots that were rated highest by 

the focus groups were included in Vermont’s 1992 statewide campaign. 

Most of the major mass-media campaigns listed 

in Table 7 employed social influence strategies similar 

to those that were successful in school-based smokingprevention programs. The California campaign, however, focused more on information-based approaches 

and most prominently on a strategy to deglamorize 

tobacco use by exposing the business side of the tobacco industry and by repositioning tobacco marketers 

as playing a significant role in the problem of adolescent tobacco use (Kizer and Honig 1990). Messages 

alerting young people to the negative impact of tobacco 

promotion were also included as a part of researchoriented campaigns (discussed later in this section) in 

Richmond, California (Hunkeler et al. 1990), and in 

Vermont (Flynn et al. 1992), but results have not yet 

been published about the effectiveness of these specific 

messages. It has yet to be established that making 

young people aware that they can be vulnerable targets 

of tobacco advertising contributes to smoking prevention (McKenna and Williams 1993). 

Theory and Research on Using Mass Media 

to Reduce Adolescent Tobacco Use 

During the past 20 years, various ideas have 

emerged on using mass media effectively to prevent the 

onset of tobacco use or bring about its cessation among 

young peopie. An important article by Flay, DiTecco, 

and Schlegel (1980) expanded previous informationbased models to include new elements that would increasethelikelihoodofpromotingandmaintaininghealth 

behaviors through the mass media. These elements included techniques to ensure that messages are attended 

to, comprehended, and accepted, as well as techniques 

to convey skills, stimulate social interaction, and reinforce behavior. Schilling and McAlister (1990) integrated 

sociaI and behavioral research and theory into mediabased prevention strategies for tobacco and drug use. 

Further, DeJong and Winsten (1990) incorporated more 

developed principles of social marketing and experiences of researchers and other practitioners in health 

promotion and commercial marketing to present a de 

tailed set of recommendations on the use of mass media 

to prevent substance abuse. 

As in the case of national campaigns, research on 

the use of mass media to bring about the prevention or 

cessation of tobacco use among young people has been 

sporadic and may warrant further commitment at the 

national level (Bauman 1992). The best-organized re 

search effort was coordinated in the mid-1980s through 

the NCI’s Smoking, Tobacco, and Cancer Program 

(Bettinghaus 1988). Three research grants coordinated 

by this program tested approaches for using mass media 

for smoking prevention and cessation among young 

people. 

The first of these studies, at the University of Southem California (Hay et al. 19881, evaluated a strategy 

developed in previous projects. In that strategy, schoolbased programs that emphasized ski& to resist sociaI 

influences to smoke were extended to include segments 

on southern California’s evening news broadcasts 

(Sussman et al. 1987). Although school programs were 

effectively carried out, the television segments were not 

able to meet the objectives of the study, because the 

commercial news organization and its Labor contracts 

did not allow the newscast to include scripted demonstrations of prevention skills. Researchers from the university were not able to participate in the production 

process, nor were they able to pilot-test the television 

segments. The authors conclude that “the resulting programming did not demonstrate social resistance skills in 

the progressive and detailed way that is necessary for 

adequate learning to take place” (p. 604). 

The second study, at the University of North 

Carolina at Chapel Hill (Bauman et al. 1988), used 

148 Prmention 
Preventing Tobacco Use Among Young People 

contemporary marketing techniques coupled with be 

havioral science theory to develop three campaigns that 

could be practical and inexpensive enough to be disseminated nationally if proven successfuI. A radio campaign 

used eight messages about expected consequences of 

smoking. Another radio campaign invited young people 

and their friends to enter a sweepstakes by pledging not 

to smoke. Lastly, a television campaign combined these 

two approaches. These campaigns were conducted as 

paid media, not as public service announcements. The 

intervention, which involved 10 media markets in the 

southeastern United States, was expected to reach 75 

percent of its adolescent target audience during 1985 and 

1986. Although none of these campaign approaches 

resulted in reductions in the onset of smoking, improvements were observed in two important psychosocial factors-the expected utility of smoking and friends’ 

approval of smoking (see “So&I Support for Smoking” 

and “Subjective Expected Utility’ in Chapter 4). The 

authors also found that radio was as effective as television for reaching the adolescent audience (Bauman, 

Padgett, Koch 1989; Bauman et al. 1991). 

The thixd study, at the University of Vermont (worden 

et al. 19881, tested the ability of mass media interventions to 

inaease the efficacy of a school-based smoking-prevention 

pm In this intervention strategy, media and school 

programssharededucationalobpctivesbutwereotherwise 

independent. A total of 36 television and 17 radio messages 

were developed by using extensive diagnostic and formative resear& with students in grades 4 through 10. The 

messages were broadcast in a four-year paid campaign in 

cities in Montana and the northeastern United States from 

1986 thmugh 1989. Results indicated that the smoking 

prevalence for students who received both the media campaign and the school program was 34 to 41 percent lower 

than for students who received the school program only 

(Figure 4). The study observed consistently positive results 

for intervening measures (Flynn et al. 1992). An alternative 

approach that used the community as the unit of analysis 

ah showed a significant difference between treatment 

groups over time (Flynn et aI. 1992). This campaign used 

various message formats and production styles, including 

nonauthoritarian appeals that avoided direct exhortations 

not to smoke. The authors suggested that because the 

media campaign was not expIicitly Iinked to the school 

Program (e.g., $e two components did not share materials, 

designs, or slogans), adolescent viewers may have perceived 

that young people across the nation were receiving the same 

nonsmoking messages-and that nonsmoking was indeed 

the norm. 

Other than the three studies funded by the NCI, 

little mass-media research has been directed at adolescent 

smoking. The recent California mass media campaign 

included young people as a major target audience; about 

one-third of the television messages, one-quarter of the 

radio messages, and over one-half of the outdoor advertisements addressed young people as welI as other specified groups (e.g., pregnant women, young adults, adults) 

(Kizer and Honig 1990). 

Although the goals of the California campaign intermingle youth and adult priorities, the goals that seem 

to apply to youth are those that deglamorize the myths 

about tobacco use, expose problems created by the tobacco industry, and provide information about the hazards of smoking. A few spots touch on these topics (Table 

7), but several others, said to be targeted to the youth 

audiences in the California media plan, seem to be intended for adults, such as spots about youth access to 

cigarette vending machines and about spots that show 

children worrying about their parents’ smoking. Measurements before and after campaign waves, however, 

indicated significant changes in message awareness 

(Popham et al. 1991), and a report by Glantz (1993) indicates an association between the media campaign and a 

decline in cigarette consumption throughout California. 

Recently released data suggest, however, that this decline 

is not being observed among youth (Pierce et al. 1993). 

Figure 4. 

20 - 

18 - 

s 

; 16- 

.Ei 14- 

E 

k 12- 

3 lo- 

% 8- 

2 

z 6- 

1 4- 

Smoking prevalence in University of 

Vermont program using mass media to 

prevent adolescent smoking 

o1 2 3 4 5 6 

Study year 

School program only 

- - School program and media campaign 

Source: Adapted from Flynn et al. (1992). 

Prevention 149 
Surgeon General’s Report 

Mass media were also used in the Midwestern 

Prevention Project, a multicomponent community program (Per&, MacKinnon, Dwyer, et al. 1989) in Kansas 

City in 1987, but effects of the media were not assessed 

separately. An evaluation of the statewide Minnesota 

campaign indicated that youth were aware of the negative personal and social consequences of smoking and 

could recall two campaign themes-that “smoking is 

unnatural” and that “not many kids my age smoke” 

(Minnesota Department of Health 1991). Mass media 

were also an integral part of a community-based 

smoking-cessation program for minorities in Richmond, 

California, in which billboards, bus posters, direct 

mail, television, coverage on a national evening television news show, and rap music video presentations sup 

ported community program activities. Both participation 

and awareness were high among these minority youth, 

although summary results have yet to be reported 

(Hunkeler et al. 1990). 

Effective Designs for Mass-Media Campaigns 

Although mass media in the United States have 

been used to convey messages urging youth not to use 

tobacco, efforts to use the media for this purpose have 

been meager when compared with the highly coordinated, well-funded campaigns of tobacco advertisers. In 

the absence of a national campaign against tobacco use, 

with coordinated themes and paid counteradvertisirtg, 

state agencies and voluntary organizations have launched 

short-term efforts that have had limited evaluations of 

their impact. Research on the potential uses of the media 

has been restricted to a few experimental studies using 

divergent media strategies, and only one of the studies has 

resulted in a significant reduction in smoking among adolescents (Flynn et al 1992). 

Although a national commitment to using mass 

media to prevent tobacco use among youth has been 

limited, sufficient evidence now exists to examine this 

tactic further. The effectiveness of a large-scale massmedia and school-based program has been demonstrated in the University of Vermont study (FIynn et al. 

1992), albeit with largely white student populations in 

northern states. In addition, several applicable principles of effective campaign design have been identified 

within the disciplines of marketing, advertising, health 

education, and the social sciences (Flay, DiTecco, 

Schlegell980; Flay 1986; Schilling and McAlister 1990; 

DeJong and Winsten 1990; Flay and Burton 1990; Flynn 

et al. 1992). These principles, which are discussed below, can be applied to future mass media programs for 

young people. 

l In planning campaigns to prevent tobacco use, target 

groups should be carefully differentiated. If a campaign is aimed at youth only, it may be best to separate 

it from community or school ties and to use media and 

message formats that appeal to youth only (Flynn et 

al. 1992). -Even within the youth population, segmentation (e.g., by age, gender, racial/ethnic group) may 

be necessary. If the campaign is community based, 

either for youth or their parents, it should closely 

connect with community resources and appeal spe 

cifically to either the youth or the parent target groupnot to both (Hunkeler et al. 1990). 

l The planning of prohealth campaigns for young people 

should attend to the critical issues of message design 

identified in the literature (Flay, DiTecco, Schlegel 

1980; Flay 1986; SchiIling and McAlister 1990; DeJong 

and Winsten 1990; FIynn et al. 1992). These issues 

include appealing to the needs and interests of the 

target group (e.g., peer approval, freedom, autonomy); 

using peer models, image appeals, or lifestyle appeals 

instead of cognitive appeals; providing novelty and 

humor (Blum 1980); avoiding exhortation; using celebrity spokespersons cautiously; and demonstrating 

preventive skills. 

l Messages should be carefully scrutinized by knowledgeable persons and by representatives of target 

groups to ensure that these messages are not conveying unintended effects that may eclipse their positive 

value (Flay and Burton 1988). Antismoking messages 

that show young people smoking or asking someone 

for a cigarette may unintentionally employ powerful 

images of the social functions of smoking, particularly 

if the supposedly negative role model is in any way 

attractive or appealing to the target audience. These 

images may greatly outweigh the impact of a voice 

over narrator’s message-a message that could be 

almost meaningless to the image-oriented target group 

of young people. 

l Diagnostic and formative research, including surveys 

and focus groups, should be employed at appropriate 

points throughout the creative process. Diagnostic 

research can identify perceptions and needs in the 

target audience that are critical for concept develop 

ment (Worden et al. 1988). Formative research, at 

both preliminary and advanced stages of message 

execution, avoids potentially damaging, unintended 

message effects (Flay and Burton 1988) and gives 

producers confidence that the message wilI be accepted and appreciated by the target audience. Pretesting during the execution phase is critical for 

messages aimed at youth, because much of the 

150 Prevention 
Preuenfing Tobacco Use Among Young Peq+ 

. 

m-sage appeal relies on production elemtm& .qwh ,\?; 

choice of actors, clothing, and music. To &J ?;u,\~~~,~. 

pro&ztion need not be Costly (Flynn trt al. t-2). In 

fact, small, independent producers may by luwtu.~t+. 

if pr&u&on quality is maintained. 

Campaigns should be intense enough to t’~uuh\ impact (Flay, DiTecco, Schlegell980). Tele\iti,>n nlLY?;- 

Sages should be aired at times when your\< ?~~~l+, 

are most likely to be watching-and ti,r h-?;t t++ 

cienq, at times when they are the prim.~rl\, \-ic\\-\.=;. 

particularly during the reruns of popular ~~rimtLtin,,, 

shows during after-school hours, since thtw ~h~~,,~ 

tend to charge relatively low rates for ~~d\-\~~isin+.. 

Adequate reach and frequency should h\ .lchic\-l,i 

by using both paid and public-service time (F.tic~.,~,~ 

McKenna, Roman0 1990). The statewide mt\Ii,\ c,,~,,- 

paigns in California, Minnesota, and htichis,j1\ ,In, 

based on paid advertising funded by earn~.~rL\~ t.llt, 

Paid media appear necessary t0 achieve s;\llvt.lnti,\\ 

exposure to targeted youth populations .\t L\\\tim,\l 

ties of the day. Campaigns should havt\ s\ltfi<i<*nt 

duration (or else should run continuously) tip in\lx,L.t 

youth throughout the critical years for srnk&inS ,,,,- 

set (Worden et al. 1988). 

. Campaigns can be cost-effective. Evidence from the 

University of Vermont study (nynn et al. 1992), which 

achieved a 35 percent reduction in Weekly smoking, 

irtdicataj that the cost per person for the estimated 

2,605 young people (7 percent of the total population 

aged 10 through 15 in the broadcast area [U.S. Department of C&nerce 1992a, b, C; R.R. Bowker 19921) 

who may have been prevented from smoking by the 

four-year intervention WCS estimated to be $233 when 

the costs of production and paid advertising were 

included, and $77 when paid advertising alone was 

included. These costs compare favorably to those 

incurred in various smoking cessation programs 

(Altman et al. 1983, in which costs ranged from $22 to 

$339 per successful quitter. Far the estimated 37,212 

students h~ grades 5 through 10 residing in areas 

receiving this media campaign, the annual cost per 

student for the total campaign was $4.08; for paid 

advertising only, the cost per student was $1.34. Comparable total campaign costs per teenager in Mincesota, with a 95 percent audience reach but fewer 

exposures than in the Vermont study, were $1.07 in 

1989 and $1.14 in 1990 (Cdey 1992). Costs can also be 

contained if media spots are shared across states or 

reused after several years. 

public Policies to Prevent Tobacco Use AIllong young People 

Effect of General-Public Smoking 

Restrictions on Young People 

Introduction 

Public smoking restrictions are an import,lnt L~jnlponent of the social environment that supports nonsmoking behavior (Rigotti 1989; Simonich 111,(, 1. 

Wasserman et al. 1991; Emont et al. 1993). Thc*v <\,ntri\L 

ute to adolescents’ percephons that nonsmc)kins is 

normative and create a social climate where smoking is 

not acceptable. Restrictions convey the additional mcssage that smoking creates health problems for smukcm 

and nonsmokers alike. Finally, rehiw to the d~gnv of 

compliance, thee restrictions reduce the numtwr of 

opportunities to smoke and thus make smoking lr%s 

convenient. The net effect of these restrictions should lw 

to reduce the psychosocial benefits of smoking to ,~d~pl~%- 

cents, making it less likely that those who exprimcnt 

with smoking will continue to smoke and ~woI~~~ dependent (USDHHS 1991). 

History of Public Smoking Restrictions 

AS documented in the 1986 and 1989 Surgeon 

Gene&‘s VJrts on smoking and health, restrictions on 

smoking in public before the 1970s were motivated prirnarily by concern over smoking as a potential fire hazard and 

byothersafetc’concems,suchasdistractionswhiledriving 

(USDHI+j l&&a, 1989). In the 197% new k!gislation was 

enacted, pti@ally in the form of state-level clean-indoorair am, to ~~cmxt the nonsmoking public from the health 

hazards md +~y&tl irritation caused by smoking. During the l%Qs, 31 states passed legislation that introduced 

mk&ons on sn~o&ng in public places and private facilities, such s w~~kp~ces or restaurants, or that extended 

existing rq-&tiom (USDHHS 1989). This and ensuing 

legislation was fueled by the accumulation of welldocumented, -de&publicized evidence of the disease risks 

asso(-iated M=II smoking (Rigotti 1989; USDHHS 1991). 

Duringthe1~,t&a~ntroleffotisp~adtothelocal 

level. By 1 w_, a total of45 state% the District of Columbia, 

and at least ji vt of cities with a population of 25,000 

Prevention 151 

161-235 95 -6 
Surgeon General’s Report 

or greater had adopted some restrictions on smoking in 

public places (Rigotti and Pashos 1991; Coahtion on SmokingORHealth1992). However,onIyafractionoftheseIaws 

could be considered comprehensive enough to provide 

meaningful protection against environmental tobacco 

smoke, and municipal laws have tended to be more extensive and stronger than state laws (Rigotti and Pashos 1991; 

USDHHS 1991). The 1990s have seen the introduction of 

biIIssponsoredbythetobaccoindustrythatinch.ideIimited 

state restrictions on smoking in public but that also preempt more restrictive current or subsequent local ordinances. States with complete or partial preemption include 

Florida, Pennsylvania, Virginia, Nevada, IUinois, New Jersey, Iowa, and Oklahoma (Rigotti and Pashos 1991; Americans for Nonsmokers’ Rights 1992~). 

Smoking Restrictions in the School 

Schools can create powerful environments for promoting a nonsmoking norm. Educational organizations 

such as the National School Boards Association ([NSBA] 

1987,1989) and the Alliance for Health, Physical Education, Recreation, and Dance (1991) have endorsed the use 

of “tobacco-free policies” as a key component of efforts to 

create smoke-free schools. 

In 1988, the NSBA, in collaboration with the ACS, 

the American Heart Association, and the American Lung 

Association, conducted a random-sample mail survey of 

school smoking policies in 2,000 of the more than 15,000 

public school districts in the United States; 1,310 (66 

percent) of the districts responded (NSBA 1989). Results 

from a similar, earlier NSBA study (NSBA 1987; USDHHS 

1991) allowed an examination of policy trends over time. 

In 1988,95 percent of aII responding school districts had 

a written policy or regulation on tobacco smoking in 

schools. AII of the written policies in the 1988 survey 

included restrictions on smoking by students; 96 percent 

addressed smoking by faculty, staff, and administration; 

and 92 percent addressed smoking by other adults. Of the 

districts responding to the 1988 survey, 17 percent 

totally banned smoking; that is, smoking by anyone was 

prohibited both on school premises and at school functions. Restrictions on adult smoking on school premises 

and at school functions more than doubled during the 

two years separating the surveys. For example, the 

proportionof districts that prohibited smoking by school 

personnel in school buildings increased from 11 percent 

in 1986 to 24 percent in 1988. In the 1988 survey, comphante by school personnel was described as “excellent” or 

“good” by 87 percent of districts with written policies, 

and 86 percent reported similar levels of compliance 

among students. Moreover, school districts with poIities that banned smoking altogether reported greater 

adherence to their policies than did districts with less 

stringent restrictions. 

In October 1989, ASTHO conducted a survey of 

state health department personnel that included information on policies that address tobacco use (CDC 1991b). 

Thirty-nine states were found to have state-level qt.&+ 

tions that restricted tobacco use in schools. Twentyseven states banned smoking for students; eight states 

banned smoking for both students and staff @XC 1991b). 

Since that survey, at least two more states have passed 

laws that prohibit any tobacco use in their schools. 

Research on topics such as the effect of school 

smoking-restriction policies on student and adult tobacco use, attitudes toward tobacco use, and compliance 

with policy remains limited. Reports from national surveys (NSBA 1989) and from schools within Minnesota 

Winnesota Department of Health 1991) indicate that 

restrictive smoking policies can gain widespread sup 

port and acceptance. Since 1985, Minnesota school districts have participated in intensive efforts to reduce 

tobacco use among adolescents (Griffin, Loeffler, KaseII 

1988). Since beginning these efforts, the number of Minnesota school districts with tobacco-free policies for students, staff, and visitors increased from 3 to 361 school 

districts (83 percent of aII districts). In May 1989, the 

Minnesota Department of Health conducted a survey in 

districts that had a tobacco-free policy in place for six or 

more months. Survey results indicated that a large majority of school districts had experienced broad accep 

tance and support for tobacco-free policies, a large number 

of perceived benefits, and few problems. For example, 62 

percent of the districts reported having no problems 

implementing their tobacco-free policies, and 98 percent 

of aII tobacco-free districts reported that they did not 

intend to weaken their policy (Minnesota Department of 

Health 1991). 

Pentz, Dwyer, et al. (1989) examined the impact of 

school smoking policies on over 4,000 adolescents in 23 

schoois in California. The schools’ written smoking poIities were evaluated on whether they banned smoking on 

school grounds, restricted students from leaving school 

grounds, banned smoking near school, and included an 

education program on smoking prevention. Schools that 

had policies in aU of these areas and emphasized prevention and cessation had significantly lower smoking rates 

than did schools with fewer policies and less emphasis 

on smoking prevention. 

Drawing on reviews of existing policy and on preliminary evaluative research, several authors (Rashak et 

al. 1986; Brink et al. 1988; DiFranza 1989; NSBA 1989) 

have identified the following characteristics of effective 

school smoking policies. 

152 Prevention 
pra)enting Tobacco Use Among Young Peopie 

Smoking on school grounds, on school buses, and 

at school-sponsored events is prohibited for students, school personnel, and visitors. 

Schools vigorously enforce the policy and consistently administer penalties for violations. 

Disciplinary measures for noncompliance with 

policy are educational as well as punitive. 

Policy development includes active collaboration 

with teacher, student, and parent groups to give 

direction and build support for tobacco-free schools. 

All components of a school’s smoking policy, including consequences for violations, are communicated in written and oral form to students, staff, and 

visitors. 

l Districtwide educational programs addressing the 

prevention of tobacco use are initiated or expanded as 

part of the policy implementation process. 

l Smokingcessation programs or other incentives are 

developed for students, school personnel, and if possible, the public. 

l Programs are periodically evaluated to provide information on acceptance and effectiveness of policy. 

l Schools do not accept any contributions from the 

tobacco industry, including direct financial support 

and materials paid for by, or produced by or for, the 

tobacco industry. 

Other Public Smoking Restrictions That Affect Youth 

Smoking or tobacco use by minors (as opposed to 

the selling of tobacco products to minors) is prohibited 

by at least 21 states (USDHHS 1992b). In general, these 

laws are remnants of a previous era of smoking restrictions; for example, the Minnesota law dates back to the 

early 1900s (Minnesota Statutes Annotated 1987). Such 

laws are rarely enforced except when young people congregating to smoke constitute a nuisance. 

Few smoking restrictions, other than school policies, are adopted specifically because of their effect on 

children. Major exceptions include restrictions on smoking in daycare facilities and restrictions on smoking by 

minors. In August 1992, legislation was introduced by 

U.S. Representative Richard Durbin and U.S. Senator 

Frank Lautenberg that would require federally funded 

programs to establish a nonsmoking policy wherever 

they provide direct services to children under age five 

(U.S. Congress 1992). 

Restrictions on daycare facilities in particular are 

important because it has been estimated that in 198813 

percent of U.S. children aged five years and younger 

(about 2.8 million1 were being regularly cared for by a 

nonrelative in a home or facility other than the child’s 

home (Dawson and Cain 1990). As of July 1992, 40 

states restricted smoking to some extent in child daycare 

facilities, but only Alaska, Arkansas, Michigan, and 

Minnesota required at least one category of daycare 

facility to be smoke-free indoors (Coalition on Smoking 

OR Health 1992; Nelson, Sacks, Addiss 1993). In Minnesota, however, these laws apply only to licensed 

daycare centers and do not extend to licensed or unlicensed family daycare homes. In a 1990 national survey 

of licensed daycare centers, nearly 55 percent of centers 

reported that they were smoke-free indoors only; another 26 percent were smoke-free indoors and outdoors 

(Nelson, Sacks, Addiss 1993). Other public smoking 

restrictions are relevant to children because young 

people frequent specific locations and are influenced 

either directly by a law or policy, or indirectly by the 

norms of these institutions, including sports facilities, 

restaurants, and shopping malls. 

Smoke-free sports facilities help break the connection 

between tobacco and sports that has been fostered by the 

tobacco industry (see “Public Entertainment’ in Chapter 5). 

The ciinxtors of many university and professional-league 

stadiums and arenas have voluntarily made their facilities 

smoke-free. These facilities include Oriole Park at Camden 

Yards in Baltimore, Maryland; Tiger Stadium in Detroit, 

Michigan; the Hubert H. Humphrey Metrodome in Minneapolis, Minnesota; Texas Stadium in Irving, Texas; and 

basketballarenasinIJhoenix,Arizona;salt IAkecity,utah; 

and Minneapolis, Minnesota (Americans for Nonsmokers’ 

Rights 1992a, b, c). At least 23 states restrict smoking in 

gymnasiums or arenas as part of their legislation for clean 

indoor air (Coalition on Smoking OR Health 1992). 

Restaurants are among the most frequented public 

facilities in the United States, and some restaurants make 

specific marketing appeals to children or adolescents 

(Simonich 1991). By 1989,44 states had included some 

restrictions on smoking in restaurants, and 51 percent of 

cities with a population of 25,ooO or greater had passed 

local ordinances restricting smoking in restaurants (Coalition on Smoking OR Health 1992; Rigotti and Pashos 

1991; Americans for Nonsmokers’ Rights 1992a). The 

1992 publication of the Environmental Protection 

Agency’s findings on the effects of environmental tobacco smoke on children have led to calls for fast-food 

restaurants to eliminate their smoking sections (Melamed 

1992; Action on Smoking and Health 1992); several have 

responded with pilot programs. 

A new ordinance (effective since June 1992) that 

prohibits smoking in enclosed private malls in Howard 

County, Maryland, is believed to be the first of its kind in 

the United States (SmokeFree Educational Services, Inc. 

1992). However, in Minnesota and elsewhere, a number 

Prevention 253 
Surgeon General’s Report 

of malls have recently voluntarily adopted smoke-free 

policies (O’Brien 1991). Maine, New York, and Washington State specifically mention shopping centers in their 

legislation for clean indoor air (Coalition on Smoking OR 

Health 1992). As public places, shopping malls should 

be subject to existing state and local restrictions on smoking in public places, but the extent to which such laws are 

enforced for these facilities is unknown. 

Effect of Smoking Restrictions on Adolescent 

Tobacco Use 

Rigotti and Pashos (1991) concluded that an inverse relationship exists between smoking restrictions 

and smoking rates; the direction of causality, if any, 

between smoking rates and smoking restrictions could 

not be determined from the evidence available. Additional evidence is provided by two recent econometric. 

studies. Simonich (1991) modeled actual cigarette consumption per capita for ages 14 and older as a function of 

price, income, advertising, and product differentiation; 

the model also included the nicotine content of cigarettes. The data set consisted of quarterly per capita 

consumption from 1959 through 1983. Siionich (1991) 

concluded that each time the proportion of all smokers in 

the United States who lived in states with smoking re 

strictions on restaurants or workplaces increased by 10 

percent, the consumption of cigarettes would decrease 

by 6.5 percent. A study by Wasserman et al. (1991) 

specifically examined teenage cigarette smoking. Smok-, 

ing data from the Second National Health and Nutrition 

Examination Survey were used to determine cigarette 

consumption. A state regulation index was constructed 

that was similar to one described in the Surgeon General’s 

1986 report on smoking and health KJSDHHS 1986a). 

Teenage cigarette demand was modeled using price, the 

regulation index, and a series of covariates. These analyses showed that restrictive smoking regulations have a 

significant effect on teenage cigarette consumption; in 

fact, the effect is stronger for teenagers than for adults. 

The authors estimated that if the average score on the 

regulation index were to increase to the highest level 

(smoking restricted in private worksites), teenage cigarette consumption would decline by 41 percent. These 

researchers concluded from data on smoking prevalence 

that smoking regulations are most effective in preventing teenagers from starting to smoke, rather than in 

reducing their consumption. 

Restrictions on Minors’ Access to Tobacco 

Introduction 

Reducing the availability of tobacco to minors is 

important for a number of reasons. Making tobacco 

more difficult to obtain makes it less likely that young 

persons experimenting with smoking will graduate to 

addiction. Adding legal sanctions to the purchase of 

tobacco will deter those young persons who are unwilling to break laws to obtain tobacco and will add to the 

perceived social unacceptability of tobacco use. Two 

croesedonal studies provide prelimmary evidence that 

suggests a negative relationship between tobacco access 

and tobacco use among young people (Jason et al. 1991; 

DiFranza, Carlson, Caisse 1992). Controlling the sale of 

tobacco to minors emphasizes the dangerous nature of 

tobacco products and places tobacco appropriately in the 

category of regulated products. These measures also 

reinforce and support the messages about tobacco that 

young people receive in school and other settings. 

Tobacco Sources for Youth 

When tobacco access laws are not enforced, young 

people purchase cigarettes from all available sources. 

Nearly all teen smokers have purchased a pack of cigarettes at least once (Gallup Organization 1993). The 

majority of minors who smoke purchase their own cigarettes. Small stores and gas stations are the major source 

of cigarettes for underage buyers; vending machines are 

more popular among the youngest adolescents; and the 

majority of adolescents who have never smoked believe 

it would be easy for them to buy cigarettes (Forster, 

Klepp, Jeffery 1989; Nova Scotia Council on Smoking 

and Health 1991; CDC 1992b; Gallup Organizationl993). 

Vending machines provide an easy, if comparatively expensive, source of tobacco for young people. 

Tobacco industry figures show that in 1988, vending 

machines sales accounted for only 4 to 8 percent of all 

cigarettes sold, but young people tend to use vending 

machines more often than the general smoking public 

(National Automatic Merchandising Association 1989). 

Vending machines were either often or sometimes used 

by 38 percent of ninth-grade daily smokers in the COMMIT survey (C ummings et al. 1992). In a Minnesota 

survey, 53 percent of 10th~graders who were weekly 

smokers reported that vending machines were a major 

source of their cigarettes (Forster, Klepp, Jeffery 1989). In 

the TAPS, vending machines were either often or sometimes used by 20 percent of 12- through E-year-old 

smokers but by only 12 percent of 16 and 17-year-olds 

(15 percent overall) (CDC 1992b). Vending machines 

were also used more frequently by younger smokers in 

a mall-intercept survey (conducted for the vending 

machine association) of 1,015 smokers aged 13 through 

17 (National Automatic Merchandising Association 1989); 

only 2 percent of the 17-year-old smokers us& vending 

machines, whereas 22 percent of the 13year-olds did so 

(Response Research, Inc. 1989). However, a survey of 

154 Prevention 
preventing Tobacco Use Among Young People 

Canadian children found that those over 15 years old 

were more likely than younger children to use vending machines (Nova Scotia Council on Smoking and 

Health 1991). 

Adults can be a source of tobacco for some adolescents. In the COMMTI’ survey of ninth-grade smokers, 17 

percent indicated that they usually obtained their cigarettes from parents or other adults (Cummings et al. 1992). 

InaCanadianstudy,25percentofsmokersaged11 through 

15 years had obtained tobacco from parents or guardians 

(NovaScotiaCouncilonSmokingandHealth1991). These 

figures do not disaim&te between adults’ intentionally 

supplying minors with tobacco and young persons’ stealing cigarettes from adults. 

Tobacco also may be obtained without purchase. 

In a survey of elementary and high school students in 

Chicago, 14 percent had received free tobacco samples 

on at least one occasion (Davis and Jason 1988). In 8 

survey of 1,692 Georgia students in grades 7 through 

12, about 5 percent of the students reported shop 

lifting cigarettes in the preceding 12 months (Cox, Cox, 

Moschis 19901. 

Studies of Young People’s Access to Tobacco 

Siice 1987,13 studies have examined the degree to 

which minors could purchase cigarettes from retail establishments. Right of those studies investigated purchases from vending machines as well as purchases from 

over-thecounter outlets; one additional study investigated sales through vending machines only. 

In the 13 over-thecounter studies, illegal sales to 

minors ranged from a low of 32 percent in Kansas to a 

high of 87 percent in both South Dakota and Oregon; the 

approximate weighted-average was 67 percent across all 

studies (Table 8). The 13 studies indicated that minors’ 

ability to purchase cigarettes is a function of the young 

people’s gender and actual or perceived age, the statutory age of legal sale, and the community’s previous 

enforcement activities. Although the range of noncompliance to age laws is wide, the majority of minors were 

able to buy cigarettes in all studies except those conducted in Kansas (32 percent were able to buy) and 

Missouri (46 percent were able to buy). Similar rates of 

noncompliance have been observed for smokeless tobacco use in one recent study (CDC 1993). 

Of the nine studies that examined vending machine sales, illegal sales ranged from 82 to 100 percent; 

the approximate weighted-average rate of illegal sales 

was 88 percent (Table 9). Resides providing baseline 

data, six of the 13 over-the-counter studies and five of the 

nine vending machine studies also evaluated the effectiveness of various enforcement strategies. The majority 

of studies had a significant impact on minors’ ability to 

purchase cigarettes: the ability to buy deaeased from a 

minimal reduction of 14 percent during six months following an educational program, to a maximum reduction of 93 percent during 18 months following a program 

of “stings,” licensing, and fines (Table 8). Although an 

average rate of reduction (relative change) is difficult to 

calculate precisely, various enforcement strategies appear able to reduce the rate of illegal over-thecounter 

salesfrom20to4Opementinlessthanayear. 

Of the five studies that evaluated the effectiveness 

of restrictions on the sale of cigarettes through vending 

machines, the results are less clear (Table 9). In some 

instances, educational programs coupled with licensing 

and fines resulted in reductions in sales, while in other 

cases these tactics had no effect. In Minnesota, some 

success followed the passage of a local ordinance requiring locking devices that must be inactivated by an employee before a purchase can be made through a vending 

machine; results were more significant, however, when 

vending machines were entirely banned. 

State and Local Laws Regarding Tobacco Distribution 

to Minors 

A number of state and local laws legally restrict 

minors’ access to tobacco, and legislative activity in this 

area is increasing (CDC 1991b; Coalition on Smoking OR 

Health 1992). All 50 states and the District of Columbia 

have adopted a minimum age of 18 for the sale of tobacco. Only Virginia does not also restrict the distribution of samples of tobacco products. Thirty-one states 

require vendors to have a license to sell tobacco products; 

14 of these will revoke such license as a penalty for 

noncompliance, and only eight actually provide for an 

enforcer (USDHI-IS 1992b). 

Over the past three years, cigarette sales through 

vending machines have been targeted as sources of tobacco for young people. Vending machines suggest a 

universal availability of cigarettes in our society, and 

their presence may discourage merchants from making 

efforts to control over-thecounter cigarette sales to minors. Because vending machines are selfservice, it is 

difficult to attach responsibility and liability to a particular individual for illegal sales to minors from vending 

machines, and employees may not feel the same responsibility they might for over-the-counter sales. 

Twenty-one states and Washington, D.C., have 

passedlawsrestrictingvendingmachinesales(uSDHHs 

1992b). A rapidly growing number of cities have re 

sticted this method of sale, and at least 30 cities in 

Minnesota, New York, California, Maryland, New Jersey, and Louisiana have totally banned cigarette vending 

machines(CoalitiononSmokingORHealth1992I. Much 

of this activity has occurred since October 1989, when 

Preuention 155 
Surgeon General’s Report 

Table 8. Published studies examining over-the-counter cigarette sales to minors, United States, 1989-1993 

Relative 

Number of reduction in 

Study and stores or Baseline Follow-up succes&l tries 

location attempts sales rate (o/o) sales rate (o/o) by minors (%I Time period 

Skretny et al. (1990) 62 intervention, NA 77 -10 * 2 weeks 

New York 58 control NA 86 

Jason et al. (1991) 20-30 60-70 36 -40 3 months 

Illinois 3 -93 18 months 

Forster, Hour&an, 

McGovern (1992) 

Minnesota 

301 53 38 -28 3 months 

Nelson, Marso, Roby 

(1989) South Dakota 

30 87 NA NA NA 

Centers for Disease 

Control [CDCI, (1990) 

Colorado 

97 55 NA NA NA 

CDC (1993) 89 46 NA NA NA 

Missouri 

*Not statistically significant. 

‘NA = Not available. 

256 Preen tion 
preventing Tobacco Use Among Young People 

Enforcement method Comments 

Intervention stores were mailed an info&tional packet 

and a supply of warning signs containing that state’s 

required wording prohibiting tobacco sales to persons 

under 18 

Minors’ ages: 14-16; 40% of intervention stores and 

none of control stores posted warning signs, but no 

effect on sales rate was observed 

Quarterly “stings,” license suspension, fines of up to $500 Minors’ ages: 12 and 13; all stores in local area visited 

before and after passage of local ordinance; proportion 

of local junior high school students reporting they were 

“regular smokers” decreased from 16% to 5% 

None, other than publicity surrounding new state law that 

increased penalties for sales to minors 

Minors’ ages: 12-15; minimum legal age was 18; all 

outlets visited multiple times by different minors; 

rates averaged 

None, baseline study only Minors’ ages: 10-13; no minimum legal age in effect 

None, baseline study only Minors’ ages: 9-17; minimum legal age was 18 

None, baseline study only Minors’ ages: 13-14; no law in effect, but new law 

making 18 the minimum age recently passed 

Prevention 157 
Surgeon General’s ~epott 

Study and 

location 

Number of 

machines or 

attempts 

Baseline Follow-up 

sales rate (o/o) sales rate (o/o) 

Relative 

reduction in 

purchases by 

minors 4%) Tie period 

Jason et al. 3-6 100 50 -50 1 month 

(1991) 0 -100 12 months 

Illinois 

Fors ter, 

Hour&an, 

McGovern 

(1992) 

Minnesota 

79 82 80 NS 3 months 

DiFranza et al. 

(1987) 

Massachusetts 

6 . 86 NA’ 0 NA NA 

Hoppock and 

Houston (1990) 

Kansas 

10 100 NA NA NA 

‘NS = Not significant. 

tNA = Not available. 

158 Prevention 
srmenting Tobacco Use Among Young People 

Enforcement methods Comments 

Letters to merchants, quarterly “stings,” license 

suspension, fines up to $500 

Minors’ ages: 12 and 13; all machines in local area 

visited before and after passage of local ordinance 

None, other than publicity surrounding new state 

law that increased penalties for sales to minors 

Minors’ ages: 12-15; minimum legal age was 18; 

all outlets visited multiple times by different minors; 

rates averaged 

None, baseline study only Minors’ age: 11; minimum legal age was 18 

None, baseline study only Minors’ ages: 12 and 15 

Prevention 259 
Surgeon General’s Report 

White Bear Lake, Minnesota, became the first city to 

abolish cigarette vending machines (Forster, Hour&an, 

We&urn 1990). Unfortunately, state legislation condoned 

by the tobacco industry in Iowa, Oregon, and Wisconsin 

includes a preemption prohibiting local governments 

from adopting more restrictive laws, thus ending community control over vending machine restrictions in these 

states. 

The policies th+ cities and states have adopted to 

restrict cigarette vending machines, short of a total ban, 

include making simple requirements about placing the 

machines in view of an employee, restricting the machines 

to certain types of businesses or private facilities, requiring 

locking devices on the machines, or making policies that 

combine these regulations (Forster, Hourigan, Weigum 

1990). Little is known about the effectiveness of these 

policies. A recent evaluation of a Saint Paul, Minnesota, 

ordinance that requires locking devices on all cigaiette 

vending machines showed that purchase success was re 

duced from 86 percent before the law took effect to 19 

percent three months later at locations where the locking 

devices were in place (Forster, Hourigan, Kelder 1992). 

However, 34 percent of the locations had not installed 

locking devices at three months; at one year, 30 percent 

still had not done so. 

Laws that prohibit minors from purchasing or possessing tobacco-instead of laws that only prohibit merchants from selling tobacco to minors-have been adopted 

by a few states. The tobacco industry has actively, sup 

ported these laws, which have been criticized by some 

health professionals as the industry’s attempt to deflect 

responsibility for illegal sales from the merchants and the 

tobacco industry onto the children (DiFranza 1992b; Carol 

1992). Laws prohibiting minors’ possession of tobacco 

should be addressed only after effective regulation and 

enforcement at the retail level are in place. 

Enforcement of Tobacco-Distribution Laws 

Enforcement is important if laws that intend to re 

strict minors’ access to tobacco are to be effective. A total 

ban on vending machine sales is clearly the easiest to 

enforce; more complicated, less restrictive laws require 

constant surveillance. In a 1990 study, the USDI-EE, OfTice 

of Inspector General, found very few locations in the 

United States where state or local laws were being actively 

enforced (USDI-PE 1992b). Results from preliminary 

cross-sectionalstudiesintwocommunitiesthathaveevaluated compliance to tobacco-distribution laws suggest that 

the prevalence of tobacco use is reduced among youth in 

those communities (Jason et al. 1991; DiFranza, Carlson, 

Cake 1992). However, more tightly controlled studies 

with biochemical confirmation of self-reported smoking 

~WLLS are needed to confirm this preliminary finding. A 

reduction in the availability of tobacco products to minoB 

canreasonablybeexpo~y~~e~~~ce~~ 

random unannounced inspections are conducted fr+ 

quently. In some jurisdictions, licensing fees are used to 

hire health inspectors needed to ensure enforcement 

(l3iFran.q 1992b). 

As discussed earlier in this chapter, Section 1926 of 

the ADAMHA Reorganization Act (Public Law 102-321), 

commonly calIed the Synar amendment, stipulates that 

to receive the full complement of block grant funding for 

treating and preventing substance abuse, states must 

enforce laws prohibiting the sale and distribution of 

tobacco products to persons under the age of 18. From 

fiscal year 1994 through fiscal year 1996, states must 

demonstrate success in reducing the availability of te 

bacco products to children under 18. These statutory 

provisions will provide significant new leverage for increased enforcement of laws to reduce sales of tobacco 

products to youth. 

Voluntary Compliance with Age-at-Sale Laws 

for Tobacco 

Numerous attempts have been made to encourage 

merchants to comply voluntarily (i.e., in the absence of 

enforcement) with laws prohibiting sales to minors 

(All-man et al. 1989; Skretny et al. 1990; Feighery, Altman, 

Shaffer 1991). The most effective of these approaches 

was a program that managed to reduce the rate of 

successful tobacco purchases by minors from 74 to 39 

percent (Altman et al. 1989), although about half of this 

improvement had disappeared within a year (Altman 

et al. 1991). The program had no effect on illegal sales 

from vending machines; 100 percent of these attempts 

were successful. 

Recently, representatives of 91 regional and corporate headquarters of U.S. tobacco companies were interviewed about their beliefs, attitudes, knowledge, and 

practices regarding young people’s access to tobacco 

(Altman et al. 1992). These individuals expressed at least 

moderate support for policies limiting teenage access to 

tobacco. Respondents’ estimates of the frequency of 

sales to minors were far below the rates reported in 

studies that arranged for youth to try making tobacco 

purchases. Spokespersonsfromm~tcompaniesreported 

having policies in place to prevent tobacco sales to minors; however, only about half of these representatives 

could state the legal age of tobacco sale in the state in 

which they lived. 

At least one corporation, SuperAmerica, has demonstrated that internal programs to reduce cigarette sales 

to minors can be effective if accompanied by consistent 

surveillance. In response to an increase in the penalty for 

the sale of cigarettes to minors in Minnesota and to 

160 Prevention 
JJreventing Tobacco Use Among Young Peqple 

convince ail employees that the company did not want 

an illegal sale, SuperAmerica initiated a comprehensive 

companywide effort among its 670 stores across the nation to eliminate tobacco sales to minors (Hardman 1992). 

The company developed training materials, including a 

training video, that address key aspects of tobacco and 

alcohol sales. These materials cover product definitions, 

legal age for purchase, instructions on when and how to 

ask for identification, acceptable forms of identification, 

detection of false identification, instructions on when 

and how to refuse a sale, and the consequences of making an illegal sale. Ail employees-from managers to 

sales clerks--view the videotape, take a quiz on the 

contents, and sign a statement that they will adhere to 

company policies and procedures as a condition of employment. Printed guidelines, such as a booklet that 

shows samples of driver’s licenses from all 50 states, are 

distributed to employees. In at least one division, area 

managers and company auditors have conducted up to 

three surveiIlance operations per month. Through ongoing educational efforts, rewards for compliant employees, and warnings or possible dismissal for repeatedly 

noncompliant employees, the company reports achieving approximately 90 percent compliance in their operations. Though the program has not been independently 

evaluated, it appears to be successful, has drawn significant public attention, and is attracting the interest of 

other businesses. 

The It’s the Law program, introduced by the To-, 

bacco Institute in December 1990, is an educational campaign intended to discourage those who are underage 

from purchasing tobacco products and to help curb youth 

access to cigarettes through aggressive work with the 

retail community and by supporting new state laws 

(Tobacco Institute 1990a). The program consists of window decals, buttons, and a packet of educational materials for merchants. In a February 1992 letter to state 

governors, the Tobacco Institute stated that “over one 

million pieces of program materials have been distrib 

uted to thousands of retail outlets across the country’ 

(Chilcote 1992, p. 2). The materials closely resemble 

those distributed by health officials and tobacco-control 

professionals in many communities. One version of the 

materials displayed a hand holding a lit cigarette with 

the text, “It’s the law/You must be 18 (19) to buy tobacco 

products.” This text, however, seems to suggest that it is 

illegal for minors to purchase tobacco, whereas in most 

states it is only illegal for merchants to sell tobacco to 

minors (Choi, Novotny, Thimis 1992). This inaccuracy is 

not a minor point; parents misinterpreting these decals 

may be reluctant to report a merchant who has sold 

tobacco to their child if they mistakenly believe their 

child has violated the law (SmokeFree Pennsylvania 1991). 

During the summer of 1991, an experiment was 

conducted to determine the efficacy of the It’s the Law 

program (DiFranza and Brown 1992). Teenagers 13 

through 16 years old attempted purchases of tobacco 

from 156 retailers in Massachusetts. Only seven of the 

retailers were participating in the It’s the Law program. 

Six of the seven participating retailers (86 percent) proved 

willing to illegally sell tobacco to the teenagers; 131 of 149 

(88 percent) nonparticipating retailers proved wiIli.ng to 

make such sales. 

Model Laws to Restrict Distribution of Tobacco to 

Minors 

Former Secretary of Health and Human Services 

Louis W. Sullixan, M.D., proposed to alI states a Model 

Sale of Tobacco Products to Minors Control Act that 

contains the following provisions (PI-IS 1990): 

l Institute 19 years as the minimum age ,for legal tobacco 

sales. One rationale for a minimum age of 19 is that 

many high school seniors are 18 years of age. Setting 

the minimum age at 19 would help keep tobacco out 

of high schools. Further raising the age to 21 would 

provide a parallel with alcohol laws and would facilitate the enforcement of both laws, since one system 

could be set up to enforce both laws. 

l Create a tobacco-sales licensing system similar to that 

used for alcoholic beverages. Without a licensing 

system, health and law enforcement officials have no 

control over who sells tobacco. A licensing system 

provides enforcement officials with a list of retailers, 

thus facilitating educational and enforcement activities. Applicants for tobacco licenses could be required 

to pass a written examination (analogous to those 

required for a driver’s license) to ensure that these 

vendors understand their legal responsibilities. 

l Establish a graduated schedule of penalties for illegal sales. 

These penalties should include suspension or revocation of a retailers license to sell tobacco because of 

repeated violations of the ageat-sale law. 

l Place primary responsibility for enforcement with a designated state agency; local law enforcement and public 

health officials should also participate and have input. 

A comprehensive enforcement program can be funded, 

without increasing the tax burden, through the sale of 

tobacco retail licenses (Davis 1991; DiFranza 1992b). 

An additional source of revenue is the state excise tax 

on tobacco, especially that portion derived from illegal sales to minors. Several authors have called for an 

“illegal profits tax” to be levied on the profit that 

tobacco companies realize from the illegal sale of their 

products to minors (Slade 1988; DiFranza and Tye 

Prevention 161 
Surgeon General’s Repay 

1990; c ummings, Pechacek, Sciandra 1992; Glantz 

1993). 

Use ctil penalties and local courts toassmfines. Attempts 

to enforce access laws through aiminal proceedings 

have proved troublesome. Police officials are reluctant 

to prosecute because it is time consuming and costly 

(USDHHS 199213). Judges are reluctant to burden offenders with a crim+l record for selling tobacco to 

minors and are more apt to suspend sentences or issue 

wamingswithnofines(Feighery,Altman,SMfer1991~. 

Civil enforcement allows violations to be handled 

through a ticketing or administrative mechanism and 

avoids the need for court hearings (Jason et al. 1991). 

Local health departments could provide such enforcement, similar to their role in performing restaurant 

inspections (Davis 1991). 

Ban cigarette vending machines. As discussed above, 

less restrictive measures against vending machine sales 

have been shown to be less effective than stronger 

measures in preventing tobacco sales to minors. 

Additional features recommended for model laws 

include requiring that retailers post highly prominent 

signs detailing that the law (for example) requires &t 

tobacco be sold from behind the checkout counter, bans 

the sale of individual cigarettes and the distribution of 

free samples of tobacco products, and bans the distribu, 

tion of tobacco through the mail (DiFranza 1992a). 

A recent study Khoi, Novotny, Thimis 1992) analyzed the adequacy of state laws restricting minors’ access to tobacco (Table 10). The study found that no state 

are meeting all the criteria set by the former Secretary of 

Health and Human Services. Only New Hampshire, 

Massachusetts, New Jersey, and Utah meet even moderate standards, and the majority of states have only basic 

protection against providing tobacco to minors. 

As was discussed earlier in this chapter, as part 

of the ADAMHA Reorganization Act Public Law 

102-321), the sale and distribution of tobacco products to 

anyone under the age of 18 is to be banned in all states by 

October 1,1993. A recent report that updates the data of 

Choi, Novotny, and Thimis (1992) examines the extent 

to which states have adopted and enforced youth access 

laws (USDHHS 1992b). All 50 states and the District of 

Columbia now ban the sale of tobacco to persons under 

the age of 18. Only Florida and Vermont, however, anz 

Table 10. Types of laws used by states to restrict minors’ access to tobacco 

Category 

None 

Number of states 

4 

Regulations 

No restrictions on the sale of cigarettes or other tobacco products to 

minors 

Nominal 5 

Basic 38* 

Law banning the sale of tobacco to minors below a minimum age 

Law banning the sale of tobacco to minors aged < 18 years 

Penalties (fines) for the sale or distribution of tobacco products to 

minors 

Moderate 

Comprehensive 

4 

0 

Basic regulations, plus the following: 

Signs at points-of-sale warning about the illegality of 

the sale of tobacco products to minors; requirement of a 

state-issued retail tobacco license 

Moderate regulations, plus the following: 

Ban on all distribution of tobacco samples and coupons 

for free samples; commitment of resources for enforcement 

through license fees; no preemption clause prohibiting 

local communities from passing more restrictive minors’ access 

laws; exemption for “sting” operations conducted at the local level 

Source: Choi, Novotny, Thimis (1992). 

*IncIudes the District of Columbia. 

162 Prevention 
prmen ting Tobacco Use Among Young People 

enforcing their laws through their liquor control agencies 

(USDI-IHS 1992b). Low priority by police and the lack of 

a designated enforcer were seen as obstacles to enforcing 

youth access laws. 

risks of smoking (see Table 11). However, the provisions 

of the Cigarette Labeling and Advertising Act were generaIly less stringent than the FTC regulations they replaced. For example, the act required that all cigarette 

packages contain the following health warning: 

Warning Labels on Tobacco Products 

Introduction 

CAUTION: Cigarette Smoking May be Hazardous to Your Health. 

For this report, the term “labeling” refers to the provision of health-related information on packages and in adwrtising. Package warning labels can include either brief 

statements printed directly on tobacco packages or more 

detailed information placed on package inserts, similar to 

the requirements for pharmaceutical products. 

History of Warning Labels on Tobacco Products 

Shortly after the Surgeon General released the 1964 

report of the Advisory Committee on Smoking and Health 

(PHS 1964), the Federal Trade Commission (FTC) proposed three administrative rules that would have required health warnings on cigarette packages and 

advertisements and imposed certain restrictions on cigarette advertising (FTC 1964a). In part, the FTC proposed 

that every cigarette advertisement and every pack, box, 

carton, and other container in which cigarettes were sold 

to the public carry one of the following warnings: 

CAUTION-CIGARETTE SMOKING IS A 

HEALTH HAZARD The Surgeon General’s Advisory Committee on Smoking and Health has 

found that cigarette smoking contributes substantially to mortality from certain specific diseases 

and to the overall death rate. 

This statutory warning was weaker than the earlier 

proposed FTC warning in that it did not specifically 

mention the risk of death from cancer and other diseases. 

Further, whereas the FTC would have required warning 

disclosures on product advertisements, the Federal Cigarette Labeling and Advertising Act temporarily (through 

June 1969) prohibited any governmental body (including federal regulatory agencies, such as the FTC) or 

individual state from requiring a health warning in cigarette advertising. The Federal Cigarette Labeling and 

Advertising Act also prohibited any health warning on 

cigarette packages other than the statement required by 

the act itself. 

CAUTION: Cigarette smoking is dangerous to 

health. It may cause death from cancer and other 

diseases. 

In preparing its final ruling, published in June 1964 

after a six-month comment period, the FIG found that 

cigarette advertisements were false and deceptive be 

cause they failed to disclose known health hazards (FTC 

1964b). The ruling therefore required alI cigarette advertising and every container in which cigarettes were sold 

to consumers to disclose prominently that cigarette smoking is dangerous and may cause death from cancer and 

other diseases. However, the final rule left the specific 

wording of the warning to the discretion of the tobacco 

manufacturers. 

The Federal Cigarette Labeling and Advertising Act 

of 1965 (Public Law 89-92) preempted the FTC regulation 

before its scheduled enactment date. This legislation, the 

first federal statute to enact labeling requirements for 

tobacco products, marks one of the earliest efforts of the 

federal government to warn the public about the health 

On the other hand, the act required the FTC to 

transmit an annual report to Congress describing the 

effectiveness of cigarette labeling, discussing current cigarette advertising and promotional practices, and making 

recommendations for legislation. In its first report to 

Congress (FTC 1963, the FTC recommended extending 

the health warning to cigarette advertisements and 

strengthening the wording: 

WARNING: Cigarette Smoking Is Hazardous to 

Health and May Cause Death from Cancer and 

Other Diseases. 

In mid-1969, lust before the expiration of the congressionally imposed temporary restrictions on its actions, the FTC proposed a rule that would have required 

all cigarette advertising “to disclose, clearly and prominently-that cigarette smoking is dangerous to health 

and may cause death from cancer, coronary heart disease, chronic bronchitis, pulmonary emphysema, and 

other diseases” (FTC 1969a). 

The subsequent Public Health Cigarette Smoking 

Act of 1969 (Public Law 91-222) banned cigarette advertising on television and radio after January 1,1971, and 

strengthened the package warning label (effective November 1970) to read as follows: 

WARNING: The Surgeon General Has Determined That Cigarette Smoking Is Hazardous to 

Your Health. 

Nonetheless, the labeling provisions of this law, like 

the Federal Cigarette Labeling and Advertising Act before 

it, were substantially less stringent than the FTC regulations 

they preempted. Furthermore, the statutory language of 

the act continued to omit specific references to the risks and 

Prevention 163 

161-235 95-7 
Surgeon General’s Repott 

Table 11. Major legislation related to information and education about tobacco and health in the United 

States, 1965-1986 A 

Law 

Federal Cigarette Labeling and 

Advertising Act (Public Law 89-92) 

Date 

1965 

Labeling requirements 

Required a health warning on cigarette 

pa&ages 

Preempted other warnings on packages 

Temporarily preempted Federal Trade 

Commission @TC) requirements of any 

health warning on cigamtte advertisements 

Little Cigar Act 

(Public Law 93-109) 

1973 None 

Comprehensive Smokeless 

Tobacco Health Education Act 

(Public Law 99-252) 

1986 Required the rotation of three health 

warnings on smokeless tobacco packages 

and advertisements (in circle-and-arrow 

format on advertisements) 

Preempted any other health warning on 

smokeless tobacco packages or advertisements (except billboards) 

Source: U.S. Department of Health and Human Services (1989). 

*In 1972, an FTC consent order extended the requirement for a health warning on cigarette packages to include cigarette 

advertisements. 

164 Preoen tion 
Prez~enting Tobacco Use Among Young People 

Advertising requirements 

Congressional 

reporting requirements Other stipulations 

Annual report to Congress on health 

consequences of smoking (U.S. 

Department of Health, 

Education, and Welfare [USDHEWI) 

None 

Annual report to Congress on 

cigarette labeling and advertising 

(FTC) 

Extended broadcast ban on 

cigarette advertising to 

“little cigars” 

None 

None 

Prohibited smokeless 

tobacco advertising on 

television and radio 

Biennial status report to Congress on 

smokeless tobacco use (USDHHS) 

Required public information 

campaign on health hazards of 

using smokeless tobacco’ 

(USDHHS) 

Biennial report to Congress on 

smokeless tobacco sales, ad\-ertising, and marketing practices OTC) 

Smokeless tobacco companies 

must provide a confidential list of 

additives and a specification Of 

nicotine content in smokeless 

tobacco products+ WSDHHS) 

‘List of additives does not identify company or cigarette brand, no ;Rlblic disclosure of additives on Packages Or 

advertisements required, and no other public disclosure allowed. - 

‘No funds have been appropriated to carry out this campaign. 

Prevention 165 
Surgeon General’s Repoti 

consequences of smoking and extended the preemption on 

nqiring any additional health warning for cigarette packages. The E;Tc was again temporarily restricted Cthrough 

June 197l) from issuing regulations that would require a 

health warning in cigarette advertising. 

After the second congressional moratorium expired 

in late 197l, the FTC announced its intention to file complaints against cigarette companies for f%lure to warn in 

their advertising that smoking is dangemus to health. Negotiations among the companies and the FTC resulted on 

March 30,1972, in consent orders nqliring that all ciw 

advertising “clearly and conspicuously” display the same 

warning req~G1-4 by Congress for cigarette packages (FTC 

1981). That consent order specified the type size of the 

warning in newspaper, magazine, and other periodical 

advertisements of various dimensions; for bi&oard advertisements, the size of the lettering was specified in inches 

m 1972). 

In 1975, the US. government f&d a complaint in the 

U.S. District Court for the District of Columbia against the 

cigarette companies for alleged violation of the consent 

order, including failure to display the health warning in 

some advertising, failure to display lettering of the specified 

size in billboard warnings, and failure to properly place the 

warning in some advertisements (FTC 1982). This action 

led to judgments in 1981 against the six major cigarette 

companies (U.S.A. v. Liggett et a.L 1981; U.S.A. v. RJ. 

Reynolds 1981), in which the tobacco manufact~~~~ were 

quiredtouselargerletteringinthewarningsdisplayedin 

biUboard advertising. In 1981, the FTC also sent a staff 

mport to Congress that concluded that the warning appearing on cigarette packages and in advertisements had be 

come overexposed and “worn out” and was thus no longer 

effective FTC 1981). The report pointed out that the existing warning was too absimct, generally difficult to remember, and not personally relevant. Further noting that a 

singular warning did not communicate sufficient information on the significant, specific risks of sm0ki.n~ the nzport 

recommended changing the shape of the warning to a 

cinzleand-arrow design (as is currently used in advertisements for smokeless tobacco products [see Figure 5]), ineasing the size of the warning, and replacing the existing 

single warning with a rotational system of warnings. 

Current Status of Warning Labels 

The 1981 FTC staff report would eventually help 

prompt passage of the Comprehensive Smoking Education 

Act Public Law 98474), which became effective on 

October 12,1984. Effective one year after being signed, this 

law required cigarette companies to rotate the following 

four wamings on all cigarette packages and in all cigarette 

advertisements: 

SURGEON GENERAL’S WARNING: Smoking 

Causes Lung Cancer, Heart JXsease, Emphysema, and May Complicate Pregnancy. 

SURGEON GENERAL’S WARNING: Quitting 

Smoking Now Greatly Reduces Serious Risks to 

Your Health. 

SURGEON GENERAL’S WARNING: Smoking 

by Pregnant Women May Result in Fetal Injury, 

Premature Birth and Low Birth Weight. 

SURGEON GENERAL’S WARNING: Cigarette 

Smoke Contains Carbon Monoxide. 

Figure 5. Health warnings required for smokeless 

tobacco advertisements (except billboards) 

may cause gum 

r 

\ WARNING: 

may cause mouth 

alternative to 

Sources: U.S. Department of Health and Human Services 

(1989); Federal Trade Commission (1981). 

166 Pre7mtion 
preuenting Tobacco Use Among Young People 

These rotational warnings retained, however, the 

rectangular visual format that the FTC staff had recommended abandoning. The congressional warnings were 

also substantively more passive in their wording 

than those suggested by the FTC. For example, the FTC 

had proposed the following two warnings to caution 

consumers on the risks of smoking during pregnancy: 

Smoking increases the risk of death of your unborn child. 

Smoking increases the risk of spontaneous abortion and stillbirth. 

In 1986, Congress extended requirements for waming labels to smokeless tobacco products by passing the 

Comprehensive Smokeless Tobacco Health Education 

Act (Public Law 99-252). This act requires tobacco manufacturers to display and regularly rotate the following 

three warnings on all smokeless tobacco packages and 

on all smokeless tobacco advertising (except billboards): 

WARNING: This product may cause mouth cancer. 

WARNING: This product may cause gum disease and tooth loss. 

WARNING: This product is not a safe alternative 

to cigarettes. 

The act stipulates that the warnings displayed in 

advertisements appear in the circle-and-arrow format 

(see Figure 5) that the FTC recommended in 1981 for 

cigarettes (FTC 1981). The act prohibits federal agencies 

as well as state or local jurisdictions from requiring any 

other health warnings on smokeless tobacco packages 

and advertisements. However, states are not preempted 

from enacting additional advertising restrictions. 

Limitations of Warning Labels 

An unintended consequence of the federally mandated warning disclosure concerns product liability (U.S. 

Congress 1989; Gostin, Brandt, Cleary 1991). Surgeon 

General Luther Terry enjoyed widespread support from 

the general public and the health community when he 

endorsed package warning labels during congressional 

testimony. Dr. Terry commented that “the public is 

awaiting these steps. Such warnings could materially 

increase public awareness of the health hazard by providing concrete evidence of governmental concern” (U.S. 

Congress 1965, p. 33). Yet no one publicly anticipated 

that the display of a federally mandated warning would 

eventually shield tobacco manufacturers from product 

liability. Ironically, the tobacco industry has thus far 

been insulated from lawsuits by legislation it has resisted 

steadfastly since 1965 (U.S. Congress 1965,1983,1989). 

In 1989, Congress considered a bill (H.R. 4543) that addressed this unintended protection, but the bill has not 

been approved. 

Although tobacco manufacturers are legally obligated to disclose health warnings on their product packaging and advertising, and althoughCongress has enacted 

legislation that has increased the size, number, and specificity of the warnings, these legal requirements have not 

been as restrictive as the FTC has recommended. More 

over, requirements for warning disclosures on promotional items (e.g., T-shirts, caps, key chains, lighters) and 

sponsorship logos (such as the Virginia Slims tennis 

tournament or the Winston Cup National Association 

for Stock Car Auto Racing [NASCAR] races) are notice 

ably absent from current legislation. Only the printed 

materials (such as catalogues and wrapping accompanying promotional items) are required to carry warning 

labels. Thus, despite the statutory ban on broadcast 

advertising, widespread corporate sponsorship of tele 

vised events enables even very young viewers to see 

cigarette brand names displayed with no health warning 

(Aitken, Leathar, Squair 1986; Blum 1991). The tobacco 

industry spent nearly $100 million on sports and sporting events in 1990, a more than 10 percent increase over 

the previous year (FTC 1992). Spending on public entertainment and promotional items has also increased 

dramatically. In contrast, spending on magazine advertisements, which do carry warning disclosures, decreased 

by more than $52 million (14 percent) from 1989 to 1990. 

Federal law regarding health warnings for tobacco 

products continues to preempt state actions, even on 

advertisements displayed solely within their jurisdiction 

(such as event sponsorship and billboard, mass transit, 

and point-of-sale advertising). The tobacco industry favors the preemption, arguing that to permit local action 

would “invite censorship” in violation of the First Amendment and would abandon “Congress’ consistent 25-year 

policy of nationally uniform regulation” (U.S. Congress 

1990, p. 80). 

Effectiveness of Warning Labels 

Warning labels have a well-established history of 

use with products associated with medical risks or 

dangerous potential consequences for users. Labeling 

information intended to inform consumers of relative 

risk and benefit is also provided on many consumer 

goods (for example, nutrition labeling on packaged foods 

and energy-consumption information on energy appliances). Research on consumer response to such labeling 

information has yielded mixed results (Beltramini 1988), 

yet two basic factors appear to influence the usefulness 

of such labels (LJSDHHS 1987b; Centre for Beh40d 

Preuen tion 167 
Surgeon Generals Report 

Research in Cancer 1992). First, to have an impact on 

consumers, warning labels must be designed to take into 

account those factors that might influence consumer response (e.g., a consumer’s previous experience with the 

product, previous knowledge of the risks associated with 

the product’s use, and level of education or literacy). 

Second, the labels should be designed in an attentiondemanding format, and the information they bear should 

be specific rather than general and written in clear, nontechnical language. 

As was noted before, the Federal Cigarette Labeling Act of 1965 (Public Law 89-92) mandated cigarette 

warning labels so that “the public may be adequately 

informed that cigarette smoking may be hazardous to 

health.” However, more specific communications objectives were not defined by any of the subsequent legislation. Information provision is clearly distinct from 

information impact (Jacoby, Chestnut, Silberman 1477). 

Research indicates that merely placing a warning on a 

label or an advertisement is not sufficient for information 

processing (Beltramini 1988). One can generally infer 

that the goal of warning labels for cigarettes has been to 

increase public knowledge about the hazards of smoking, but without more specific goals it is difficult to evaluate whether the labels have had an impact on consumer 

decision-making or behavior. Moreover, it is unclear 

which “public” Congress intended to be “adequately 

illfOlTlld” Is the public that segment of the general 

populace who currently smoke, that segment who could 

potentially begin to smoke (principally young people), or 

that portion of the public (principally ad@) who have 

decided to try to quit smoking? Clearly, a warning can 

communicate effectively to one segment of the public 

without having an impact on the others. 

Without clear objectives or operational definitions, 

no ready standards are available to evaluate the effects 

of warning labels; and although warning labels have 

been required since 1966, little had been reported about 

their effectiveness in meeting any objective (USDHHS 

1987b). Currently, there are no controlled studies that 

permit definitive assessment of the independent impact 

of cigarette warning labels on knowledge, beliefs, attitudes, or smoking behavior. The few available empirical 

studies deal with the visibility of cigarette warnings in 

advertising and consistently indicate that the Surgeon 

General’s warnings are given little attention or consideration by viewers. Research on package warning labels is 

even scarcer. 

In a 1978 Starch Message Report survey, only 2 

percent of adults exposed to cigarette ads in 24 different 

magazines read the Surgeon General’s warning in those 

ads (FTC 1981). Similarly, a 1978 study for the Brown and 

Williamson Tobacco Company found that only 2 percent 

of the respondents read the entire warning in seven ads 

for Kool cigarettes; the average time spent “examining” 

the warning was less than a second. In an advertising 

copy test conducted for the Liggett & Meyers Tobacco 

Company in 1976, no respondents read the entire warning (FTC 1981). 

More recent studies suggest that little attention is 

paid to the post-1985 rotational warnings. To examine 

adolescent viewing of tobacco advertisements, Fischer et 

al. (1989) adapted the market research methodology of 

eye-tracking. A computer recorded eye movement as 

subjects viewed five different tobacco advertisements 

with no time constraints. The average viewing time of 

the warnings totaled only 8 percent of the total advertise 

ment viewing time. These data further indicate that 

more than 40 percent of subj&s did not even view the 

warning. An additional 20 percent looked at the warning but failed to actually read it. Given such strong 

evidence of negligible viewing and processing of waming labels, Fischer et al. (1989) concluded that existing 

warnings are unlikely to effectively counter the images 

of independence, romance, and fun inherent in tobacco 

advertising. 

Evidence from other studies suggests thatimagery 

draws attention away from the text of the warnings 

(Richards and Zakia 1981; Zemer 1986). The FTC suggested that cigarette companies were explicitly designing advertising to “divert or distract attention away from 

the health consequences of smoking” (FNJ 1981, p. 2-2). 

Intentionally or not, the sheer volume of cigarette advertising, all of which attempts to incorporate the basic 

themes of product satisfaction, positive image associations, and risk minimization (Popper 19861, may overwhelm the health-promoting effect of warnings in 

advertisements (Schwartz 1986). 

Research indicates that novel warning formats are 

more likely to capture viewer attention (Cohen and Srull 

1980). The potential communications effectiveness of the 

more pointed post-1984 warnings may have been diminished with the retention of the original rectangular shape 

of the pre-1985 warnings (Bhalla and Lastovicka 1984). 

Similarly, although the shape of the warnings in 

smokeless tobacco advertisements may have been novel 

initially, the size and color of these warnings may now 

have a reduced effect (Popper and Murray 1989). 

Some studies suggest that warning labels may not 

be readable in some advertising media. Davis and 

Kendrick (1989) found that under typical driving conditions, the average motorist could read an entire warning 

in about one-half of billboard advertisements on streets 

and in only 5 percent of billboard advertisements on 

highways. Stationary observers could not read the 

warnings in any of the transit advertisements studied. 

All warnings in the study were in compliance with the 

congressionally mandated FTC warning-size templates. 

168 Proven tion 
Preventing Tobacco Use Among Young People 

By contrast, subjects could almost always read the brand 

names and identify the advertisement’s notable imagery. 

Despite the negligible attention and poor readability reported across these studies, there is some evidence 

that consumers have moderate awareness of the current 

four warning messages. Using a warning recognition 

test (rather than a test of the prominence or strength of 

the message) to assess basic awareness and attention, 

Lieberman Research (unpublished data) found that onehalf of smokers (but fewer than one-half of nonsmokers) 

were able to correctly recall one of the rotational warnings. Nearly all recalled the single ~1~1985 warning. 

However, Fischer et al. (1989) obtained different results 

in their masked recall test with adolescents. After adolescents viewed a series of ads, the researchers covered up 

the advertisement headings, all specific references to 

cigarette brand names, and the Surgeon General’s waming. Three-fourths of participants could identify the 

masked warning as a health message, but only 19 percent 

could recall even the general theme of the warning. 

These data may suggest that adolescents are generally 

aware of the presence of warning labels in tobacco ads 

but are far less informed than adults are of the specific 

health messages. Similarly low levels of warning recall 

among young adults were found for the smokeless tobacco warnings (Popper and Murray 1989). 

Research in communication effectiveness (Day 

1973) suggests that when viewers actually attend and 

read them, warnings do more than merely provide 

information. Warnings can also produce potentially 

affective and behavioral impacts (Beltramini 1988). 

Analyses of the wording and format of mandated health 

warnings have suggested reasons for the limited affective and behavioral impact that can occur even under 

optimal conditions of attention and processing. For 

example, use of any conditional words such as c12n and 

may can dramatically reduce the effect of the entire 

warning (Linthwaite 1985). Since two of the current 

rotational warnings include the word may (see Table 

12), consumers may minimize the inherent health wamings of these messages (Dumas 1992). Furthermore, 

although the information presented in the current wamings is more detailed and more absolute than the pre1985 single warning, it is also presented in a more 

impersonal manner. Readers may be more likely to 

believe, learn from, and act on warnings that are personally relevant than on warnings that are abstract and 

technical (Fishbein 1977). 

Analysis of the general public’s knowledge of the 

health risks of smoking could provide some evidence of 

the impact of warnings. Although such knowledge has 

clearly increased since 1966, when the first health wamhg label was required, the effect of the warnings cannot 

be isolated from a number of other information sources, 

such as reports of the Surgeon General or reported research in the news (FTC 1974; Murphy 1980; USDHHS 

1987a). Similarly, it is impossible to determine any independent effects of health warnings on aggregate cigarette sales (FTC 1967,1969b) or to isolate the independent 

effects of advertising on those aggregate sales. Indeed, 

the two effects counter one another and therefore confound research. However, a recent and extensive discussion of the issues in the Australian publication Health 

Warnings and Contents Labelling on Tobacco Products reports formative data on providing more noticeable and 

informative labels to consumers and assembles a compendium of warnings worldwide (Centre for Behavioural 

Research in Cancer 1992). 

Perhaps the most powerful indirect indicator of the 

effect of cigarette warnings is the number of smokers and 

consumers who remain unaware of the health risks of 

smoking. After a comprehensive review of studies on 

health-risk awareness, including publicly generated studies and those conducted by the tobacco industry, the FTC 

concluded that significant numbem of consumers and still 

higher numbers of smokers were unaware of even the 

most rudimentary risk information about smoking (FTC 

1981). It was this lack of consumer awareness that led the 

FTC in 1981 to call for a larger and more attentiondemanding format and for expanded (16 different) rotational warnings for cigarettes. 

Effect of Tobacco Taxation 

Introduction 

Tobacco is taxed in a variety of ways by federal, 

state, and local government. The most important of these 

taxes are the federal and state excise taxes on cigarettes 

and the general state sales tax applied to tobacco products in most states. Historically, these taxes have been 

seen as an effective way to generate revenues, as with 

taxes on alcohol. However, in recent years, increased 

taxation of tobacco products has been supported as a 

public health measure aimed at discouraging smoking 

and other tobacco use. 

History of Tobacco Taxation 

Federal Tobacco Taxes 

During the late eighteenth and early nineteenth 

centuries, the federal government experimented with 

excise taxes on tobacco products. However, because of 

opposition from both producers and consumers, the taxes 

imposed in 1794,1812,1816, and during the Civil War 

were repealed and finally reduced to one cent per pack. 

During the first half of the twentieth century, federal 

taxes were, as before the Civil War, increased to help 

Prevention 169 
Surgeon General’s Report 

Table 12. Health warnings required on tobacco packages and advertisements in the United States, 1966-1993 

Health warnings Effective dates Packages Advertisements 

Cigarettes 

CAUTION: 

Cigarette Smoking May Be Hazardous 

to Your Health. 

January 1,1966- 

October 31,197O 

WARNING: 

The Surgeon General Has Determined 

That Cigarette Smoking Is Dangerous 

to Your Health. 

November 1,1970- 

October 11,1985 

March 30,1972- 

October 11,1985 

SURGEON GENERAL’S WARNING: 

Smoking Causes Lung Cancer, Heart 

Disease, Emphysema, and May 

Complicate Pregnancy. 

October 12,1985-present 

SURGEON GENERAL’S WARNING: 

Quitting Smoking Now Greatly Reduces Serious Risks to Your Health. 

October 12,1985-present 

SURGEON GENERAL’S WARNING: 

Smoking by Pregnant Women May 

Result in Fetal Injury, Premature Birth 

and Low Birth Weight. 

October 12,1985-present 

SURGEON GENERAL’S WARNING: 

Cigarette Smoke Contains Carbon 

Monoxide. 

October 12,1985-present 

Smokeless tobacco 

WARNING: February 27,1987-present 

This product may cause mouth cancer. 

WARNING: February 27,1987-present 

This product may cause gum disease 

and tooth loss. 

WARNING: 

This product is not a safe alternative to 

cigarettes. 

February 27,1987-present 

X 

X 

X* 

X+ 

X+ 

X+ 

X+ 

X X% 

X Xt 

X X$ 

Source: Federal Trade Commission (1981). 

*Required by Federal Trade Commission consent order. All other warnings required by federal legislation. 

+The four warnings mandated for cigarette advertisements on outdoor billboards are slightly shorter versions of the same 

messages. 

The warnings on advertisements must appear in a circle-and-arrow format (see Figure 5). No warnings are required on 

outdoor billboards. 

170 Prevention 
Preventing Tobacco Use Among Young People 

finance U.S. military involvement. The last of a series of 

increases took place on November 1, 1951, during the 

Korean War, when the tax was increased from seven to 

eight cents per pack The tax remained at that level for 

the next 30 years. 

Over the past decade, however, the federal tax on 

cigarettes has been increased significantly. These recent 

increases were motivated by a different goal-the need 

to raise revenues to deal with the increasing federal 

budget deficit. The first of these deficit-motivated increases occurred on March 1, 1983, as part of the Tax 

Equity and Fiscal Responsibility Act of 1982, when the 

tax was doubled to 16 cents per pack. This increase was 

intended as a temporary measure that would be repealed 

by October 1,1985. However, after being extended several times, the doubling of the tax was made permanent 

in 1986. 

As part of the Omnibus Budget Reconciliation Act 

of 1985, a tax of 24 cents per pound was levied on snuff, a 

tax of 8 cents per pound was imposed on chewing tobacco, and a tax of 45 cents per pound was applied to 

pipe tobacco. The Omnibus Budget Reconciliation Act of 

1990 further increased federal taxes on cigarettes from 16 

cents to 20 cents per pack on January 1,199l; a scheduled 

additional increase of 4 cents per pack was levied on 

January 1,1993. As of 1993, federal taxes on other tobacco products are 36 cents per pound for snuff, 12 cents 

for chewing tobacco, and 67.5 cents for pipe tobacco. 

This represents a tax of less than 3 cents per can of snuff 

or pouch of chew; the tax on a pack of cigarettes is 

24 cents. Yet even though federal taxes on tobacco 

have increased recently, they have become a less important source of revenue for the federal government. In 

1950, tobacco excise taxes accounted for 3.36 percent of 

all federal revenues; by 1989, they accounted for only 

0.44 percent of revenues (Congressional Budget Office 

KBOI 1990). 

State and Local Tobacco Taxes 

In 1921, Iowa became the first state to impose an 

excise tax on cigarettes, followed in 1923 by Georgia, 

South Carolina, South Dakota, and Utah. By the end of 

the 192Os, six additional states had enacted a cigarette 

excise tax. By 1940, more than half of all states levied 

taxes on cigarettes, and by 1950, only a handful of states 

were not imposing an excise tax. In 1969, North Carolina 

became the last state to enact an excise tax on cigarettes. 

As with the federat government, the imposition of, and 

increases in, state cigarette taxes have partly represented 

attempts to raise revenue rather than to lower smoking 

prevalence. Warner (1981) argues that this financial 

motive is especially clear in the history of excise taxes on 

cigarettes in the six major tobacco-producing states. The 

average date when these states instituted a cigarette excise tax was 1939-one year earlier than the average for 

the remaining states, and many years before the widespread publicity on the health hazards of smoking. Just 

before the negative publicity, the average tax rate for 

these six states was 2.5 cents per pack, a figure only 

slightly less than the other states’ average of 2.9 cents per 

pack. As is discussed later, the difference has increased 

greatly since then. 

Some evidence suggests that state governments 

have recently used cigarette excise taxes as a major part 

of antismoking campaigns. This conch.rsion can be drawn 

from reviewing the number of increases in state excise 

tax rates after the mid-1950s release of the first scientific 

studies that linked smoking to poor health, and particularly after the 1964 release of the initial Surgeon General’s 

report on smoking and health (PHS 1964). For instance, 

during the latter half of the 1950s more than eight tax 

increases occurred per year among the states, whereas 

fewer than three per year occurred each year in the early 

1950s. Similarly, in the year after the 1964 Surgeon 

General’s report, there were a record 22 increases in state 

excise taxes on cigarettes. 

The established pattern of tax increases continued 

during the period when the Fairness Doctrine permitted 

antismoking messages on television and radio, and again 

after the 1971 ban on television and radio advertising 

(Warner 1981). Moreover, as Warner (1981) notes, the 

once negligible difference between the tax rates in the 

tobaccoproducing states and in the remaining states widened significantly over this period. This differenoz has 

continued to widen since 1981.. By January 1,1992, the 

average tax rate in the tobacco-producing states was 7 

cents per pack, whereas the average tax rate in the remaining 44 states and Washington, D.C., was 26 cents per pack. 

The active use of cigarette and other tobacco taxes 

to discourage tobacco use in some states and the relative 

inaction in others results in large differences in taxes and, 

consequently, in cigarette prices among states. For 

example, the cigarette excise tax ranges from less than 

3 cents per pack in Virginia to 60 cents per pack in Hawaii 

(see Table 13). When local taxes are added, the 

differences become even larger in some locations. The 

differences in taxes and prices create incentives for the 

casual smuggling (i.e., involving relatively small quantities, generally for personal use> and organized smuggling (i.e., involving large quantities, generally for resale) 

of cigarettes from low-tax localities to high-tax localities 

and create incentives for other tax-evasion activities. 

The dative ease of transporting cigarettes across localities has encouraged some people to profit from this 

activity (Advisory Commission on Intergovernmental Relations [ACIRI 1977,1985). Although casual smuggling 

Prezwrztion 171 
Surgeon General’s Report 

Table 13. State* cigarette taxes, July I,1993 

Excise tax rate Sales tax’ 

State (cents per 204garette pack) (cents per pack) 

Alabama 16.5 7 

Alaska 29.0 0 

Arizona 18.0 9 

Arkansas 31.5 9 

California 35.0 15 

Colorado 20.0 0 

Connecticut 47.0 12 

Delaware 24.0 0 

District of Columbia 65.0 13 

Florida 33.9 12 

Georgia 12.0 6 

Hawaii 60.0 9 

Idaho 18.0 9 

Illinois 30.0 13 

Indiana 15.5 9 

Iowa 36.0 11 

Kansas 24.0 9 

Kentucky 3.0 9 

Louisiana 20.0 8 

Maine 37.0 11 

Maryland 36.0 IO 

Massachusetts 51.0 9 

Michigan 25.0 7 

Minnesota 48.0 14 

Mississippi 18.0 11 

Missouri 13.0 7 

Montana 19.3 0 

Nebraska 34.0 9 

Nevada 35.0 13 

New Hampshire . 25.0 0 

New Jersey 40.0 12 

New Mexico 21.0 9 

New York 56.0 8 

North Carolina 5.0 6 

North Dakota 44.0 11 

Ohio 24.0 8 

Oklahoma 23.0 8 

Oregon 28.0 0 

Pennsylvania 31.0 11 

Rhode Island 37.0 14 

South Carolina 7.0 8 

South Dakota 23.0 7 

Tennessee 13.0 14 

Texas 41.0 13 

Utah 26.5 9 

Vermont 20.0 9 

Virginia 2.5 7 

Washington 54.0 13 

West Virginia 17.0 10 

Wisconsin 38.0 10 

Wyoming 12.0 0 

Sources: Tobacco Institute (1992); Action on Smoking and Health (1993). 

*Includes the District of Columbia. 

‘%es tax information is for November 1,1992. 

Total state tax 

(cents per pack) 

23.5 

29.0 

27.0 

40.5 

50.0 

20.0 

59.0 

24.0 

78.0 

45.9 

18.0 

69.0 

27.0 

43.0 

24.5 

47.0 

33.0 

12.0 

28.0 

48.0 

46.0 

60.0 

32.0 

62.0 

29.0 

20.0 

19.3 

43.0 

48.0 

25.0 

52.0 

30.0 

64.0 

11.0 

55.0 

32.0 

31.0 

28.0 

42.0 

51.0 

15.0 

30.0 

27.0 

54.0 

35.5 

29.0 

9.5 

67.0 

27.0 

48.0 

12.0 

172 Preumtion 
Prwenting Tobacco Use Among Young People 

had long been a problem, states reported that organized 

smuggling increased significantly after the tax increases 

of the mid- to late-1960s. Some states were discouraged 

from adding further taxes that would motivate increased 

smuggling and result in a net loss of revenues generated by cigarette taxes. In 1978, in response to pressure 

from states with high cigarette taxes, the Federal Contraband Cigarette Act (Public Law 95-575) was enacted. 

This act prohibited the single-transaction transport, receipt, shipment, possession, distribution, or purchase of 

more than 60,000 cigarettes not bearing the tax indicia 

of the state in which the cigarettes were initially sold. 

The act dealt only with the organized smuggling of 

cigarettes, described by the ACIR as the major problem, 

and ignored the less problematic casual smuggling 

(Kleine 1993). The ACIR (1985) suggests, however, that 

the law was even more effective than its proponents 

would have predicted. 

California and Massachusetts recently enacted two 

large increases in their excise taxes on tobacco. In 

November 1988, California voters passed Proposition 99, 

which went into effect in January 1989. This law increased California’s state excise tax on cigarettes from 10 

cents per pack to 35 cents per pack. As was mentioned 

earlier, one of the notable features of Proposition 99 is 

that 20 percent of the additional revenue raised from the 

tax increase is earmarked for the state’s antismoking 

activities. Legislation similar to Proposition 99 was passed 

in Massachusetts in November 1992. This measure, which 

took effect on January 1,1993, includes a 25-tent increase 

in the state excise tax and a 25 percent increase in the tax 

on chewing tobacco. 

Besides the specific taxes applied to cigarettes, 45 

states and Washington, D.C., have general sales-taxes 

that apply to cigarettes. In all but four of these states, the 

sales-tax base includes the excise tax. This arrangement 

adds an additional 5 to 14 cents per pack to the price of 

cigarettes in these states (see Table 13). 

State taxes on other tobacco products have also 

become more widespread. By January 1,1992, a total of 

37 states had imposed a tax on at least some tobacco 

products other than cigarettes; only 14 states were 

collecting such taxes in 1964. The same time period 

witnessed similar activity at the local level. By fiscal year 

1991, 373 cities had imposed additional taxes on cigarettes, and 49 cities were levying taxes on other tobacco 

products. In addition, 38 counties were charging their 

own cigarette taxes, and 29 counties were assessing additional taxes on other tobacco products. The largest of 

these local cigarette taxes are those imposed in New York 

City (8 additional cents per pack) and in Chicago (24 

additional cents per pack, including city and county 

excise taxes). 

Cigarette Tax Increases and Cigarette Prices 

After scientific evidence of the harmful health consequences of cigarette smoking appeared in the mid1950s states began to increase cigarette excise taxes not 

only to raise revenues but to discourage people from 

smoking. Because the combined federal and state taxes 

accounted for almost half of the average retail price of 

cigarettes, these state tax increases resulted in increases 

in the real price of cigarettes (i.e., the price of cigarettes 

relative to the price of ail goods and services, as measured by the National Consumer Price Index) (Table 14). 

The relative price of cigarettes also rose as a result of the 

state tax increases. This trend was accelerated after the 

1964 release of the first Surgeon General’s report on 

smoking and health. The resultwas that between 1955 

and 1971, the nominal price of cigarettes had risen by 

over 70 percent (almost half of this increase was attributed to the state tax increases), and the real price of 

cigarettes had risen by over 13 percent. 

These increases in real cigarette prices were shortlived. The rapid inflation of the 197Os, coupled with the 

relative stability of state excise taxes on cigarettes, led to 

a sharp drop in real cigarette prices between 1971 and 

1981. Federal taxes remained fixed at 8 cents per pack 

during this period. As was discus& earlier, the emergence of organized smuggling in response to the growing differences in state and local taxes discouraged states 

from continuing to increase cigarette taxes. Combined 

federal and state taxes, as a percentage of retail cigarette 

prices, fell from 47 percent at the beginning of this period 

to 33 percent in 1981. The absolute cost of producing 

cigarettes fell throughout this period, largely because of 

a decrease in the average quantity of tobacco per cigarette as the market share for ‘low tai” cigarettes increased (Harris 1987X The overall result was that between 

1971 and 1981, the real price of cigarettes declined by 

almost 28 percent. 

Beginning in 1982, this downward trend in real 

cigarette prices was reversed as state taxes rose in anticipation of the doubling of the federal excise tax on cigarettes that was scheduled for January 1, 1983. These 

combined taxincreasesled to the largest singlc+year jump 

in prices (from 1982 to 1983). However, Harris (1987) 

argues that the main cause of the increase in the real price 

of cigarettes from 1981 through 1986 was not the increase 

in either the federal tax or state taxes, but rather the 

increases in the wholesale prices of cigarettes because of 

markups by manufacturers. He contends that most of 

these markups were not justified by increases in the cost 

of production. Instead, he suggests that markups were 

the result of a coordinated price increase by the six firms 

that dominate the tobacco industry. More recent data 

lend support to Harris’s argument: although state and 

Prezwntion 173 
Surgeon General’s Report 

Table 14. Cigarette taxes and cigarette prices per pack, 1955-1991 

Year 

Average 

state tax 

(cents) 

Taxes as Real+ 

Average percent- Real’ Real’ average 

Average cigarette age of average average cigarette 

federal price average state tax* federal price 

tax (cents) (cents) price’ (cents) tax (cents) (cents) 

1955 3.5 8.0 22.7 48.7 13.1 29.9 84.7 

1956 3.8 8.0 23.2 47.4 14.0 29.9 85.3 

1957 3.9 8.0 23.8 48.8 13.9 28.5 84.7 

1958 4.0 8.0 25.0 48.0 13.8 27.7 86.5 

1959 4.2 8.0 25.6 46.6 14.4 27.5 88.0 

1960 4.7 8.0 26.1 48.9 15.9 27.0 88.2 

1961 4.7 8.0 26.1 43.6 15.7 26.8 87.3 

1962 5.1 8.0 26.9 48.3 16.9 26.5 89.1 

1963 5.2 8.0 26.8 49.4 17.0 26.1 87.6 

1964 5.6 8.0 27.9 49.3 18.1 25.8 90.0 

1965 5.9 8.0 28.2 49.8 18.7 25.4 89.5 

1966 6.9 8.0 30.0 51.4 21.3 24.7 92.6 

1967 7.1 8.0 30.5 50.8 21.3 24.0 91.3 

1968 8.4 8.0 32.3 49.2 24.1 23.0 92.8 

1969 9.1 8.0 32.8 48.9 24.8 21.8 89.4 

1970 10.2 8.0 37.1 47.7 26.3 20.6 95.6 

1971 10.7 8.0 38.9 46.8 26.4 19.8 96.0 

1972 11.6 8.0 40.0 47.7 27.8 19.1 95.7 

1973 12.1 8.0 40.3 48.4 27.3 18.0 90.8 

1974 12.1 8.0 41.8 47.6 24.5 16.2 84.8 

1975 12.2 8.0 44.5 44.5 22.7 14.9 82.7 

1976 12.4 8.0 47.9 41.4 21.8 14.1 84.2 

1977 12.5 8.0 49.2 40.5 20.6 13.2 81.2 

1978 12.9 8.0 54.3 37.1 19.8 12.3 83.3 

1979 12.9 8.0 56.8 35.5 17.8 11.0 78.2 

1980 13.1 8.0 60.0 34.5 15.9 9.7 72.8 

1981 13.2 8.0 63.0 33.1 14.5 8.8 69.3 

1982 13.5 8.0 69.7 29.9 14.0 8.3 72.2 

1983 14.7 12.0 81.9 26.8 14.8 12.0 82.2 

1984 15.3 16.0 94.7 33.2 14.7 15.4 91.1 

1985 15.9 16.0 97.8 32.3 14.8 14.9 90.9 

1986 16.2 16.0 104.5 30.8 14.8 14.6 95.3 

1987 16.9 16.0 110.0 29.9 14.9 14.1 96.8 

1988 18.2 16.0 122.2 28.1 15.4 13.5 103.3 

1989 21.8 16.0 127.5 26.5 17.6 12.9 102.8 

1990 24.7 16.0 144.1 26.4 18.9 12.2 110.3 

1991 25.9 20.0 153.3 25.6 19.0 11.7 112.6 

Source: Tobacco Institute (1992). 

rercentages cannot be calculated directly from the tax and price information, since taxes are weighted average taxes for the 

entire fiscal year, whereas prices and percentages are generally as of November 1. 

‘Real taxes and prices are obtained by dividing the actual taxes and prices by the National Consumer Price Index, with the 

average of 1982-l 984 being the benchmark. AII data are for the fiscal year ending June 20. 

State taxes are a weighted average of the tax in taxing states, including Washington, D.C. (42 in 1955,51 in 1970 and after). 

Price refers to the median retail price in aII taxing states. 

174 Prewn tion 
Preventing Tobacco Use Among Young People 

federal taxes have increased since the late 1980% the 

percentageoftheretailpriceofcigarettesaccountedforby 

these taxes actually fell from 33 percent in 1981 to 26 

percent in 1991 (Tobacco Institute 1992). The combined 

effect of increases in federal and state taxes and in 

manufacturers price resulted in the real price of cigarettes increasing by over 60 percent between 1981 and 

1991. This upward trend in real cigarette prices is expected to continue at least through 1993, as the federal tax 

increases to 24 cents per pack as part of the 1990 deficitreductionagreement. Therefore,althoughtaxesaccounted 

for a smaller percentage of the increased retail price of 

cigarettes from 1981 to 1991, the increased taxes, along 

with manufacturers’ price increases, were still passed on 

to consumers, and the real price of cigarettes increased. 

Effect of Excise Taxes on Tobacco Use 

One of the fundamental principles of economics, 

illustrated by a downward-sloping demand curve, states 

that as the real price of any commodity rises, consumption of that commodity falls. Some researchers have 

speculated that the consumption of an addictive product, such as cigarettes, might be an exception to this rule. 

However, numerous econometric studies, including 

several recent studies that explicitly model the addictive aspects of cigarette smoking, confirm that this 

fundamental economic principle does indeed apply 

to cigarettes. Thus, since increases in cigarette excise 

taxes generally result in increased cigarette prices, 

these tax increases may be effective in reducing cigarette 

consumption. 

Economists use the concept of price ‘elasticity of 

demand to describe the sensitivity of consumption to 

changes in price. The price elasticity of demand is de 

fined as the percentage change in consumption that 

results from a 1 percent increase in price. For example, 

a price elasticity of -0.5 implies that a 10 percent increase 

in price would reduce consumption by five percent. 

A brief review of recent U.S. studies of cigarette de 

mand follows. 

Aggregate Data Studies 

One set of recent studies of cigarette demand used 

aggregate data. Price elasticity estimates obtained from 

these studies ranged from -0.14 to -1.23; the majority of 

these estimates fell within the narrower range from -0.20 

to -0.50. All but two of the estimates were obtained from 

econometric studies that besides examining the effect of 

price, used income, demographic variables, and other 

policy-related variables to explain differences in cigarette consumption. Failing to include such potentially 

important determinants of demand could lead to biased 

estimates of the effects of price and other policies on 

cigarette smoking. Several of these studies made theoretical and empirical attempts to model the addictive 

aspects of cigarette consumption. In contrast with 

the econometric analyses, Peterson et al. (1992) used 

an epidemiologic approach similar to the quasiexperimental approach of Baltagi and Goel(1987). Both 

studies obtained estimates of the price elasticity of demand that were consistent with those obtained from 

econometric studies. 

Differences in the estimates obtained from these 

studies partly resulted from differences in theoretical and 

empirical modeling methods. For example, the studies 

that used a pooled time series of state cross-sections 

might provide estimates of the price elasticity that exceed 

the true value of the elasticity if cigarette smuggling is 

ignored, since studies based on aggregate data use state 

cigarette sales figures as their measure of consumption. 

That is, states with relatively low cigarette taxes and 

prices may sell a substantial number of cigarettes to 

residents of nearby states where prices are higher. Thus, 

the sales figures from the states with lower cigarette taxes 

and prices will overstate cigarette consumption within 

those states, whereas those with higher taxes and prices 

will understate consumption. Many of the most recent 

studies, however, including those by Baltagi and Levin 

(19861, Becker, Grossman, and Murphy (19921, and 

Chaloupka and Saffer (1992), have controlled for this 

problem. Siily, if the addictive aspects of COIISUIYIP 

tion are ignored, the estimated price elasticity may be 

biased. Again, many of these recent studies, including 

Baltagi and Levin (19861, Becker, Grossman, and Murphy 

(19921, and Keeler et al. (1992) estimated demand equations that explicitly model the addictive aspects of consumption. In addition, at the aggregate level, cigarette 

prices and quantity are simultaneously determined by 

the interaction of cigarette supply and demand. Ignoring 

this simultaneity would lead to biased estimates of the 

effects of cigarette prices on demand. Bishop and Yoo 

(1985) and Porter (1986) explicitly modeled this relationship and estimated price elasticities of demand that fell 

within the -0.20 to -0.50 range generally found in other 

studies based on aggregate data. Finally, two of these 

studies, Keeler et al. (1992) and Flewelling et al. (1992), 

considered the effects of the relatively large change in the 

California cigarette excise tax. Their estimated price 

elasticities suggest that the impact of price on demand is 

independent of the level of price. 

Even with the differences in data, theoretical modeling, and estimation techniques, one general conclusion 

can be drawn from these aggregate studies-increases in 

cigarette prices will reduce cigarette consumption. At 

least part of this reduction is likely due to adolescents’ 

quitting smoking, reducing the amount they smoke, or 

not taking up smoking in the first place &JSDIII-IS 1991). 

Prevention 175 
Surgeon General’s Report 

Microlevel Data Studies 

Another set of recent studies of cigarette demand 

include those that used microlevel data-that is, data 

from groups of individuals instead of aggregate data 

sets. As with the studies that used aggregate data, these 

studies consistently indicated that cigarette smoking is 

affected negatively by price. Each of the studies carefully 

dealt with the smuggling problem that could bias the 

estimates of the price elasticities. Because they were 

based on microlevel data, the studies also avoided the 

simultaneity problems that arise when working with 

aggregate data. That is, no individual smoker consumes 

enough cigarettes to affect market price, so prices could 

be appropriately treated as exogenous in these studies. 

Many of these studies, however, examined issues 

that cannot be addressed when using aggregate data. 

Studies that use microlevel data can assess the effect of. 

prices and other policies, not only on average cigarette 

consumption (the focus of aggregate studies), but also on 

the probability that an individual smokes and on average consumption among smokers. Similarly, the effects 

of policy variables on smoking initiation and cessation 

can be explored. Microlevel data can be used to consider 

the differential effects of increased cigarette excise taxes 

and other policies on alternative demographic groups 

(by age or by gender, for example). 

Lewit and Coate (1982) took advantage of crosssectional survey data not only to estimate equations of 

the demand for cigarettes, but also to determine smok; 

ing prevalence and patterns of smoking participation. In 

addition, this study estimated separate demand equations for different age groups (20-25 years, 26-35 years, 

and 36-74 years) and for men and women. These investigators found that a price increase appeared to effect 

the decision to become a smoker rather than the decision 

to smoke less frequently. They also found that the smoking behavior of young adults (20 to 25 years old) was 

more sensitive to price changes than that of older 

individuals. Finally, they found that male smokers, 

particularly those aged 20 to 35 years, were quite 

responsive to price, whereas female smokers were essentially unaffected by price. 

Mullahy (1985) introduced myopic addiction (i.e., 

the concept that addiction outweighs an individual’s 

foresight or concern for future well-being) into his theoretical model of cigarette smoking. This model implies 

that at any given time, smoking initiation, regular use, 

and the amount of cigarettes smoked depend on an 

individual’s smoking history. This model and other studies that formally model the addictive aspects of smoking 

incorporate the concepts of tolerance, reinforcement, and 

withdrawal that distinguish addictive consumption from 

nonaddictive consumption. Treating smokers as 

myopic, however, implies that the future consequences 

of their smoking are ignored when they make current 

decisions. Mullahy estimated separate demand equations for men and women and found that both the decision to smoke and the quantity of cigarettes consumed 

by smokers were negatively related to cigarette prices for 

each gender. As in the Lewit and Coate study, Mullahy 

found that cigarette prices had a greater impact on the 

decision to smoke than they do on cigarette consump 

tion. Similarly, he found that men were somewhat more 

responsive to price than women (average elasticities of 

-0.56 and -0.39, respectively). 

Chaloupka (1990,1991a, b) applied the Becker and 

Murphy (1988) model of rational addictive behavior to 

cigarette smoking. As in the Mullahy model, addiction is 

accounted for by recognizing that current smoking decisions depend on past smoking, whereas rationality implies that the future consequences of an individual’s past 

and current smoking behavior are considered when making current choices. Chaloupka found both that cigarette 

smoking is addictive--that is, it depends on past smoking-and that individuals who smoke also consider future consequences. He found that increases in cigarette 

prices reduce average cigarette consumption significantly 

and that the effects of price increases on consumption are 

understated if the addictive aspects of consumption are 

ignored. In contrast with the findings of Lewit and 

Coate, Chaloupka found that adolescents and young 

adults (aged 17 through 24 years) were less responsive to 

price than are older age groups. Chaloupka also found, 

like Lewit and Coate, that women were much less responsive to price than men. 

Wasserman et al. (1991) used several of the Health 

Interview Surveys conducted during the 1970s and 1980s 

to estimate the effects that taxes and regulations restricting smoking in public places have on adult cigarette 

demand. These investigators also examined whether the 

price elasticity of demand has changed over time. Using 

a generalized linear model, they found that the negative 

impact of cigarette prices on demand has increased over 

time. The estimated price elasticity of demand in 1970 

(0.06) suggested that increases in cigarette excise taxes 

would not discourage cigarette smoking. However, the 

authors estimated an increasingly negative effect of 

cigarettepricesondemandfrom1974 (-0.17) through1985 

(-023).Theyestimatedthatby1988,thepriceelasticityof 

demand would increase (in absolute value) to -0.28. This 

finding that the price elasticity of demand is becoming 

more negative over time contradicts the findings of the 

studies based on aggregate data by BaItagi and Goel. The 

estimated elasticities of Wasserman et al. were approximately half those estimated by Lewit and Coate, who 

used the same data. Wasserman et al. attributed these 

relatively low estimates to their including an index that 

276 Prevention 
Preventing Tobacco Use Among Young People 

measured state-level antismoking regulations and was 

highly correlated with price. When this index was omitted, the effects of price on demand were overstated, since 

they included the true price effect as well as the effect of 

the omitted regulations. The findings of Wasserman et al. 

for youth will be discussed in detail in the next section. 

The implications of these studies on older adolescents’ and young adults’ responsiveness to price are not 

conclusive. Lewit and Coate’s examination of individuals 20 years old and older concluded that upward price 

elasticity is increasingly negative (and thereby has a 

stronger effect) for younger age groups. The addictive 

model that Chaloupka used, however, suggested that 

less addicted smokers (those who have a shorter history 

of smoking, for example) will be less responsive to price 

than their more addicted counterparts. His estimated 

long-run price elasticities of demand for older adolescents and young adults were consistent with this h.ypothesis. The following section addresses more 

specifically the effect of price on the smoking behavior 

of young people. 

Price Responsiveness of Adolescent Smokers 

A third set of recent econometric studies focused 

on youth. Each of these studies, as with the studies of 

adult smoking that employ microlevel data, carefully 

controlled for cigarette smuggling. Besides including 

cigarette prices and other determinants of demand employed in the studies of adult smoking, these youth 

studies included parental characteristics (such as education level and income) as proxies for parental smoking 

practices, which have been shown to be associated with 

youth smoking. 

The first comprehensive studies of the price responsiveness of cigarette smoking among youth were 

completed in the early 1980s. Lewit, Coate, and 

Grossman (19811 used Cycle III of the Health Examination Survey (HES-III), which was conducted from March 

1966 through March 1970, to look at the effects of cigarette prices, of the negative cigarette advertising broadcast under the Fairness Doctrine, and of various 

socioeconomic and demographic factors affecting cigarette smoking by youth (persons 12 through 17 years 

old). Besides examining average cigarette consumption among all youth, the authors also estimated equations for smoking participation for all youth as well as 

equations for cigarette demand for young smokers. This 

methodology, similar to that used by Lewit and Coate, 

allowed the authors to distinguish the effect of price on 

the decision to smoke from its effect on smokers’ consumption of cigarettes. The authors found that most of 

the impact of prices on cigarette smoking was on the 

decision to smoke rather than on smokers’ average 

consumption of cigarettes: estimated price elasticity 

was -1.20 for smoking participation and -0.25 for cigarette demand. Furthermore, the estimated price elasticity of demand among youth in this study (-1.44) was 

more than three times as high as the estimate for adults 

in Lewit and Coate’s study and nearly two times as high 

as that studys estimate for young adults (persons aged 

20 through 25 years). 

These findings were mostly confirmed in a related 

study by Grossman et al. (1983). This study used data 

from the 1974,1976,1977, and 1979 National Household 

Surveys on Drug Abuse. The surveys were analyzed 

separately because of differences in the definition of 

smoking. As the authors noted, the estimates from this 

study should be interpreted cautiously, since the sample 

sizes were much smaller than those of the study based on 

the HESIB. In general, Grossman et al. found that the 

decision to smoke was negatively related to the price of 

cigarettes; their summary estimate of this elasticity was 

-0.76. Again, this estimate was substantially higher, in 

absolute value, than that obtained for adults by Lewit 

and Coate, and it implies that young people’s decision to 

smoke is much more responsive to price than the comparable decision for adults. However, Grossman et al. 

found that once the decision to smoke has been made, 

average consumption decisions by young smokers were 

virtually unresponsive to price. 

Warner (1985,1986) used the age-specific price elasticities of participation and demand from Lewit and 

Coate to obtain comparable estimates of price elasticity 

for teenagers (persons aged 12 through 17and 18 through 

19). He used these age-specific data to estimate that the 

doubling of the federal excise tax in 1983 reduced the 

number of teenage smokers by 800,000, assuming that 

average cigarette prices increased by the 8 cents that the 

tax increased. These estimates form the basis for a U.S. 

General Accounting Office (GAO) report, which concluded that raising the federal tax further by 20 cents per 

pack would have reduced the number of teenage smokers by an additional 500,000 in 1989 (GAO 1989). The 

GAO predicted a subsequent reduction of 125,000 

smoking-related deaths for this age group as a result of 

the proposed 20-tent tax increase. 

Similarly, Harris (1987) used the Lewit, Coate, and 

Grossman estimates, among others, to examine the effects that the 1983 doubling of the federal excise tax on 

cigarettes had on cigarette smoking and health. He 

concluded that the tax increase and the coordinated price 

increases it induced kept 600,000 teenagers (persons aged 

12 through 17 years) from starting to smoke. Basing his 

findings on epidemiologic studies of the 195Os, 1960s 

and 197Os, Harris concluded that 54,000 more teenagers 

would live to age 65 as a result of this tax. 

Prevention 177 
Surgeon General’s Report 

The recent study by Wasserman et al. (1991) contradicted the general conclusion of Lewit and Coate that 

teenage cigarette smoking is more responsive than adult 

smoking to changes in cigarette prices. Wasserman et al. 

used the Second NationaI Health and Nutrition Examination Survey (1976-1980) ( NHANESII) to estimate the 

effects of cigarette prices and antismoking regulations on 

cigarette smoking by youth aged 12 through 17. In both 

the generalized linear models and the two-part models 

they estimated, the authors found a statisticaIIy insignificant effect of cigarette prices on average cigarette consumption among ah youth, on smoking participation 

rates among ah youth, and on cigarette consumption by 

young smokers. Given the range of estimates obtained, 

the investigators could not reject the hypothesis that the 

price elasticity of demand for teenagers was StatisticaIIy 

different from their estimate of -0.23 for adults. Their 

estimates for youth were consistent with ChaIoupka’s, 

(1991b) young adult estimates, which aIso employed 

NHANESII data. As was discussed earlier, Wasserman 

et al. suggested that one of the reasons for their relatively 

low estimated price elasticity of demand was their including an index that captured antismoking regulations 

as a determinant of demand. Thus, they concluded that 

the price effects estimated in other studies may have 

been biased upwards, since prices aione were being credited with the effects of various contemporaneous antismoking regulations that likely played an important role 

in discouraging young people from smoking. 

Grossman (1991) noted, however, that the study by 

Wasserman et al., while a valuable contribution to the 

empirical literature on cigarette demand, should not be 

considered as offering the definitive estimates of the price 

elasticity of demand, particuIarly for youth. Others, ineluding ChaIoupka (1988) and ChaIoupka and Saffer (1992), 

did not find that the estimated price elasticity of demand 

was sensitive to the inclusion of measures of antismoking 

regdations, although these other studies used smaIIer 

sample sizes than did Wasserman et al. Furthermore, 

including the regulation index may be less relevant in a 

teenage sample, since the index assumes its highest value 

in states that restrict smoking in private worksites. If the 

regulations themselves have no direct impact on smoking 

but are instead proxies for antismoking sentiment, then 

enatig very restrictive measures may not n&y 

reduce youth smoking. For example, during the 198Os, 

restrictions on public smoking were enacted across the 

United States, yet smoking onset rates among young 

people did not decline significantly (see ‘Trends in Cigarette Smoking” in Chapter 3). Finally, the Wasserman et 

al. (1991) findings for a relatively smaII sample of youth 

(N = 1,891) should be interpreted cautiously when compared with those obtained by Lewit, Coate, and Grossman 

(1981) (N = 5,308). 

Discussion 

The large amount of empirical Iiterature on the 

relationship between cigarette prices and cigarette smoking suggests that increased excise taxes on cigarettes 

would significantly reduce overah rates of cigarette smoking. Much of. the impact of higher prices would come 

from encouraging cessation among current smokers and 

discouraging initiation among young smokers. The price 

responsiveness of adolescents is at least as high, if not 

significantly higher, than that of adults-a finding that 

suggests that an increase in cigarette taxes would result 

in large reductions in smoking prevalence and cigarette 

consumption among teenagers. 

Although numerous studies of aggregate cigarette 

demand and several studies of cigarette smoking among 

youth have been completed in recent years, the relationship between other tobacco taxes and the use of tobacco 

products other than cigarettes has not been examined. 

Tax Policies Under Consideration 

Increased taxes on cigarette and other tobacco products have been widely used in recent years as a source of 

federal, state, and local revenue. These taxes also are 

seen as a way to improve public health by discouraging 

cigarette smoking. Two proposals discussed in the 1989 

Surgeon General’s report on smoking and health 

(USDHHS 1989) have received the most attention. The 

first proposal is to increase tobacco taxes in general and 

to change the way in which these taxes are caIcuIated. 

The second proposal would earmark the revenue generated by tobacco taxes to pay for tobaccocontrol programs or the health care costs related to smoking. Most 

of the proposals discussed below concern cigarette taxes; 

similar policies could be adopted for taxes on other tobacco products as well. 

Increasing Tobacco Taxes 

An increase in the federal excise tax on cigarettes is 

the most widely supported tax policy proposal. Proponents-which include a number of public health groups, 

such as the American Lung Association, the AMA, the 

ACS, the American Heart Association, and the American 

Public Health Association-argue that the cigarette tax 

should be increased, because even after recent increases, 

the real value of the tax is .&II well below what it was in 

1951. Also suggested is the repeal of the federally approved exemption for state taxes of cigarette sales on 

military bases and Native American reservations. 

SimiIarly, despite recent increases in state excise 

taxes on cigarettes, the average state’s real excise tax on 

cigarettes is at about the same level as it was shortly after 

the release of the first Surgeon General’s report on smoking and health. In several states (notably the large 

178 Prevention 
Preventing Tobacco Use Among Young People 

tobacco-producing states), the effects of inflation have 

been allowed to substantially reduce the values of these 

taxes. Although additional tax increases in states that 

have continually raised their cigarette excise taxes over 

time could spur a return to the organized smuggling of 

the 197Os, this problem possibly could be solved by 

levying larger tax increases in the states that have relatively low cigarette taxes and by instituting a tax in the 

four states that currently exclude cigarettes from the instate sales tax. 

These tax increases’would raise cigarette prices in 

the short run; without continued increases, however, the 

real value of the tax would be reduced by inflation over 

time. Given the importance of taxes in cigarette prices, 

the real cigarette price could even decline, as it did from 

1971 to 1981. An alternative might be to replace the 

excise tax with an ad valorem tax, which would increase 

proportionately as the nontaxed price of cigarettes increases. The federal government imposes an ad valorem 

tax on large cigars only, and most states levy ad valorem 

taxes on tobacco products other than cigarettes. 

An ad valorem tax, however, may have an unintended consequence of lulling the public’s awareness of 

a tax increase, since ad valorem taxes may be perceived-and accepted-as part of overall inflation. 

Periodic increases in excise taxes, on the other hand, may 

be publicized each tune they occur and thus may stimulate public discussion of the health effects of smoking. 

Canada’s experience with ad valorem taxes suggests that 

any mechanism that raises cigarette prices will be effective in reducing cigarette smoking. 

To offset declines in real revenues due to inflation, 

Canada switched to an ad valorem tax on cigarettes at 

both the federal and provincial levels in the 1980s. These 

ad valorem taxes were partly responsible for a 25 percent 

increase in real cigarette prices, which was accompanied 

by a 10 percent decline in adult consumption of cigarettes (Sweanor 1991). In 1984, however, the ad valorem 

tax system was dropped after heavy lobbying by the 

tobacco industry and a lack of support from public health 

groups. Since then, there have been large increases in 

both federal and provincial excisetaxes. By June 1,1991, 

the average total tax on a pack of 20 cigarettes in Canada 

was $3.72, more than eight times what it was in 1980 and 

approximately seven times the average in the United 

States. The large increases in Canadian taxes since 1985 

are estimated to have reduced adult consumption by 35 

percent and teenage consumption by 62 percent. These 

data included tobacco imported from the United States 

( Sweanor 1991; see Figure 6). Canada’s experience in the 

1980s provides a nationwide example of the effect of a tax 

increase on cigarette smoking among young people. 

Figure 6. Real* cigarette prices and cigarette smoking prevalence among Canadians aged 15-19 years, 1979-1991 

451 ,,...I. 1 een 

l-n_-, r-L ^--- --;a- :-. 

42 

-1 

‘;; 

s 

39- 

8 36- 

6 

‘;ii 5 33- 

k M2 

9 

’ 

2?- 

cn 24- 

21 

1 

18-l 

,- 270 

‘a., 

,,. 

15 i I I I I I I I I I I I 

1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 

Year 

Sources: Health and Welfare Canada (1991); Sweanor (1992). 

*The price of cigarettes relative to the price of all goods and services in Canada, adjusted for inflation with 1979-1980 

being the benchmark years. 

Prevention 179 
Related proposals include indexing the federal cigarette excise tax to the rate of inflation or to some measure 

of cigarette prices. Each of these proposals would have 

the benefit of offsetting the effects of inflation on the 

value of the taxes and tax revenue over time, and each 

would be only slightly more cumbersome to administer 

than current tax structures. 

Opponents of these tax changes argue that increases 

would place an unfair burden on the poor. In general, excise 

taxes and other consumption taxes are regressive, in that 

they require lower-income individuals to pay a greater share 

of their incomes in taxes. The CR0 estimates that increased 

cigarette excise taxes would most affect individuals in the 

lowest income categories (CR0 1990). However, as the CBO 

alsoexplains,altemativetaxandtransferpoliciescouldoffset 

the regressiveness of a tax increase. Proponents of these tax 

changes point out that lung cancer and other smokingrelated diseases also disproportionately affect the poor; 

moreover, if the tax revenues are earmarked to programs 

directed to the poor, then the overall policy is not regressive. 

Another side effect of an increase in the federal 

tax on cigarettes would be the reduction of state and 

local cigarette tax collections as cigarette consumption 

falls. On the other hand, if state taxes on cigarettes 

increase with federal taxes, state revenues could increase 

as well, as occurred in 1983. Lastly, opponents of tax 

changes argue that increases in taxes would also increase 

incentives to evade taxes. The CBO estimates, however, 

that any resulting increases in tax evasion would be 

relatively minor. 

Earmarking Taxes 

The apparent success of Proposition 99 in California has increased interest in adopting similar policies 

Conclusions 

Surgeon General’s Rep~ 

elsewhere. Of the revenues generated from the tax increase of 25 cents per pack, 20 percent are dedicated to 

antismoking education, 5 percent to research, 5 percent 

to environmental and other specified programs, and 70 

percent to medical care for the poor. Recent attempts by 

the governor to redirect some of these revenues to other 

purposes were stopped by the state courts. Similar earmarking of part of the state excise on cigarettes takes 

place in Nebraska (for its cancer and smoking research 

program), Minnesota (for the state public health fund), 

Utah (for its tobacco-control programs), and Indiana (for 

subsidizing of child care). Earmarking the revenues 

from tobacco taxes to tobacco-control programs reinforces the impact that increased tobacco taxes have on 

tobacco consumption. Early evidence from California 

(Hewelling et al. 1992; Keeler et al. 1992) indicates that 

the combined impact of the increased excise tax on 

cigarettes and the increased tobacco-control activities 

funded by these tax increases has resulted in reduced 

cigarette consumption. 

OnitsNovember1992ballot,Massachusettspassed 

a measure similar to Proposition 99. This measure 

institutes a state excise tax increase of 25 cents per 

cigarette pack and a 25 percent increase in the tax on 

chewing tobacco. Some of the revenue from the increases may be dedicated to tobacco-control programs. 

Public health professionals in Colorado, Nebraska, Arkansas, Michigan, and Oregon are advocating similar 

measures. These types of large increases in cigarette 

excise taxes, where at least part of the increased revenues 

is earmarked for other antismoking activities, have the 

added advantage of stimulating the discussion of the 

health consequences of smoking. As a result, reductions 

in smoking may be larger than anticipated. 

This chapter reviewed a large body of literature 

concerning programs and policies to prevent tobacco use 

among young people. These measures, from education 

to taxation, are strongly supported by the United States 

public. Given the number of young people who continue 

to initiate use during adolescence, and given the strong 

role of the social environment in the process of initiation, 

efforts to prevent the onset of tobacco use may need 

multiple, complementary components, including those 

described in this chapter, and may need to be implemented at the national, state, and community levels to 

have long-term impact. 

1. Most of the American public strongly favor policies 

that might prevent tobacco use among young people. 

These policies include tobacco education in the schools, 

restrictions on tobacco advertising and promotions, a 

complete ban on smoking by anyone on school 

grounds, prohibition of the sale of tobacco products to 

minors, and earmarked tax increases on tobacco 

products. 

2. School-based smoking-prevention programs that 

identify social influences to smoke and teach skills to 

resist those influences have demonstrated consistent 

and significant reductions in adolescent smoking 

180 Prevention 
pyeventing Tobacco Use Among Young People 

prevalence, and program effects have lasted one to 

three years. Programs to prevent smokeless tobacco 

use that are based on the same model have also demonstrated modest reductions in the initiation of smokeless tobacco use. 

3. The effectiveness of school-based smoking-prevention programs appears to be enhanced and sustained 

by comprehensive school health education and by 

communitywide programs that involve parents, mass 

media, community organizations, or other elements 

of an adolescent’s social environment. 

4. Smoking-cessation programs tend to have low SUCcess rates. Recruiting and retaining adolescents in 

formal cessation programs are difficult. 

5. Illegal sales of tobacco products are common. Active 

enforcement of age-at-sale policies by public officials 

and community members appears necessary to prevent minors’ access to tobacco. 

6. Econometric and other studies indicate that increases 

in the real price of cigarettes significantly reduce cigarette smoking; young people are at least as responsive 

as adults to such price changes. Maintaining higher 

real prices of cigarettes depends on further tax increases to offset the effects of inflation. 

Prevention 181 
preventing Tobacco Use Among Young People 

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