CONTROL 

TOBACCO 

AND 

SMOKING 

MONOGRAPH 

Changing

Adolescent 

Smoking

Prevalence 

Where It Is and Why 

U.S. DEPARTMENT OF HEALTH 

AND HUMAN SERVICES 

Public Health Service 

National Institutes of Health 

National Cancer Institute 

14 
CONTROL 

TOBACCO 

AND 

SMOKING 

MONOGRAPH
14 

Changing 

Adolescent 

Smoking 

Prevalence 

Where It Is and Why 

U.S. DEPARTMENT OF HEALTH


AND HUMAN SERVICES


Public Health Service


National Institutes of Health


National Cancer Institute

Smoking and Tobacco Control Monographs Issued to Date 

Strategies to Control Tobacco Use in the United States: a blueprint for public health action in the 1990’s. Smoking 

and Tobacco Control Monograph No. 1. Bethesda, MD: U.S. Department of Health and Human Services, 

Public Health Service, National Institutes of Health, National Cancer Institute. NIH Publication No. 92-3316, 

December 1991. 

Smokeless Tobacco or Health: An international perspective. Smoking and Tobacco Control Monograph No. 2. 

Bethesda, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of 

Health. NIH Publication No. 92-3461, September 1992. 

Major Local Tobacco Control Ordinances in the Unites States. Smoking and Tobacco Control Monograph No. 3. 

Bethesda, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of 

Health. NIH Publication No. 93-3532, May 1993. 

Respiratory Health Effects of Passive Smoking: Lung cancer and other disorders. The Report of the U.S. Environmental 

Protection Agency. Smoking and Tobacco Control Monograph No. 4. Bethesda, MD: U.S. Department of Health 

and Human Services, Public Health Service, National Institutes of Health, NIH Publication No. 93-3605, 

August 1993 

Tobacco and the Clinician. Interventions for Medical and Dental Practice. Smoking and Tobacco Control 

Monograph No. 5. Bethesda, MD: U.S. Department of Health and Human Services, Public Health Service, 

National Institutes of Health. NIH Publication No. 94-3693, January 1994. 

Community-based Interventions for Smokers: The COMMIT Field Experience. Smoking and Tobacco Control 

Monograph No. 6. Bethesda, MD: U.S. Department of Health and Human Services, Public Health Service, 

National Institutes of Health. NIH Publication No. 95-4028, August 1995. 

The FTC Cigarette Test Method for Determining Tar, Nicotine, and Carbon Monoxide Yields of U.S. Cigarettes. Report 

of the NCI Expert Committee. Smoking and Tobacco Control Monograph No. 7. Bethesda, MD: U.S. 

Department of Health and Human Services, Public Health Service, National Institutes of Health. NIH 

Publication No. 96-4028, August 1996. 

Changes in Cigarette Related Disease Risks and Their Implication for Prevention and Control. Smoking and Tobacco 

Control Monograph No. 8. Bethesda, MD: U.S. Department of Health and Human Services, Public Health 

Service, National Institutes of Health. NIH Publication No. 97-4213, February 1997. 

Cigars. Health Effects and Trends. Smoking and Tobacco Control Monograph No. 9. Bethesda, MD: U.S. 

Department of Health and Human Services, Public Health Service, National Institutes of Health. NIH 

Publication No. 98-4302, February 1998. 

Health Effects of Exposure to Environmental Tobacco Smoke. The Report of the California Environmental Protection 

Agency. Smoking and Tobacco Control Monograph No. 10. Bethesda, MD: U.S. Department of Health and 

Human Services, Public Health Service, National Institutes of Health, National Cancer Institute. NIH 

Publication No. 99-4645, August 1999. 

State and Local Legislative Action to Reduce Tobacco Use. Smoking and Tobacco Control Monograph No. 11. 

Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National 

Cancer Institute, NIH Publication No. 00-4804, August 2000. 

Population Based Smoking Cessation: Proceedings of a Conference on What Works to Influence Cessation in the 

General Population. Smoking and Tobacco Control Monograph No. 12. Bethesda, MD: U.S. Department of 

Health and Human Services, National Institutes of Health, National Cancer Institute, NIH Publication No. 00-

4892, November 2000. 
Preface


This monograph is the first major update of adolescent smoking behavior since the groundbreaking reports of the Surgeon General and the 

Institute of Medicine in 1994. The authors of this National Cancer Institute 

(NCI) Monograph report some progress toward reducing tobacco use among 

adolescents but also highlight areas in which more efforts need to be made. 

Several chapters examine trends in adolescent smoking behavior, 

among all adolescents nationally, different racial/ethnic groups, and among 

adolescents residing in specific States. Other chapters examine these trends 

using different national surveys as data sources and different analytical 

methods. Finally, the remaining chapters present data on macro-level policies and factors that influence the initiation and maintenance of smoking 

behavior among adolescents. 

National survey data are used in chapters 3, 4, 8, and 9 to examine 

trends in adolescent smoking. Chapter 8, “Changes in Adolescent Smoking 

Behaviors in Sequential Birth Cohorts,” is the most extensive, reviewing 

data from 5-year birth cohorts from 1926-1930 to 1981-1985. The data 

show that initiation rates have declined over time at all ages for males 

while female cohorts showed little indication of a decline in initiation for 

ages under 16 years and an increasing initiation rate for ages 16 and older. 

Chapter 9, “Pattern of Adolescent Initiation Rates over Time: National and 

California Data,” compares cross-sectional data from national surveys with 

data from the State of California shortly after the passage of Proposition 99. 

It was this law that provided tobacco control groups with funding to 

launch an aggressive anti-smoking campaign. Following the enactment of 

Proposition 99, adolescent smoking showed a significant decrease in 

California compared with the national experience during this time, primarily among adolescent males. 

Chapters 6, 7, and 9 report results from statewide projects in three of 

the States at the forefront of tobacco control in this country. Chapter 6, 

“Changing Adolescent Smoking Prevalence: Impact of Advertising 

Intervention,” describes progress in Massachusetts. Chapter 7, “Predictors of 

Tobacco Use among Adolescents in Florida, 1998-1999,” examines data 

from Florida and includes a study of the predictors of tobacco use among 

adolescents in that state. As noted above, Chapter 9, “Pattern of Adolescent 

Initiation Rates over Time: National and California Data,” analyzes adolescent smoking over the period 1990-1996, the period following the enactment of Proposition 99, which was marked by a large increase in tobacco 

control activity in California. 

i 
Smoking and Tobacco Control Monograph No. 14 

While several of the chapters present data on various racial/ethnic 

groups, Chapters 14, 15, 16, and 17 focus exclusively on describing and 

explaining smoking behavior of African American, Hispanic/Latino, Asian 

American and Pacific Islander, and American Indian and Alaskan Native 

adolescents. Chapter 14, “African American Teen Cigarette Smoking: A 

Review,” delineates the protective factors that may contribute to substantially lower prevalence rates among African American adolescents and risks 

factors that may contribute to increases in smoking that began in the early 

1990’s. Little is known on how protective and risk factors explain the “late 

onset” of smoking and transition to higher smoking rates among African 

American adults. Data are limited and do not often distinguish smoking 

rates among subgroups of people of African heritage. 

Chapter 15, “Understanding Tobacco-Use Research among 

Hispanic/Latino Adolescents: A Sociocultural Perspective,” suggests that 

explaining prevalence rates among Hispanic/Latino adolescents requires an 

understanding of the complex interfacing of changing demographics, heterogeneity among subgroups, sociodemographics, culture, language capabilities and preferences, role of acculturation, immigrant status, gender, social 

networks, and tobacco advertising and promotion. Prevalence rates are 

increasing although they are still lower than for Whites and American 

Native Indians. 

Chapter 16, “Asian American and Pacific Islander Adolescent Cigarette 

Smoking: A Review,” reviews factors associated with smoking, but strongly 

suggests that national data often mask the differences in tobacco use 

among American Asian and Pacific Islander ethnic subgroups. Small sample 

sizes in surveillance studies and lack of understanding on factors associated 

with tobacco use among subgroups often limit the generalizability of the 

results. Aggregate data from the California Youth Tobacco Survey document 

Asian youth susceptibility to smoking and dramatic increases in smoking 

rates from 1993-1996. Additional studies are needed to closely monitor 

prevalence rates and dissect factors influencing initiation among American 

Asian and Pacific Islander ethnic subgroups. 

Chapter 17, “American Indian and Alaskan Native Teen Cigarette 

Smoking: A Review,” examines the historical and cultural context of tobacco use among American Indian and Alaskan Native adolescents. American 

Indians and Alaskan Native adolescents have consistently reported the 

highest percentage of cigarette smokers in the nation and these rates continue into adulthood. These rates vary by geographical region and among 

Native Indian groups. Reducing the harmful effects of tobacco in tandem 

with preserving Native culture calls for unique approaches to tobacco control among Native Indian adolescents. 

While there are either limited aggregate data or subgroup data within 

African American, Hispanic/Latino, Asian American and Pacific Islander, 

and American Indian and Alaskan Native adolescents, these chapters offer 

explanations for factors that influence smoking initiation. It has long been 

recognized that a single tobacco control initiative is not equally successful 

ii 
Preface 

in all geographical areas or groups of different ethnic, educational, or economic backgrounds. These chapters each contribute to an understanding of 

the complexity and subtleties of tobacco control in this country. 

This Monograph examines some of the macro-level influences of smoking behavior among adolescents. Two chapters address the effect of the 

media. Media influences are important and relevant for many reasons, 

including the enormous budget the tobacco industry devotes to advertising 

cigarettes, and that a large portion of this advertising is directed at young 

people. Chapter 10, “Changing Adolescent Smoking Prevalence: Impact of 

Advertising Intervention,” examines this impact and addresses the use of 

advertising to deliver tobacco prevention messages. Chapter 13, “The Role 

of Tobacco Advertising and Promotion in Smoking Initiation,” reports on 

the possible causal relationship between tobacco marketing and youth 

smoking initiation. Additional chapters analyze the impact of other macrolevel factors. Chapter 12, “The Impact of Price on Youth Tobacco Use,” 

examines how the price of cigarettes may influence youth smoking. Data 

suggests that youth are more responsive to cigarette price increases than are 

young adults and adults. Youth with greater disposable income smoke more 

than those with fewer resources and price sensitivities may differ for population subgroups. Little is still known about the impact of large price 

increases on cigarette demand and the black market in tobacco products 

and the long-term impact of price changes on addictive behaviors over 

time. 

The results presented in Chapter 11, “Has Youth Access to Tobacco 

Changed over the Past Decade?” are not encouraging. Youth access to cigarettes has not changed in the recent past and youth often obtain cigarettes 

from a variety of noncommercial and commercial resources. Although 

many states and communities have laws prohibiting the sale of cigarettes to 

minors, these laws are not always fully enforced. Curtailing illegal sales may 

reduce rates, but high compliance rates are necessary in order to see any 

effect since compliance rates may underestimate the commercial availability 

of cigarettes to minors. 

In summary, while this Monograph documents some successes in the 

reduction of youth smoking initiation in some States and localities, there 

remains a need for an ongoing and exhaustive search for solutions, followed by committed and successful application to enable the country to 

reach its goals in the area of adolescent smoking. 

iii 
Acknowledgements 

This monograph is the result of a conference and set of analyses 

commissioned and funded jointly by the National Cancer Institute and the 

Tobacco Control Section of the California Department of Health Services. 

The conference was held on May 24 and 25, 1999, in San Diego, California. 

Draft sections of this volume were subjected to peer review and revision, 

and the resultant draft of the entire volume was also subjected to peer 

review and revision. 

The senior scientific editor for this monograph was David M. 

Burns, M.D., Professor of Medicine, University of California San Diego, San 

Diego, California. Richard H. Amacher was the managing editor of the 

volume and project director for the KBM Group Inc., Silver Spring, 

Maryland, who contracted with the National Cancer Institute to produce 

this volume. William Ruppert, M.S., Health Program Specialist, Tobacco 

Control Section, California Department of Health Services, Sacramento 

California, was the project officer for the contract with the Tobacco Control 

Section, California Department of Health Services. 

Chapter 1 

Chapter 2 

Overview of Recent 

Changes in Adolescent 

Smoking Behavior 

Changing Demographic 

Patterns of Adolescent 

Smoking over the Past 

23 Years: National 

Trends from the 

Monitoring the Future 

Study 

David M. Burns, M.D. 

Professor of Medicine 

School of Medicine 

University of California, 

San Diego School of 

Medicine 

San Diego, CA 

Lloyd D. Johnston, Ph.D. 

Distinguished Research 

Scientist and Program 

Director 

Institute for Social Research 

University of Michigan 

Ann Arbor, MI 

Lloyd D. Johnston, Ph.D. 

Distinguished Research 

Scientist and Program 

Director 

Institute for Social Research 

University of Michigan 

Ann Arbor, MI 

v 
Smoking and Tobacco Control Monograph No. 14 

Chapter 3 

Chapter 4 

Chapter 5 

Trends and Subgroup 

Differences in Tobacco 

Use among High School 

Students in the United 

States, 1991-1997 

Trends in Adolescent 

Smoking in the United 

States: Data from the 

National Household 

Survey on Drug Abuse, 

1994 through 1998 

Cigarette Smoking 

among Adolescents in 

California, 1990-1996 

Sherry A. Everett, Ph.D., M.P.H.


Health Scientist


Centers for Disease Control 


and Prevention 

Division of Adolescent and 

School Health 

Atlanta, GA 

Charles W. Warren, Ph.D.


Statistician Demographer


Office on Smoking and Health


Centers for Disease Control


and Prevention


Atlanta, GA


Andrea N. Kopstein, Ph.D., 


M.P.H.


Statistican


Substance Abuse and Mental


Health Service 


Administration (SAMHSA)


Division of Population Surveys


Rockville, MD


David M. Burns, M.D.


Professor of Medicine


University of California,


San Diego School of Medicine


San Diego, CA


Jacqueline M. Major, M.S.


Statistician


Tobacco Control Policies


Project 

University of California at 

San Diego 

San Diego, CA 

Jerry W. Vaughn, B.S. 

Programmer/Analyst 

Tobacco Control Policies 

Project 

University of California at 

San Diego 

San Diego, CA 

vi 
Acknowledgements 

Chapter 6	 Changing Social Norms 

to Decrease Adolescent 

Tobacco Use: 

Massachusetts, 1993-

1996 

Chapter 7	 Predictors of Tobacco 

Use among Adolescents 

in Florida, 1998-1999 

Chapter 8	 Changes in Adolescent 

Smoking Behaviors in 

Sequential Birth 

Cohorts 

Christy M. Anderson, B.S.


Statistician


Tobacco Control Policies


Project 

University of California at 

San Diego 

San Diego, CA 

Thomas G. Shanks, M.P.H., 

M.S. 

Principal Statistician 

Tobacco Control Policies 

Project 

University of California at 

San Diego 

San Diego, CA 

Carolyn Celebucki, Ph.D. 

Director of Research and 

Evaluation 

Massachusetts Department 

of Public Health 

Tobaco Control Program 

Boston, MA 

Diane M. Turner-Bowker, 

Ph.D. 

Massachusetts Department 

of Public Health


Tobacco Control Program


Boston, MA


Ursula E. Bauer, Ph.D., 


M.P.H.


Epidemiologist


Bureau of Epidemiology


Florida Department of 


Health


Tallahassee, Florida


Tammie M. Johnson, M.P.H.


Bureau of Epidemiology


Florida Department of


Health


Christy M. Anderson, B.S.


Statistician


Tobacco Control Policies


Project


vii 
Smoking and Tobacco Control Monograph No. 14 

Chapter 9	 Pattern of Adolescent 

Initiation Rates over 

Time: National and 

California Data 

University of California at 

San Diego 

San Diego, CA 

David M. Burns, M.D.


Professor of Medicine


University of California,


San Diego School of 


Medicine


San Diego, CA


Jacqueline M. Major, M.S.


Statistician


Tobacco Control Policies


Project 

University of California at 

San Diego 

San Diego, CA 

Jerry W. Vaughn, B.S. 

Programmer/Analyst 

Tobacco Control Policies 

Project 

University of California at 

San Diego 

San Diego, CA 

Thomas G. Shanks, M.P.H., 

M.S. 

Principal Statistician 

Tobacco Control Policies 

Project 

University of California at 

San Diego 

San Diego, CA 

Christy M. Anderson, B.S.


Statistician


Tobacco Control Policies


Project 

University of California at 

San Diego 

San Diego, CA 

David M. Burns, M.D. 

Professor of Medicine 

University of California, 

San Diego School of 

Medicine 

San Diego, CA 

viii 
Acknowledgements 

Chapter 10 

Chapter 11 

Chapter 12 

Chapter 13 

Chapter 14 

Changing Adolescent 

Smoking Prevalence: 

Impact of Advertising 

Interventions 

Has Youth Access to 

Tobacco Changed over 

the Past Decade? 

The Impact of Price on 

YouthTobacco Use 

The Role of Tobacco 

Advertising and 

Promotion in Smoking 

Initiation 

African American Teen 

Cigarette Smoking: A 

Review 

Cornelia Pechmann, Ph.D. 

Associate Professor of 

Marketing 

Graduate School of 

Management 

University of California at 

Irvine 

Irvine, CA 

Joseph R. DiFranza, M.D. 

Professor of Family Health 

and Community Medicine 

University of Massachusetts 

Medical Center 

Worcester, MA 

Frank J. Chaloupka, Ph.D.


Professor 


Department of Economics


University of Illinois at


Chicago


Chicago, IL


Rosalie Liccardo Pacula, 


Ph.D.


Associate Economist


Faculty Research Fellow


The RAND Corporation


Santa Monica, CA


Lois Biener, Ph.D.


Senior Research Fellow


Center for Survey Research


University of Massachusetts


at Boston


Boston, MA


Michael B. Siegel, M.D., 


M.P.H.


Boston University


School of Public Health


Boston, MA


Phillip S. Gardiner, Dr.P.H.


Social and Behavioral 


Sciences Research 


Administrator


ix 
Smoking and Tobacco Control Monograph No. 14 

Chapter 15	 Understanding TobaccoUse Research among 

Hispanic/Latino 

Adolescents: A 

Sociocultural 

Perspective 

Chapter 16	 Asian American and 

Pacific Islander 

Adolescent Cigarette 

Smoking: A Review 

Chapter 17	 American Indian and 

Alaska Native Teen 

Cigarette Smoking: A 

Review 

Office of the President


Tobacco-Related Disease


Research Program


University of California


Oakland, CA


Lourdes Baezconde-


Garbanati, Ph.D., M.P.H., 


M.A.


Research Assistant Professor


Director


Hispanic/Latino Tobacco


Education Network 

University of Southern 

California 

Los Angeles, CA 

Betty M. Hong, M.P.H. 

Asian Pacific Islander 

Tobacco Education Network 

Asian & Pacific Islander 

American Health Forum 

San Francisco, CA 

Felicia Schanche Hodge, 

Dr.P.H. 

Center for American Indian 

Research and Education 

University of California at 

San Francisco 

Berkeley, CA 

x 
Acknowledgements 

The editors are indebted to a number of distinguished scientists, 

researchers, and others in the government, universities, and the private sector who contributed critical reviews during the formation of this final 

monograph. We are also grateful for the guidance and support provided by 

Stephen Marcus, Ph.D., who has been given the responsibility to continue the STCP monograph series in the future. 

Maria G. Carmona


Program Director


Pacific Institute for Research and


Evaluation


Rockville, MD


Jeri Day, M.P.H.


Health Education Consultant


Tobacco Control Section


California Department of Health


Services


Sacramento, CA


Pebbles Fagan, M.P.H., Ph.D.


Health Scientist


Tobacco Control Research Branch


National Cancer Institute


Bethesda, MD


Cathy L. Backinger, M.P.H., Ph.D.


Program Director


Tobacco Control Research Branch


National Cancer Institute


Bethesda, MD


Dileep G. Bal, M.D.


Chief of Cancer Control Branch


California Department of Health


Services


Sacramento, CA


Lester Breslow, M.D., M.P.H.


Professor of Public Health


University of California at Los 


Angeles


Los Angeles, CA


David Cowling


Research Scientist


Tobacco Control Section


California Department of Health


Services


Sacramento, CA


Merrill Eisenberg


Research Specialist


Behavioral Sciences


University of Arizona


Tucson, AZ


Karen K. Gerlach, Ph.D., M.P.H.


Program Officer


Robert Wood Johnson Foundation


Princeton, NJ


Thomas J. Glynn, Ph.D.


Director, Cancer Science and Trends


American Cancer Society


Washington, D.C.


Pamela W. Goslar


Health Program Manager


Tobacco Education and Prevention


Program 

Arizona Department of Health 

Services 

Phoenix, AZ 

Donna Grande


Director, Full Court Press


Full Court Press


Tucson, AZ


xi 
Smoking and Tobacco Control Monograph No. 14 

Ellen R. Gritz, Ph.D.


Professor and Chair


Department of Behavioral Science


University of Texas


Houston, TX


Rosalie Lopez Hirano


Office Chief


Tobacco Education and Prevention


Program 

Arizona Department of Health 

Services 

Phoenix, AZ 

Susanne Hildebrand-Zanki, Ph.D. 

Director of the Tobacco Related 

Disease Research Program 

Office of the President 

University of California 

Oakland, CA 

Thomas P. Houston, M.D. 

Director of The Smokeless States 

National Program Office 

The Smokeless States National 

Program Office


American Medical Association


Chicago, IL


Gerald Kilbert


Administrator


The Healthy Kids Program Office


California Department of Education


Sacramento, CA


Hye-Ryeon Lee


Assistant Research Scientist


Arizona Cancer Center


University of Arizona


Tucson, AZ


Jon C. Lloyd, M.A.


Health Program Policy and 


Development Specialist


Tobacco Control Section


California Department of Health


Services


Sacramento, CA


Jesse N. Nodora, Dr.P.H.


Local Projects Administrator


Tobacco Education and Prevention


Program 

Arizona Department of Health 

Services 

Phoenix, AZ 

Terry F. Pechacek, Ph.D.


Associate Director for Science


Office on Smoking and Health


Centers for Disease Control and


Prevention


Atlanta, GA


Sue Roberts, M.S.


Local Program Evaluation Lead


Tobacco Control Section


California Department of Health


Services


Sacramento, CA


April Roeseler, M.S.P.S.


Chief of Local Programs Unit


Tobacco Control Section


California Department of Health


Services


Sacramento, CA


Carol M. Russell, M.P.H.


Chief of Program Services


Tobacco Control Section


California Department of Health


Services


Sacramento, CA


Colleen Stevens, M.S.W.


Chief of Media Campaign Unit


Tobacco Control Section


California Department of Health


Services


Sacramento, CA


Frances A. Stillman, Ed.D.


Director of the ASSIST Evaluation


Tobacco Control Research Branch


National Cancer Institute


Rockville, MD


xii 
Acknowledgements 

Judith D. Wilkenfeld


Senior Advisor for Tobacco Policies


Food and Drug Administration


Parklawn Building


Rockville, MD


Myra Young


Consultant


The Healthy Kids Program Office


California Department of Education


Sacramento, CA


William Ruppert, M.S.


Health Program Specialist


Tobacco Control Section


California Department of Health


Services


Sacramento, CA


Donald Shopland


Special Expert


Smoking and Tobacco Control


Research Branch


National Cancer Institute


Rockville, MD


Kathryn B. Gower, B.S. 

University of California 

at San Diego 

San Diego, CA 

Maureen Arnn 

University of California 

at San Diego 

San Diego, CA 

Melissa Sage 

University of California 

at San Diego 

San Diego, CA 

In addition, the editors would like to thank the following individuals 

for their input and assistance on the monograph as Senior Reviewers: 

Cheryl L. Perry, Ph.D.


Professor


Division of Epidemiology


School of Public Health


University of Minnesota


Minneapolis, MN


Jean Forster, Ph.D., M.P.H.


Professor


Division of Epidemiology


School of Public Health


University of Minnesota


Minneapolis, MN


John K. Worden, Ph.D.


Research Professor


The University of Vermont


Burlington, VT


Terry F. Pechacek, Ph.D.


Associate Director for Science


Office on Smoking and Health


Centers for Disease Control and 


Prevention


Atlanta, GA


Gary Giovino, Ph.D.


Senior Research Scientist


and Director


Tobacco Control Research Program


Roswell Park Cancer Institute


Buffalo, NY


Gilbert J. Botvin, Ph.D.


Director and Professor


Institute for Preventive Research


Weill Medical College


Cornell University


New York, NY


xiii 
Smoking and Tobacco Control Monograph No. 14 

The editors also acknowledge the following individuals at the Tobacco 

Control Policies Project, University of California at San Diego, San 

Diego, California, for their assistance in the preparation of the monograph: 

Robert W. Davignon, M.S. 

Production Editor 

Christy M. Anderson, B.S. 

Statistician 

Jerry W. Vaughn, B.S. 

Programmer/Analyst 

Sharon Buxton 

Administrative Assistant 

Don F. Harrell 

Administrative Assistant 

Finally, the editors and STCP staff would like to acknowledge the contributions of the following staff members at KBM Group, Inc., Silver Spring, 

Maryland, who provided technical and editorial assistance in the preparation of the monograph: 

Ann L. Kreske, M.S. 

Editor/Graphic Designer 

Brian E. Steyskal, B.S. 

Editor/Graphic Designer 

Heidi S. Volf, B.A. 

Proof Reader/Graphic Designer 

Judith A. O’Neill, B.A. 

Proof Reader 

Yaa Nsia Opare-Phillips, B.S. 

Administrative Assistant 

xiv 
Contents


Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .i 

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v 

Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xv 

Chapter 1: Overview of Recent Changes in Adolescent Smoking 

Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 

Changes in Adolescent Smoking Behavior over Time . . . . . . . . . . . .1 

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 

Chapter 2: Changing Demographic Patterns of Adolescent Smoking 

over the Past 23 Years: National Trends from the Monitoring the 

Future Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 

Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 

Chapter 3: Trends and Subgroup Differences in Tobacco Use among 

High School Students in the United States, 1991-1997 . . . . . . . .35 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 

Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 

Chapter 4: Trends in Adolescent Smoking in the United States: Data 

from the National Household Survey on Drug Abuse, 1994 

Through 1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 

Data Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 

Data Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63 

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67 

Chapter 5: Cigarette Smoking among Adolescents in 

California, 1990-1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 

Definition of Smoking for Adolescents . . . . . . . . . . . . . . . . . . . . . .69 

xv 
Smoking and Tobacco Control Monograph No. 14 

Change in Adolescent Smoking Behaviors, 1990-1998 . . . . . . . . . .70


Predictors of Adolescent Initiation . . . . . . . . . . . . . . . . . . . . . . . . .77


Comparison of California with Other States Using Current


Population Survey Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96


Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100


References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100


Chapter 6: Changing Social Norms to Decrease Adolescent 


Tobacco Use: Massachusetts, 1993-1996 . . . . . . . . . . . . . . . . . . .101


Background and Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101


Trends in Massachusetts and the Nation Prior to MTCP . . . . . . . .102


Trends Since 1993 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103


Changes in Correlates of Smoking: 1993-1996 . . . . . . . . . . . . . . .112


Changes in Lifetime and Current Smoking Associated 


with Correlates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117


Impact of Perceived Increasing Cigarette Prices . . . . . . . . . . . . . .118


Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .119


References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120


Chapter 7: Predictors of Tobacco Use among Adolescents in 


Florida, 1998-1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121


Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121


Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121


Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .122


Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138


References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139


Chapter 8: Changes in Adolescent Smoking Behaviors in 


Sequential Birth Cohorts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .141


Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .141


Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .141


Have Age-Specific Adolescent Initiation Rates 


Changed over Time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .142


Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .153


Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .154


References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155


Chapter 9: Pattern of Adolescent Initiation Rates over Time:


National and California Data . . . . . . . . . . . . . . . . . . . . . . . . . . .157


Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157


Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .158


Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .159


Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .164


References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .170


Chapter 10: Changing Adolescent Smoking Prevalence: Impact 


of Advertising Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . .171


Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .171


Should Antismoking Advertising Be Used for 


Tobacco Use Prevention? . . . . . . . . . . . . . . . . . . . . . . . . . . . .171


xvi

Contents 

How Should Advertising Campaigns Be Designed? . . . . . . . . . . . .177


Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .179


References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .179


Chapter 11: Has Youth Access to Tobacco Changed over the


Past Decade? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .183


Sources of Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .183


Measures of Tobacco Availability . . . . . . . . . . . . . . . . . . . . . . . . .184


Evidence That Availability Affects Use . . . . . . . . . . . . . . . . . . . . .186


Trends in the Availability of Tobacco to Minors . . . . . . . . . . . . . .188


Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189


References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189


Chapter 12: The Impact of Price on Youth Tobacco Use . . . . . . . . .193


Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .193


Prices and Adult Tobacco Use . . . . . . . . . . . . . . . . . . . . . . . . . . . .193


Prices and Youth/Young Adult Smoking . . . . . . . . . . . . . . . . . . . .194


Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .196


Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .198


References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .198


Chapter 13: The Role of Tobacco Advertising and Promotion


in Smoking Initiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .201


Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .201


Tobacco Marketing and Youth Smoking: Evidence for a


Causal Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .201


Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .210


References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .210


Chapter 14: African American Teen Cigarette Smoking:


A Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .213


Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .213


Protective Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .214


An Increase in Risk Factors and a Decline in Protective 


Factors Equals an Increase in African American Teen


Smoking Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .217


Validity of African American Self-Reports About 


Cigarette Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .221


Outstanding Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .222


Key Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .223


References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .223


Chapter 15: Understanding Tobacco-Use Research among 


Hispanic/Latino Adolescents: A Sociocultural Perspective . . . .227


Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .227


A Sociocultural Framework for Hispanic/Latino Adolescent


Tobacco Use Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .229


xvii 
Smoking and Tobacco Control Monograph No. 14 

Environmental Factors: Tobacco Advertising and Promotion . . . .236


Researching Tobacco Use among Hispanic/Latino Adolescents . . .237


References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .239


Chapter 16: Asian American and Pacific Islander Adolescent 


Cigarette Smoking: A Review . . . . . . . . . . . . . . . . . . . . . . . . . . .243


Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .243


Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .243


AAPI Tobacco Research: Epidemiology & Behavioral . . . . . . . . . .245


Factors Affecting AAPI Youth Smoking . . . . . . . . . . . . . . . . . . . . .247


Domestic and International Advertising and Promotion . . . . . . .251


Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .252


References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .252


Chapter 17: American Indian and Alaska Native Teen 


Cigarette Smoking: A Review . . . . . . . . . . . . . . . . . . . . . . . . . . .255


Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .255


Traditional Use of Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .255


Cultural Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .257


Smoking Prevention and Control . . . . . . . . . . . . . . . . . . . . . . . . .258


Policy Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .259


Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .259


References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .260


xviii 
Overview of Recent Changes in 

Adolescent Smoking Behavior 

David M. Burns, Lloyd D. Johnston 

This chapter provides a synopsis and integration of a range of findings 

put forward by the authors of this monograph. The reader is referred to the 

relevant chapters for the complete exposition of the findings, their place in 

the larger literature, and the supporting references. 

INTRODUCTION One principal aim of tobacco control programs is the prevention 

of smoking initiation. Adolescent smoking prevalence peaked during the 

1940s for males and during the early1970s for females. Since the 1940s, 

there has been a substantial decline in smoking prevalence among adolescent males. However, during the 1980s, the decline in prevalence stopped 

and began to level. The decline from the peak prevalence in the 1970s was 

less dramatic among female adolescents than male. During the 1990s, both 

genders experienced an increase in smoking prevalence and smoking rates 

among males and females are now similar. Recent changes in smoking 

behavior have been comprehensively documented in a report by the 

Centers for Disease Control and Prevention (CDC, 2000). 

Data from the Monitoring the Future study (see Chapter 2) show a dramatic increase in adolescent smoking prevalence (Figure 1-1) during the 

1990s, and similar trends have been observed with the Youth Risk Behavior 

Survey (YRBS) (see Chapter 3). The National Household Survey on Drug 

Abuse (NHSDA) showed an increase in the incidence of initiation over the 

same period (see Chapter 4). This volume examines the increases in smoking prevalence, defines the demographic composition and determinants of 

smoking, and identifies some of the approaches to dealing with this public 

health problem. 

CHANGES IN ADOLES- The Monitoring the Future study (Chapter 2) has been 

CENT SMOKING conducted consistently since 1975 and offers the most 

BEHAVIOR OVER TIME complete set of cross-sectional measures of adolescent 

smoking behavior since that time. Figure 1-1 presents trends in prevalence 

of any smoking within the last 30 days from 1975 to 2000 for 12th-grade 

students and from 1991 to 2000 for 8th- and 10th-grade students. The data 

in Figure 1-1 suggest a peak in 12th-grade smoking prevalence in the mid1970s, followed by a short period of decline, then by a 10-year period from 

1980 to 1990, during which prevalence remained level. Beginning in the 

1990s, all three grades showed a nearly simultaneous period of increasing 

current and daily smoking. The smoking prevalence peaked for 8th- and 

10th-grade students in 1996 and for 12th-grade students in 1997. However, 

all grades have shown declines in prevalence over the last few years. These 

national trends are confirmed by data from the BRFS and NHSDA surveys 

(see Chapters 3 and 4). 

1

Smoking and Tobacco Control Monograph No. 14 

Figure 1-1 

Trends in 30-Day Prevalence of Cigarette Smoking for 8th-, 10th-, and 12th-Graders, 

1975-2000 

50 

12th Grade 

8th Grade 

10th Grade 

45 

40 

35 

Percentage 30 

25 

20 

15 

10 

5 

0 

’74’75’76’77’78’79’80’81’82’83’84’85’86’87’88’89’90’91’92’93’94’95’96’97’98’99’00 

Calendar Year 

NOTE: Data from the most recent Monitoring the Future Study was used in this figure. Other sections of this monograph present


older data available at the time the chapters were written.


SOURCE: Monitoring the Future Study, University of Michigan.


It is possible to estimate smoking initiation rates for the years prior to 

the availability of the cross-sectional survey data (i.e., pre-1975) by using 

recall of the age of smoking initiation from surveys of adults (see Chapters 

8 and 9). When gender-specific trends in adolescent smoking initiation over 

the last half-century are examined using this approach (See Chapter 9), 

rates of smoking initiation among adolescent males have decreased significantly since 1940 (Figure 1-2). Adolescent females, who had rates of initiation that were substantially lower than those for adolescent males prior to 

1970, increased their rates of initiation between 1940 and 1960, and then 

their rates declined slightly during the early 1960s. Female adolescents aged 

12-17 sharply increased their rates of initiation following Philip Morris’ 

introduction and marketing of Virginia Slims brand of cigarettes in the late 

1960s. Male and female adolescent initiation rates have been similar since 

the mid-1970s. 

Most of the change in initiation seen over the last several decades can 

be attributed to the changes in rates among older 15- to 17-year-old adolescents, with rates among 12- to 14-year-old adolescents changing much less. 

This rise in adolescent smoking initiation during the late 1960s and early 

1970s is confirmed by examining the age at which first regular smoking 

occurred as reported by 12th-grade students in the Monitoring the Future 

2 study (See Chapter 2). 
Chapter 1 

Figure 1-2 

Incidence of Smoking among 12- to 17-Year-Old Adolescents, 1940-1992 

9 

8 

7 

6 

5 

4 

3 

2 

1 

0 

1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 

Females 

Males 

Year 

National estimates of current smoking within the last 30 days for adolescents have increased between 1991 and 1997 as measured by both the 

Monitoring the Future study (Figure 1-1; see Chapter 2) and the Youth Risk 

Behavior Survey (YRBS), and these trends occurred across all age groups of 

adolescents and in both genders. Recent data suggest that these trends of 

increasing prevalence are reversing (see Figure 1-1), but they remain a critical public health concern. 

Demographic Composition Recent increases in adolescent smoking prevalence 

of the Recent Increase in rates have occurred across all racial and ethnic 

Adolescent Smoking groups, but the magnitude of the changes has not 

Prevalence been uniform. Cross-sectional survey data from the 

Monitoring the Future study (see Chapter 2) show small differences in 

smoking prevalence rates among White, Hispanic, and African American 

12th-grade adolescents in 1976, near the start of the study (Figure 1-3). 

However, during the period of general decline in use (1977–1981), smoking 

prevalence among Africa American and Hispanic 12th-grade students 

declined more than among Whites. Thereafter, through 1992, cigarette 

smoking prevalence rates among Hispanic adolescents remained stable, but 

at lower levels than among Whites. Smoking prevalence rates among 

African American students continued to decline steadily from 1981 to 1992, 

opening a very large differential with White smoking rates and a sizeable 

Initiation Rate (%) 

3

Smoking and Tobacco Control Monograph No. 14 

Figure 1-3 

Trends in 30-Day Prevalence of Cigarette Smoking by Race/Ethnicity for 12th-Graders, 

1975-1998 

50


45


40


35


Hispanic 

Black 

White 

Percentage 30


25


20


15


10


5


0
 ’75’76’77’78’79’80’81’82’83’84’85’86’87’88’89’90’91’92’93’94’95’96’97’98 

Calendar Year 

Source: The Monitoring the Future Study, University of Michigan. 

differential with Hispanic rates. After 1992, all three groups showed some 

increase in smoking, though the increase was smallest among Hispanics. 

There also was a change in smoking prevalence associated with population 

density; the increase in teen smoking prevalence during the 1990s was 

greatest in the non-urban areas. 

These differences in smoking behavior are confirmed by analyses of the 

YRBS data (see Chapter 3) and of the NHSDA data (see Chapter 4). 

Reconstructed initiation rates from the adult Current Population Survey 

(CPS) (see Chapter 9) also suggest that there is a difference between age-specific initiation rates at every age of non-Hispanic White adolescents and 

those of Hispanic and African-American adolescents. 

In contrast to the national data, which show that there has been a clear 

increase in smoking prevalence rates among African American adolescents, 

data from two states with strong tobacco control programs—California and 

Massachusetts (see Chapters 5 and 6, respectively)—show smaller increases 

in smoking prevalence rates. These states also do not show an increase in 

smoking prevalence rates among African American adolescents. In these 

states, the increase in smoking prevalence was most evident among nonHispanic White and Asian adolescents. 4 
Chapter 1 

Other demographic characteristics that are associated with differences 

in adolescent smoking trends are presented and discussed in Chapter 2, 

based on findings from the Monitoring the Future study. However, the 

greatest divergence in trends is that associated with race/ethnicity. 

Changes in the Social Educational aspirations and school performance have long 

Predictors of been established as strong correlates of cigarette smoking 

Adolescent Smoking (Bachman et al., 1978; Johnston, 1973), and they define 

populations of adolescents who have clear differences in smoking prevalence (see Chapter 2). Self-described school performance is strongly correlated with smoking prevalence in the NHSDA (See Chapter 4), and the 

Monitoring the Future study demonstrates a clear difference in smoking 

prevalence between two groups of 12th-grade students with different educational aspirations (see Chapter 2). However, the increase in smoking prevalence that occurred in the mid-1990s was observed in both of these groups 

of 12th-grade students. 

Data from California collected in 1990, 1993, and 1996 demonstrate an 

increase in smoking prevalence among adolescents (see Chapter 5) over this 

interval, and smoking prevalence was strongly associated with self-described 

below-average school performance. However, the prevalence of smoking 

among students with poor school performance did not change between 

1990 and 1996. In contrast, there was an increase in smoking prevalence 

for adolescents who described their school performance as average or above 

average. This suggests that the increase in smoking prevalence in California 

occurred among those same students with whom smoking prevention 

efforts generally have been most successful. Parental smoking and sibling 

smoking were also strongly associated with adolescent smoking. 

Furthermore, the increases in smoking prevalence across the survey years 

occurred among adolescents with and without the influence of parental or 

sibling smoking. 

Examining changes in adolescents’ perception of the number of their 

friends who are smokers offers some insight into the reasons for the 

increase in adolescent prevalence (see Chapter 5). Adolescents who reported 

three or more friends who smoked had a smoking prevalence approximately ten times that of adolescents who reported that none of their friends 

smoked. However, there did not appear to be any increase between 1990 

and 1996 in smoking prevalence within each category of number of friends 

who smoked. For example, the prevalence of smoking went from 4.4 percent in 1990 to 3.8 percent in 1996 among 16- to 17-year-old adolescents 

who had no male friends who smoked and from 41.0 percent in 1990 to 

36.4 percent in 1996 among those who had three or more male friends who 

smoked. This would suggest that the power of perceived adolescent peer 

smoking to predict, and possibly influence, adolescent smoking prevalence 

had not increased between 1990 and 1996. What has changed is the fraction of adolescents who report that multiple friends smoke. For example, 

the percentage of 14- to 15-year-old adolescents who reported that none of 

their male friends smoked declined from 61.7 percent in 1990 to 38.1 per5

Smoking and Tobacco Control Monograph No. 14 

cent in 1996, while the percentage who reported that three or more of their 

male friends smoked increased from 13.1 percent in 1990 to 38.0 percent in 

1996. This increase in reporting friends who smoked between 1990 and 

1996 was evident for all age groups and for both male and female friends; 

and it demonstrates a dramatic rise in adolescents’ perception of the number of their peers and friends who smoke. Part of this change in perception 

is likely to be based on an accurate assessment of the increase in adolescent 

smoking prevalence that has occurred in California between 1993 and 

1996, but the magnitude of the increases in perception of adolescent smoking (a tripling of friends and doubling of peers) is vastly out of proportion 

with the real change in prevalence (from 9.2 percent in 1990 to 12 percent 

in 1996). This suggests that a change may have occurred over this interval 

in the perception of adolescents about how common smoking is among 

their peers. Tobacco industry advertising and promotional efforts may have 

been successful in convincing adolescents that smoking is the norm for 

their peer group, and certainly public health efforts to de-normalize tobacco 

use among adolescents were not successful in altering the perceptions of 

these adolescents. 

Effects of Tobacco Tobacco advertising and promotional activities are an 

Industry Promotional important catalyst in the smoking initiation process. A 

Efforts review of the existing evidence on the relationship 

between exposure to advertising or having a tobacco promotional item and 

smoking behavior (see Chapter 13) suggests that there is a causal relationship between tobacco marketing and smoking initiation. Tobacco advertisements may be particularly attractive to adolescents who are looking for an 

identity similar to that offered by the images in the ads. These are the 

youths who are likely to retain tobacco promotional items, while those 

whose identity needs are met in other ways would likely lose, discard, or 

forget about them. Owning the items offers the opportunity to the vulnerable group to "try on the image of a smoker" (Feighery et al., 1998). Doing so 

is likely part of a longer term process of accepting the image and, eventually, the smoking behavior that goes with it. 

Effects of Counter- In Florida (see Chapter 7), mean scale scores on an index of 

Advertising and receptivity to tobacco company promotions declined by 10 

Other Tobacco percent from 2.0 in 1998 to 1.8 in 1999 among middle 

Control Programs school students in conjunction with a state-wide intensive 

media tobacco-control program. Among high school students, mean scores 

declined by 20 percent from 2.0 in 1998 to 1.6 in 1999. Declines in receptivity were evident (and of similar magnitude) across all racial/ethnic 

groups. Over the same interval, the prevalence of current cigarette use 

declined among middle school students from 18.5 percent in 1998 to 15.0 

percent in 1999, and among high school students, from 27.4 percent in 

1998 to 25.2 percent in 1999. Among middle school students, declines in 

current cigarette use were substantial and significant for both males and 

females. Among high school students, however, the decline was statistically 

significant only among females. Among both middle and high school stu6

Chapter 1 

dents, the declines were most pronounced among non-Hispanic White students. The only difference across the two survey years in the models predicting cigarette use was a small, but statistically significant, decrement in 

the magnitude of the odds ratio for number of friends who smoked cigarettes in 1999 compared to 1998. 

After the passage of Proposition 99 in California in 1988, which 

increased the tax on a pack of cigarettes by 25 cents, initiation rates among 

older Californian boys decreased significantly. In 1991, these rates were significantly lower than initiation rates among boys of the same age in the 

rest of the nation (see Chapter 9). This suggests that early tobacco control 

efforts in California, which were predominantly media intensive, may have 

differentially impacted this age group during the early years of the campaign. There did not appear to be a significant change in smoking initiation 

among Californian girls of any age after the passage of Proposition 99. 

Smoking prevalence among adolescents increased between 1990 and 1996 

in California, but the magnitude of the increase was proportionately less 

than that for the nation as a whole. 

A similar effect was observed in Massachusetts (see Chapter 6), where 

smoking rates for youths remained flat between 1993 and 1996, in contrast 

to the increase nationally. It is postulated that a large cohort of junior high 

school smokers advancing into high school may have overwhelmed a prevention program in Massachusetts based on de-normalization of smoking 

in junior high school. What is promising is that whatever pressure this 

smoking cohort might have exerted on younger students appears to have 

been mitigated by the tobacco control work in Massachusetts. The data are 

consistent with effectiveness of the Massachusetts tobacco control program 

in changing social norms and are supportive of behavior change in younger 

grades, among males, among African Americans, and possibly among girls. 

All grades showed increases from 1993 to 1996 in the proportion reporting 

that many of their friends disapprove of smoking. This is consistent with 

success in changing social norms, even if mitigated somewhat by a reduction in those reporting that all friends disapprove of smoking. 

There is evidence that antismoking advertising can help to deter adolescents from smoking cigarettes, but, to date, the evidence is indirect. 

Research suggests that certain types of advertising messages work better 

than others. According to Pechmann and Goldberg’s (1998) findings, three 

of the seven message types tested were efficacious in terms of reducing adolescents’ intent to smoke: One of the negative consequences messages 

(Endangers Family) and both of the normative information messages 

(Negative Smoker Role Models, Positive Nonsmoker Role Models). Based on 

these findings, at least, it appears that antismoking messages that are directed at adolescents should focus on smoking’s negative consequences on family members and on smoking-related norms. 

Research clearly indicates that tobacco control interventions conducted 

at the macro level can be very effective in reducing cigarette smoking 

among adolescents. In particular, these include increased tobacco taxation 

and stronger tobacco control policies. 

7 
Smoking and Tobacco Control Monograph No. 14 

CONCLUSIONS 

1. Cigarette smoking prevalence among adolescents increased during 

much of the 1990s, but more recently began to decline. The increase in 

smoking prevalence occurred across all racial and ethnic groups, but 

appears to have been somewhat lower among female, Hispanic, and African 

American adolescents. 

2. The increase in smoking prevalence was accompanied by an increase 

in the fraction of adolescents reporting that their friends smoked, and this 

may indicate a re-normalization of tobacco use among adolescents. 

3. Evidence on the relationship between exposure to advertising or having a tobacco promotional item and smoking behavior suggests that there is 

a causal relationship between tobacco marketing and smoking initiation. 

4. Tobacco control interventions conducted at the macro level can be 

very effective in reducing cigarette smoking among adolescents. 

REFERENCES 

Bachman, J.G., O’Malley, P.M., Johnston, J. Youth in 

Transition: Volume VI. Adolescence to Adulthood: 

Change and Stability in the Lives of Young Men. 

Ann Arbor, MI: Institute for Social Research, 

1978. 

Centers for Disease Control and Prevention. Youth 

Tobacco Surveillance—United States, 1998–1999. 

CDC Surveillance Summaries (October 13). 

Morbidity and Mortality Weekly Reports 49(SS10):1-94, 2000. 

Feighery, E., Borzekowski, D.L., Schooler, C., Flora, J. 

Seeing, wanting, owning: The relationship 

between receptivity to tobacco marketing and 

smoking susceptibility in young people. Tobacco 

Control 7(2):123-128, 1998. 

Johnston, L.D. Drugs and American Youth. Ann Arbor, 

MI: Institute for Social Research, 1973. 

Pechmann, C., Goldberg, M. Evaluation of ad strategies for preventing youth tobacco use. In: Report 

submitted to the California Tobacco Related 

Disease Research Program, 1998. 

8

Changing Demographic Patterns of 

Adolescent Smoking over the Past 23 

Years: National Trends from the 

Monitoring the Future Study 

Lloyd D. Johnston 

INTRODUCTION Over the past quarter century, some important changes have 

occurred in the levels and patterns of cigarette smoking by American young 

people. Given the known consequences of smoking for morbidity and mortality rates (NCI, 1997) and the enduring nature of smoking habits established during adolescence (Burns et al., 1997; O’Malley et al., 1988), changes 

in smoking behaviors carry extraordinary implications for the health and 

longevity of these cohorts of youngsters throughout their lives. In this 

chapter, the overall trends in adolescent smoking for the period of 1975 to 

1998—as well as differential trends for a number of key demographic subgroups—are documented and discussed. Changes in transition rates over 

the same period are also considered. 

METHODS The data presented here all derive from the Monitoring the Future (MTF) 

study, which has been conducted by the author and his colleagues at the 

University of Michigan since 1975. Funded by the National Institute on 

Drug Abuse, MTF tracks and studies young people’s use of many substances, 

ranging from tobacco to heroin (Johnston et al., 1998). Because the study 

uses a cohort-sequential design in which each graduating class of high 

school seniors is followed in a panel study for many years past graduation, 

it can address a wide range of research questions (Johnston et al., 1996). 

The present chapter draws upon the cross-sectional data gathered annually from sequential graduating classes of 12th graders since 1975. The 

chapter will also draw upon data gathered from sequential classes of 8th 

and 10th graders since 1991, when these two lower grade levels were added 

to the study’s design. 

Samples Each year, a large, nationally representative sample of students in public 

and private schools within the coterminous United States is separately 

drawn for each of the grade levels (8, 10, and 12). The sample sizes usually 

range from 16,000 to 18,000 students per grade, with students coming from 

125 to 160 schools at each grade level. Nonparticipating schools are 

replaced in the sample, but students absent on the day of the administration are excluded since no make-up administrations are given. Usually, 9 to 

17 percent of students are absent on the day of the administration. 

9 
Smoking and Tobacco Control Monograph No. 14 

A three-stage stratified random sampling procedure is used. The first 

stage is the selection of primary sampling units (PSUs), which are counties 

and/or communities selected by the University of Michigan’s Survey 

Research Center Sampling Section to be included in the study. These counties and/or communities contain populations that are highly representative 

of the nation as a whole. The second stage is the random selection of 

schools from a listing of all schools in each PSU, taken with probability proportionate to their estimated size. Schools are invited to participate for a 

period of 2 years, so a half-sample, which is in itself drawn to be nationally 

representative, is entering the sample each year. The third stage is the random selection of classrooms within each school, which is done only in 

those schools for which subsampling is indicated (usually those containing 

more than 300 students in the grade). 

Field Procedures On a mutually agreed-upon day in the spring, University of 

Michigan staff members go to each selected school to conduct the data collection. Self-administered questionnaires are distributed to the students, 

usually in their normal classrooms during a normal class period. Class periods last approximately 45 minutes. The confidential questionnaires, of 

which there are multiple forms, are randomly distributed to individuals. 

These questionnaires, most of which are 12 pages in length, are self-administered and are answered in optically scannable booklets. 

The questionnaires are completed by the students and collected by the 

University of Michigan staff members, who immediately remove the booklets from the schools and ship them to a central location for optical scanning. The data are cleaned and edited, and cases with high levels of inconsistency and/or improbably high rates of reported drug use are deleted. 

Measures Most of the measures reported in this chapter, all of which are contained in all of the questionnaire forms, are based on self-reported data 

from students. The regions wherein the study is conducted and their population sizes are both derived from census categorization (more detail on the 

measures may be found in Johnston et al., 1997 & 1998). 

Cigarette smoking is among the various measures of the study. Cigarette 

smoking is measured with two questions. The first, “Have you ever smoked 

cigarettes?” is used to determine lifetime smoking prevalence (i.e., one or 

more cigarettes ever smoked). It is also used to determine the prevalence of 

having ever smoked regularly, which is defined as the proportion of respondents who answer “regularly in the past” or “regularly now.” The other 

question asked is “How frequently have you smoked cigarettes in the past 

30 days?” This question is used to determine the prevalence and frequency 

of current smoking (“past 30 days”), the prevalence of “current daily” 

smoking (one or more cigarettes per day during the past 30 days), and the 

prevalence of “current half-pack a day” smoking. In the present chapter, 

emphasis is given to the prevalence of any cigarette smoking in the past 30 

days (“current smoking”) and to the prevalence of daily cigarette smoking 

in the past 30 days (“current daily” smoking). 

10

Chapter 2 

Among the demographic and other characteristics to be discussed here 

are gender, college plans, socioeconomic level of the parents (as measured 

by their average education level), region, population density, and racial/ethnic identity. 

• Gender is self-reported. 

• College plans are measured by the question “How likely is it that 

you will do each of the following things?” One of the choices given 

is “Graduate from college (four-year program).” Those who respond 

to this choice with “probably will” or “definitely will” are considered to be college-bound. 

• Parental education is measured as the mean of two identical questions. One question asks for the highest level of education obtained 

by the mother and the other asks for that obtained by the father. 

Stepparents and foster parents can be substituted for natural parents, where appropriate, and one missing data case is allowed. 

• Race/ethnicity is measured by the answer to a single question: “How 

do you describe yourself?” Because of limited sample sizes for most 

minority groups, the only data presented here are from those identifying themselves as “White (Caucasian),” as “Black or AfricanAmerican,” or as any one of four categories of Hispanics. 

It should be noted that, over the life of the study, high priority has 

been given to keeping the method and measures constant, so that observed 

shifts in outcomes will not be caused by method artifacts. 

In general, measures of substance use, including smoking, have shown 

high levels of reliability. Smoking measures, in particular, have shown a 

high level of stability across the years (O’Malley et al., 1983). Good evidence of the validity of these measures also exists (see Johnston et al., 

1998). 

RESULTS Table 2-1 presents the data on the smoking trends observed over the life 

of the study for 8th-, 10th-, and 12th-grade students. Note that data are 

only available from 1991 to 1998 for the 8th and 10th grades, but are available from 1975 to 1998 for 12th grade—a 23-year span. Because of the 

longer span covered, emphasis will be given here to the 12th-grade data, 

though the relevant tabular data are included here for the lower two grades 

as well. 

Overall Trends The reader is reminded that “cohort effects” (lasting differences 

across age between different birth or class cohorts) have generally predominated over period effects (differences defined by the calendar year in which 

they occur) in explaining smoking (Burns et al., 1997; O’Malley et al., 

1988). Therefore, what we observe to be happening among 12th graders 

during a given historical period may be an “echo” of changes first observable among those same cohorts at earlier ages and, therefore, in a prior historical period. For example, Figure 2-1 gives trends in lifetime prevalence of 

cigarette use for various grade levels using the retrospective grade-of-firstuse data from each of the 12th-grade classes. It shows that the downturn in 

smoking observed among 12th graders in the years 1977-1981 was actually 

observable in earlier time periods, when those same students 

were in lower grades. 11 
12 Table 2-1 

Long-Term Trends in Prevalence of Cigarettes for Eighth, Tenth, and Twelfth Graders 

Year 

Grade Level 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 Lifetime 

8th Grade — — — — — — — — — — — — 10th Grade — — — — — — — — — — — — 12th Grade 73.6 75.4 75.7 75.3 74 71 71 70.1 70.6 69.7 68.8 67.6 

Thirty-Day 

8th Grade — — — — — — — — — — — — 10th Grade — — — — — — — — — — — — 12th Grade 36.7 38.8 38.4 36.7 34.4 30.5 29.4 30 30.3 29.3 30.1 29.6 

Daily 

8th Grade — — — — — — — — — — — — 10th Grade — — — — — — — — — — — — 12th Grade 26.9 28.8 28.8 27.5 25.4 21.3 20.3 21.1 21.2 18.7 19.5 18.7 

1/2 Pack+ per Day 

8th Grade — — — — — — — — — — — — 10th Grade — — — — — — — — — — — — 12th Grade 17.9 19.2 19.4 18.8 16.5 14.3 13.5 14.2 13.8 12.3 12.5 11.4 

Approx. N’s 

8th Grade — — — — — — — — — — — — 

10th Grade — — — — — — — — — — — — 12th Grade 9,400 15,400 17,100 17,800 15,500 15,900 17,500 17,700 16,300 15,900 16,000 15,200 
Table 2-1 (continued) 

Year Change 

Grade Level 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1997–Lifetime 

8th Grade — — — — 44 45.2 45.3 46.1 46.4 49.2 47.3 45.7 –110th Grade — — — — 55.1 53.5 56.3 56.9 57.6 61.2 60.2 57.7 –2

12th Grade 67.2 66.4 65.7 64.4 63.1 61.8 61.9 62 64.2 63.5 65.4 65.3 –0

Thirty-Day 

8th Grade — — — — 14.3 15.5 16.7 18.6 19.1 21 19.4 19.1 –010th Grade — — — — 20.8 21.5 24.7 25.4 27.9 30.4 29.8 27.6 –2

12th Grade 29.4 28.7 28.6 29.4 28.3 27.8 29.9 31.2 33.5 34 36.5 35.1 –1

Daily 

8th Grade — — — — 7.2 7 8.3 8.8 9.3 10.4 9 8.8 –010th Grade — — — — 12.6 12.3 14.2 14.6 16.3 18.3 18 15.8 –2

12th Grade 18.7 18.1 18.9 19.1 18.5 17.2 19 19.4 21.6 22.2 24.6 22.4 –2

1/2 Pack+ per Day 

8th Grade — — — — 3.1 2.9 3.5 3.6 3.4 4.3 3.5 3.6 0

10th Grade — — — — 6.5 6 7 7.6 8.3 9.4 8.6 7.9 –012th Grade 11.4 10.6 11.2 11.3 10.7 10 10.9 11.2 12.4 13 14.3 12.6 –1

Approx. N’s 

8th Grade — — — — 17,500 18,600 18,300 17,300 17,500 17,800 18,600 18,100 

10th Grade — — — — 14,800 14,800 15,300 15,800 17,000 15,600 15,500 15,000 

12th Grade 16,300 16,300 16,700 15,200 15,000 15,800 16,300 15,400 15,400 14,300 15,400 15,200 

Note: Level of significance of difference between the 2 years indicated: * = 0.05, ** = 0.01, *** = 0.001. 

Source: The Monitoring the Future Study, University of Michigan. 

13 
14 Figure 2-1 

Percentage of Cigarette Smoking on a Daily Basis: Trends in Lifetime Prevalence for Earlier Grade Levels (Based on Retrospective Reports from 12th Graders) 

35


12th Grade 

11th Grade 

10th Grade 

9th Grade 

8th Grade 

6th Grade 

Percentage who Used, by Grade Indicated 30
 25
 20
 15
 10


5
0


’69 ’71 ’73 ’75 ’77 ’79 ’81 ’83 ’85 ’87 ’89 ’91 ’93 ’95 ’97 

Calendar Year 

SOURCE: The Monitoring the Future Study, University of Michigan. 
Chapter 2 

Figure 2-2 

Trends in 30-Day Prevalence of Cigarette Smoking for 8th, 10th, and 12th Graders 

50 

40 

30 

20 

10 

0 

12th Grade 

10th Grade 

8th Grade 

’75 ’76 ’77 ’78 ’79 ’80 ’81 ’82 ’83 ’84 ’85 ’86 ’87 ’88 ’89 ’90 ’91 ’92 ’93 ’94 ’95 ’96 ’97 ’98 

Calendar Year 

SOURCE: The Monitoring the Future Study, University of Michigan. 

The data in Figure 2-1 show that an increase in youth smoking initiation was occurring in the 1970s (and possibly earlier); the increase was followed by a period of decline, and then a long period in which initiation 

rates, as well as current smoking rates, remained level (Figure 2-2). 

Beginning in the 1990s, however, all three grades showed a nearly simultaneous period of increasing current and daily smoking rates (though the 

12th graders were 1 year later than the lower grades in turning up and, subsequently, in turning down). This nearly simultaneous movement suggests 

that a “period effect” occurred in the 1990s in addition to the more usual 

cohort and age effects. Furthermore, virtually all demographic subgroups 

exhibited this upturn (Tables 2-2 and 2-3). It has been suggested that these 

facts in combination imply that contemporaneous culture-wide forces were 

at work. Among the most plausible possibilities are 1) changes in the quantity and the quality (more youth-oriented) of cigarette advertising and promotion, 2) growing exposure of youths to smoking by popular role models 

in movies and television (both on and off screen), and 3) a decline in the 

price of cigarettes. 

After a substantial and proportional increase in smoking rates among all 

three grades during the early and mid-1990s, evidence of a turnaround 

began to appear in 1997 (for the 8th and 10th graders) and in 1998 (for the 

12th graders) and rates began to decline. It is suspected that the extensive 

adverse publicity associated with the emerging tobacco settlement and the 

Congressional and Administration debate over that settlement played an 

important role in bringing about this modest turnaround. If so, the nascent 

decline may not be one that continues, since the public debate has now 

subsided considerably. 

Percentage 

15

Smoking and Tobacco Control Monograph No. 14 

Table 2-2 

Cigarettes: Trends in 30-Day Prevalence of Use by Subgroups for Eighth and Tenth Graders 

Percentage of 8th Graders Who Used in the Last 30 Days 

Class of: 1991 1992 1993 1994 1995 1996 1997 1998 Change 

Approx . N: 17,500 18,600 18,300 17,300 17,500 17,800 18,600 18,100 1997–1998 

Total 14.3 15.5 16.7 18.6 19.1 21.0 19.4 19.1 –0.3 

Sex 

Male 15.5 14.9 17.2 19.3 18.8 20.6 19.1 18.0 –1.1 

Female 13.1 15.9 16.3 17.9 19.0 21.1 19.5 19.8 0.3 

College Plans 

0 or <4 Years 29.2 31.9 34.1 36.6 36.5 39.2 40.0 40.1 0.1 

4-Year Degree 11.8 13.1 14.3 16.1 16.8 18.2 16.9 16.5 –0.4 

Region 

Northeast 13.7 14.4 15.0 17.8 18.6 22.1 18.0 15.6 –2.4 

North Central 15.5 16.5 16.3 18.5 20.9 23.2 20.0 22.3 2.3 

South 15.7 17.0 18.2 19.5 19.4 21.1 21.0 21.1 0.1 

West 10.0 12.2 16.4 18.0 16.5 17.1 17.1 15.1 –2.0 

Population Density 

Large MSA 12.8 15.0 14.1 15.5 16.5 19.4 15.8 16.4 0.6 

Other MSA 14.9 15.3 17.8 20.7 19.4 21.4 19.7 17.7 –2.0 

Non-MSA 14.8 16.4 17.9 17.8 21.5 22.1 22.8 24.8 2.0 

Parental Educationa 

1.0–2.0 (Low) 26.2 24.1 23.3 26.1 25.3 26.5 26.9 26.7 –0.2 

2.5–3.0 16.4 16.9 19.8 20.6 22.7 24.4 22.4 23.9 1.5 

3.5–4.0 13.9 14.9 17.4 20.1 20.8 21.4 20.9 21.4 0.5 

4.5–5.0 10.1 13.3 12.5 14.9 14.9 18.4 16.2 14.2 –2.0 

5.5–6.0 (High) 11.3 11.5 13.3 15.1 14.5 17.3 15.3 13.8 –1.5 

Race (2-yr avg.)b 

White — 16.2 17.8 18.9 20.7 22.7 22.8 21.5 –1.3 

Black — 5.3 6.6 8.7 8.9 9.6 10.9 10.6 –0.3 

Hispanic — 16.7 18.3 21.3 21.6 19.6 19.1 20.1 1.0 

16

Chapter 2 

Table 2-2 (continued) 

Percentage of 10th Graders Who Used in the Last 30 Days 

Class of: 1991 1992 1993 1994 1995 1996 1997 1998 Change 

Approx. N: 14,800 14,800 15,300 15,800 17,000 15,600 15,500 15,000 1997–1998 

Total 20.8 21.5 24.7 25.4 27.9 30.4 29.8 27.6 –2.2* 

Sex 

Male 20.8 20.6 24.6 26.6 27.7 30.1 28.2 26.2 –2.0 

Female 20.7 22.2 24.5 23.9 27.9 30.8 31.1 29.1 –2.0 

College Plans 

0 or <4 Years 36.5 35.0 41.9 42.2 46.3 46.2 47.2 45.2 –2.0 

4-Year Degree 17.3 18.6 21.0 21.7 24.7 27.8 26.8 24.5 –2.3 * 

Region 

Northeast 22.4 21.9 27.1 24.5 27.8 31.7 29.3 30.1 0.8 

North Central 22.9 24.3 26.0 28.8 30.1 32.5 31.7 29.5 –2.2 

South 21.2 19.8 24.0 25.7 30.8 33.4 32.2 29.8 –2.4 

West 16.7 20.2 21.2 20.1 19.6 20.8 23.2 19.6 –3.6 

Population Density 

Large MSA 19.7 21.6 22.5 22.3 23.3 26.2 26.6 22.5 –4.1 * 

Other MSA 20.3 20.3 23.8 26.3 28.9 31.1 28.9 26.6 –2.3 

Non-MSA 22.7 23.7 28.2 26.7 31.3 33.9 34.9 35.7 0.8 

Parental Educationa 

1.0–2.0 (Low) 23.5 28.4 29.5 26.4 30.9 28.7 28.2 28.0 –0.2 

2.5–3.0 24.1 23.3 28.0 29.1 33.2 33.8 33.2 33.0 –0.2 

3.5–4.0 20.4 20.6 24.8 26.0 27.8 31.6 30.9 27.3 –3.6 * 

4.5–5.0 18.5 19.5 20.1 22.6 25.9 28.7 28.5 25.7 –2.8 

5.5–6.0 (High) 18.5 18.9 21.4 20.7 21.8 27.8 24.6 22.5 –2.1 

Race (2-yr avg.)b 

White — 24.1 26.0 27.8 29.7 32.9 34.4 33.2 –1.2 

Black — 6.6 7.5 9.8 11.5 12.2 12.8 13.7 0.9 

Hispanic — 18.3 20.5 19.4 21.4 23.7 23.0 21.3 –1.7 

* = 0.05 Level of significance of difference between the two most recent classes: 

— 	indicates data not available. See Table D-43 for the number of subgroup cases and 

Appendix B for definition of variables in Johnston, O’Malley, and Bachman (1998), 

National Survey Results on Drug Use from the Monitoring the Future Study, 1975–1998, 

Volume I: Secondary School Students. Rockville, MD: National Institute on Drug Abuse. aParental education is an average score of mother’s education and father’s education. bTo derive percentages for each racial subgroup, data for the specified year and the previous 

year have been combined to increase subgroup sample sizes and thus provide more 

stable estimates. 

Source: The Monitoring the Future Study, University of Michigan. 

17

18 Table 2-3. Cigarettes: Trends in 30-Day Prevalence of Use by Subgroups for Twelfth Graders 

Percentage Who Used in the Last 30 Days 

Class of: 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 

Approx. N: 9,400 15,400 17,100 17,800 15,500 15,900 17,500 17,700 16,300 15,900 16,000 15,200 

Total 36.7 38.8 38.4 36.7 34.4 30.5 29.4 30.0 30.3 29.3 30.1 29.6 Sex 

Male 37.2 37.7 36.6 34.5 31.2 26.8 26.5 26.8 28.0 25.9 28.2 27.9 Female 35.9 39.1 39.6 38.1 37.1 33.4 31.6 32.6 31.6 31.9 31.4 30.6 

College Plans 

0 or <4 Years — 46.3 46.2 44.6 43.0 39.6 38.1 38.7 38.0 37.9 40.5 38.5 4-Year Degree — 29.8 29.4 27.4 26.0 22.3 22.3 22.1 23.3 22.7 22.8 24.0 

Region 

Northeast 40.1 41.8 43.0 40.6 37.0 34.1 31.5 32.1 34.6 33.5 34.2 35.2 

North Central 39.5 41.3 40.5 39.0 36.6 31.5 32.4 33.5 33.2 31.4 34.1 32.5 

South 36.2 39.1 37.6 35.7 35.4 31.8 28.9 29.4 28.7 28.6 25.6 26.1 

West 26.3 28.3 27.7 27.3 24.8 21.2 21.8 20.4 21.8 22.9 26.3 23.3 

Population Density 

Large MSA 39.7 40.4 40.9 37.5 33.4 31.2 30.6 32.1 30.8 31.3 31.9 30.8 Other MSA 35.1 35.9 36.1 34.3 33.5 29.7 27.4 27.8 29.1 28.2 28.5 28.0 Non-MSA 36.7 40.9 39.2 39.4 36.4 30.9 30.9 31.2 31.5 29.3 30.8 31.0 

Parental Educationa 

1.0–2.0 (Low) 37.2 43.2 39.6 38.1 38.1 32.7 32.5 32.6 32.7 33.6 32.3 28.6 2.5–3.0 37.0 41.2 40.8 39.3 35.9 34.2 31.7 32.0 32.2 31.8 32.3 32.3 3.5–4.0 31.9 35.3 37.3 34.0 33.3 28.0 28.2 29.0 28.0 28.1 29.7 29.7 4.5–5.0 32.3 35.0 33.0 32.6 30.1 25.7 26.0 25.5 27.8 25.2 27.7 26.4 5.5–6.0 (High) 26.8 30.8 32.8 31.9 29.6 24.0 22.5 25.1 25.5 23.7 22.6 26.7 

Race (2-yr avg.)b 

White — — 38.3 37.6 36.0 33.0 30.5 30.7 31.3 31.2 31.3 31.9 

Black — — 36.7 32.7 30.2 26.8 23.7 21.8 21.2 19.3 18.1 16.9 Hispanic — — 35.7 32.8 26.8 22.6 23.2 24.7 24.7 25.3 25.5 23.7 
Table 2-3 (continued) 

Percentage Who Used in the Last 30 Days 

Class of: 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 

Approx. N: 16,300 16,300 16,700 15,200 15,000 15,800 16,300 15,400 15,400 14,300 15,400 15,200 1

Total 29.4 28.7 28.6 29.4 28.3 27.8 29.9 31.2 33.5 34.0 36.5 35.1 

Sex 

Male 27.0 28.0 27.7 29.1 29.0 29.2 30.7 32.9 34.5 34.9 37.3 36.3 Female 31.4 28.9 29.0 29.2 27.5 26.1 28.7 29.2 32.0 32.4 35.2 33.3 

College Plans 

0 or <4 Years 39.7 37.5 38.0 37.5 38.1 38.6 37.3 40.9 43.5 45.0 45.7 46.7 4-Year Degree 24.3 24.4 24.1 25.4 24.2 23.8 27.3 28.0 29.9 30.8 33.1 31.3 

Region 

Northeast 34.1 31.2 29.4 31.9 30.5 29.6 34.2 33.2 34.4 38.5 40.6 35.9 North Central 31.7 31.1 34.9 34.0 34.6 31.7 33.2 36.2 37.8 37.7 39.3 40.0 South 26.0 28.0 26.4 26.1 25.4 26.4 29.0 30.7 33.5 33.2 35.0 34.3 

West 26.6 23.9 22.7 25.1 23.2 22.8 22.9 24.0 26.5 24.4 30.5 29.1 

Population Density 

Large MSA 29.3 26.9 25.9 27.9 26.2 25.6 29.5 29.0 33.9 32.1 34.9 32.9 Other MSA 28.2 28.3 28.2 29.6 29.3 26.9 29.8 31.1 31.7 32.6 35.7 34.2 Non-MSA 31.8 31.4 32.2 30.4 28.6 31.5 30.3 33.8 36.2 38.2 40.0 39.7 

Parental Education 

1.0-2.0 (Low) 28.8 28.1 25.4 26.3 31.3 27.1 26.5 26.2 31.2 31.5 31.2 32.3 

2.5-3.0 31.4 29.9 30.8 30.8 28.7 30.3 30.4 32.8 35.0 35.5 36.5 36.0 

3.5-4.0 28.8 27.8 29.4 29.3 28.4 27.8 29.9 31.4 33.2 33.2 35.6 36.7 

4.5-5.0 27.6 28.6 27.0 29.1 26.9 25.8 30.1 32.0 32.6 34.5 37.5 34.2 

5.5-6.0 (High) 29.3 27.8 26.3 28.6 27.1 25.5 30.5 30.4 34.0 32.9 38.5 33.1 

Race (2-yr avg.) 

White 32.1 32.2 32.2 32.3 32.2 31.8 33.2 35.2 36.6 38.1 40.7 41.7 

Black 14.2 13.3 12.6 12.2 10.6 8.7 9.5 10.9 12.9 14.2 14.3 14.9 

Hispanic 22.7 21.9 20.6 21.7 24.0 25.0 24.2 23.6 25.1 25.4 25.9 26.6 

19 

Level of significance of difference between the two most recent classes: * = 0.05, ** = 0.01, *** = 0.001. “


“—” indicates data not available.


See Johnston et al., 1998, Table D-44 for the number of sub group cases and Johnston et al., 1998, Appendix B for definition of variables.


Source: The Monitoring the Future Study, the University of Michigan.


aParental education is an average score of mother’s education and father’s education.
bTo derive percentages for each racial subgroup, data for the specified year and the previous year have been combined to increase subgroup sample sizes and thus 

stable estimates. 
Smoking and Tobacco Control Monograph No. 14 

Figure 2-3 

Trends in 30-Day Prevalence of Cigarette Smoking by Gender for 12th Graders 

50


45


40


Females 

Males 

Percentage 35


30


25


20


15


10


’75’76’77’78’79’80’81’82’83’84’85’86’87’88’89’90’91’92’93’94’95’96’97’98 

Calendar Year 

SOURCE: The Monitoring the Future Study, University of Michigan. 

Gender Differences Before this study was launched in 1975, earlier studies had 

shown that males tended to have higher rates of smoking than females 

(U.S. DHHS, 1994). However, by 1976, females not only caught up to their 

male counterparts in 12th grade, but also attained a higher 30-day prevalence of smoking for some years thereafter (Figure 2-3). By 1990, however, 

males closed the gap and have been slightly more likely to smoke than 

females in the years since. Because a slightly higher proportion of male current smokers smoke at the “half-pack-a-day” level, there was practically no 

gender difference in that measure in the years of 1979-1990, after which 

period the “half-pack-a-day” smoking level for males in the 12th grade 

exceeded that for females in the same grade. 

Differences by Region There have been some consistent, long-term differences in 

student smoking rates across the four major census regions. As Figure 2-4 

illustrates, the West consistently has had the lowest rate of smoking, at least 

as far back as 1975. The Northeast and North Central generally have had 

the highest (and roughly equivalent) rates. The South has tended to fall in 

the middle. However, the South showed the greatest decline in smoking 

rates in the first part of this 23-year study, and then the greatest increase 

from 1985 to 1997, thus bringing its smoking rates close to the levels 

observed in the Northeast and North Central. 

20 
Chapter 2 

Figure 2-4 

Trends in 30-Day Prevalence of Cigarette Smoking by Region for 12th Graders 

50 

45 

40 

35 

30 

25 

20 

15 

10 

’75’76’77’78’79’80’81’82’83’84’85’86’87’88’89’90’91’92’93’94’95’96’97’98 

West 

South 

North Central 

Northeast 

Calendar Year 

SOURCE: The Monitoring the Future Study, University of Michigan. 

It should be noted that, over this 23-year interval, the proportion of the 

sample coming from each of the four regions has changed somewhat. In 

proportion to the total sample size, the South has shown the most growth, 

followed by the West, while the Northeast and North Central have both 

declined by roughly three percentage points each. Insofar as regional differences reflect cultural differences, this geographical redistribution of the 

population could be having subtle effects on the smoking rates. 

Differences by Three broad levels of population density have been distinPopulation Density guished for these analyses: self-representing metropolitan statistical areas, or “large MSAs” (currently, the 16 largest cities); “other MSAs” 

as defined by the Census; and non-metropolitan areas (“non-MSAs”). As 

Figure 2-5 shows, there were no very great differences in 30-day smoking 

prevalence among these three strata from 1975 to 1993, although the areas 

categorized as “other MSAs” tended to have slightly lower than average 

rates for much of that time period. After 1993, the increase in smoking rates 

was sharpest in the non-metropolitan (“non-MSA”) stratum; by the late 

1990s, this stratum had the highest smoking rate. A similar divergent 

change can be seen at grades 8 and 10 as well (see Table 2-2). 

Percentage 

21

Smoking and Tobacco Control Monograph No. 14 

Figure 2-5 

Trends in 30-Day Prevalence of Cigarette Smoking by Population Density for 12th 

Graders 

50 

45 

40 

35 

30 

25 

20 

15 

10 

’75’76’77’78’79’80’81’82’83’84’85’86’87’88’89’90’91’92’93’94’95’96’97’98 

Non-MSA 

Other MSA 

Large MSA 

Calendar Year 

NOTE: Census categories: Large MSA = 18 largest Standard Metropolitan Areas, Other MSA = all other Metropolitan Statistical 

Areas, Non-MSA = areas not designated as Metropolitan Statistical Areas 

SOURCE: The Monitoring the Future Study, University of Michigan. 

Over the 23-year life of the study, the proportion of the national sample 

coming from non-metropolitan areas has declined considerably, by about 7 

to 10 percentage points. This reflects the continuation of longer term trends 

in migration to urban areas. 

Differences by In recent years, perhaps the most dramatic differences in trends 

Race/Ethnicity in youth smoking associated with demographic subgroups have 

occurred in relation to the dimension of race/ethnicity. Figure 2-6 and Table 

2-3 show that there was little difference in smoking rates in 1976 among 

Whites, Hispanics, and African Americans. However, during the period of 

general decline in tobacco use (1977–1981), smoking rates among Blacks 

and Hispanics declined more than among Whites. Thereafter, the smoking 

rates of Hispanics moved more or less in parallel with those of Whites; that 

is, their use stayed stable, although at somewhat lower levels, through 

1992. However, smoking rates among African American students continued 

to decline steadily from 1981 to 19921, opening a very large differential 

Percentage 

1. Note that a 2-year moving average has been presented here for the three racial/ethnic 

groups in order to smooth out some of the random fluctuations that result from the limited 

annual sample sizes for the two minority groups. 

22

Chapter 2 

Figure 2-6 

Trends in 30-Day Prevalence of Cigarette Smoking by Race/Ethnicity for 12th Graders 

45 

40 

35 

30 

25 

20 

15 

10 

5 

’75’76’77’78’79’80’81’82’83’84’85’86’87’88’89’90’91’92’93’94’95’96’97’98 

Hispanic 

Black 

White 

Calendar Year 

SOURCE: The Monitoring the Future Study, University of Michigan. 

with the smoking rates of Whites and a sizeable differential with Hispanic 

smoking rates. After 1992, all three racial/ethnic groups showed some 

increase in smoking rates, though the increase was least among Hispanics. 

As a proportion of the national sample of 12th-grade students, the 

Hispanic population has grown considerably over the 23-year interval (by 

roughly 8 percentage points), the Black population has grown modestly (by 

about 2 percentage points), and the White population has declined substantially (by about 10 percentage points). Had these changes in ethnic composition not been taking place, one might have expected somewhat more of 

an increase in the overall smoking rates than was actually observed (since 

the two minority groups generally have lower smoking rates than Whites). 

It is possible, therefore, that this change in the ethnic composition of the 

population masked some of the effects of other cultural forces that were 

leading to increased smoking rates among youths. 

Differences Associated Over the life of the study, an important change in the 

with Parents’ association between parental education and the cigaEducational Level rette smoking rates of their children has gradually 

emerged with the 12th graders. As Figure 2-7 illustrates, there was a fairsized negative association between parental education and children’s smokPercentage 

23

Smoking and Tobacco Control Monograph No. 14 

Figure 2-7


Trends in 30-Day Prevalence of Cigarette Smoking by Parents’ Average Education for


12th Graders


45


40


5 (High) 

4 

3 

2 

1 (Low) 

Percentage 35


30


25


20


’75’76’77’78’79’80’81’82’83’84’85’86’87’88’89’90’91’92’93’94’95’96’97’98 

Calendar Year 

NOTE: Parental education is an average score of mother’s education and father’s education reported on the following scale: 1. 

Completed grade school or less, 2. Some high school, 3. Completed high school, 4. Some college, 5. Completed college, 6. 

Graduate or professional school after college. Missing data were allowed on one of the two variables. 

SOURCE: The Monitoring the Future Study, University of Michigan. 

ing rates at the beginning of the study. In the last half of the 1970s, this 

association maintained, as all five parental education strata distinguished in 

the figure showed a decline in rates of smoking among the children from 

the mid-1970s through 1981. However, for roughly the decade that followed, this association gradually disappeared. During this time, smoking 

rates among children in the higher parental education strata gradually rose 

and rates among children in the lower parental education strata declined 

some (note that these changes pretty much canceled each other out in the 

overall smoking statistics). Since around 1990, there has been little difference in children’s smoking rates among the various parental education strata, with the exception that the lowest stratum (which is fairly small) did 

not show as large an increase in smoking rates in the 1990s as did the other 

strata. 

Of course, some of this change in the association between parental 

education and smoking rates may be explained in terms of the differential 

racial/ethnic trends just discussed (since race/ethnicity is correlated with 

social class). Another explanation for this change may be the changing proportions represented by the three racial/ethnic groups in the total sample of 

24 
Chapter 2 

the study. It should be noted that, in the lower grades, there still is a negative association between parental education and current smoking (Table 2-

2). The fact that this association is not currently observable among 12th 

graders could reflect social class differences in the age at which smoking is 

initiated, but not in the smoking rate eventually attained. It could also indicate that differential rates of dropping out of school among the different 

social strata lead to a leveling of differences by 12th grade. 

Overall, the average educational level of students’ parents was rising 

steadily over the 23-year, historical interval covered by the study. Between 

1975 and 1998, the size of the group representing the lowest educational 

stratum fell from about 20 percent of the national sample to about 8 percent, whereas the proportion in the top two strata increased from roughly 

20 percent to roughly 38 percent of the sample (each level is defined by an 

absolute level of educational attainment). Given the nature of the changes 

in adult smoking that were occurring during that period—overall adult 

smoking rates were declining—and the fact that an increasing proportion of 

students were being raised by more educated adults, one would have 

expected that substantially more students were being exposed to constructive parental influences with regard to smoking. If this conjecture is true, 

then the impact of other cultural influences that have caused youth smoking rates to rise in the 1980s and 1990s may have been partially masked or 

offset by these more positive parental influences. 

Differences Associated Educational aspirations and eventual educational attainwith College Plans ment have long been strong negative correlates of cigarette smoking (Bachman et al., 1978; Johnston, 1973). Thus, it comes as no 

surprise that, across the full 23-year interval of this study, data have shown 

that those who plan to attend college have been much less likely to smoke 

than those who do not (Figure 2-8). There have been two important 

changes in this relationship, however. One change was that the proportional difference between the two groups (college-bound vs. non-college-bound) 

narrowed considerably as the ratio of current smoking among the collegebound students rose from 57 percent of the non-college-bound rate in 1982 

to 73 percent of that rate in 1993. The other change was that the proportion of 12th graders planning to attend college rose considerably—a trend 

that might have been predictable from the fact that the average educational 

level of their parents also had been rising. 

The proportion of the sample claiming to be college-bound increased 

from about 51 percent of the sample in 1976 to about 79 percent by 1998— 

an increase of more than 50 percent. Given the long-standing differences in 

smoking rates for these two groups, one might have expected the shift to 

reduce the overall level of youth smoking. Clearly, this did not happen, 

which again could mean that other cultural influences working in the 

opposite direction more than offset any effects of educational aspiration. It 

could be, however, that the differences in educational aspirations were really proxies for other things that differentiated the two groups, things that 

perhaps did not shift over time (e.g., academic ability). Therefore, the 

25

Smoking and Tobacco Control Monograph No. 14 

Figure 2-8 

Trends in 30-Day Prevalence of Cigarette Smoking by College Plans for 12th Graders 

50 

45 

40 

35 

30 

25 

20 

15 

10 

’76 ’77 ’78 ’79 ’80 ’81 ’82 ’83 ’84 ’85 ’86 ’87 ’88 ’89 ’90 ’91 ’92 ’93 ’94 ’95 ’96 ’97 ’98 

None or <4 Years 

Complete 4 Years 

Calendar Year 

SOURCE: The Monitoring the Future Study, University of Michigan. 

migration into the college-bound camp simply narrowed the differences 

between these two groups regarding those other factors and, thus, narrowed 

the differences in their smoking rates as well. 

Changes in Transition Changes in current smoking levels are brought about 

Rates across Time both by changes in initiation rates and changes in rates 

of transition to various stages of involvement with smoking. Table 2-4 provides trend data on a number of such transition rates along with other 

ratios of interest. The data show that there have been some systematic 

trends over the period 1975-1998 and, as might be expected, they correlate 

in general with changes in the level of current smoking. 

For example, in the period of declining rates of current smoking among 

12th graders (1977 through 1981), a number of transition rates were also 

declining. The rate of transition from “lifetime” use to current (“30-day”) 

use declined from 0.51 to 0.41; rates from “lifetime” use to “current daily” 

use declined from 0.38 to 0.29; and rates from “lifetime” use to “current 

half-pack-a-day” use declined from 0.26 to 0.19. Similarly, transition from 

“lifetime” use to ever smoking “regularly” fell from 0.43 to 0.34 and the 

Percentage 

26

Chapter 2 

subsequent transition from ever smoking “regularly” to current smoking fell 

from 0.84 to 0.79. Note the much smaller proportional shift in the transition rate for those who already have established a regular smoking pattern. 

During the long period of stability in current smoking rates among 12th 

graders (1981 through 1992), most of the transition rates remained fairly 

steady. Note, however, that the ratio of “current half-pack-a-day” smoking 

to any current smoking, which is not a transition rate, continued to decline 

after 1981, from 0.46 in 1981 to 0.37 in 1988, before stabilizing. 

Finally, in the period of increasing current smoking rates among 12th 

graders (1992 through 1997), most of the transition rates increased. Again, 

the ratio of “half-pack-a-day” smoking to current smoking moved differently, this time holding steady at around 0.36 to 0.39, which was about where 

it was in 1986. 

Table 2-4 also shows that, during the life of the study, there was a 

downward shift in the proportion of current daily smokers who were smoking at a level of half-pack a day or more. That proportion fell from 0.68 in 

1978 to 0.58 by 1991, where it has remained. This downward shift of smoking levels, in theory, could have important long-term health consequences 

for the smokers if more of the daily smokers could maintain a lighter habit. 

However, it is quite possible that this shift reflects more the effects of 

increasing environmental constraints on smoking in the high schools during this historical period rather than any lasting shift in the self-restraint of 

smokers. If so, the ratio would be expected to shift back up to prior levels of 

smoking after these graduating classes leave high school and its constraints. 

The fact that the transition rate from regular use to current smoking is 

so high, and has changed so little over the years, is consistent with the 

notion that a pattern of regular smoking is hard to change once it is established. This transition seems to have been least affected by whatever social 

forces brought about the changes in initiation and continuation of cigarette 

smoking at the earlier stages of involvement. 

Table 2-5 shows the rate of transition from “ever smoking” to “current 

smoking” for all of the various demographic subgroups discussed above. 

These differential trends in the transition rates (which are the complement 

of the quitting rate) help to explain some of the diverging subgroup trends 

discussed above. In particular, note how substantially the transition rate fell 

(or the rate of discontinuing smoking rose) among African American adolescents during the period 1976-1998. 

27

28 

Table 2-4 Trends in Various Smoking Events and in Transition Rates across Them: Twelfth Graders, 1975–1998 

Percentage Who Used 

Class of: 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 Approx. N: 9400 15400 17100 17800 15500 15900 17500 17700 16300 15900 1

Lifetime 73.6 75.4 75.7 75.3 74.0 71.0 71.0 70.1 70.6 69.7 Thirty-Day 36.7 38.8 38.4 36.7 34.4 30.5 29.4 30.0 30.3 29.3 Current Daily 26.9 28.8 28.8 27.5 25.4 21.3 20.3 21.1 21.2 18.7 Current 1/2 Pack or More per Day 17.9 19.2 19.4 18.8 16.5 14.3 13.5 14.2 13.8 12.3 Ever Smoked Regularly 32.7 32.6 31.9 29.5 25.8 24.1 24.6 24.2 21.9 22.1 Ratios: 

30-Day/Lifetime 0.50 0.51 0.51 0.49 0.46 0.43 0.41 0.43 0.43 0.42 Current Daily/Lifetime 0.37 0.38 0.38 0.37 0.34 0.30 0.29 0.30 0.30 0.27 Current 1/2 pk+/Lifetime 0.24 0.25 0.26 0.25 0.22 0.20 0.19 0.20 0.20 0.18 

Current Daily/30-Day 0.73 0.74 0.75 0.75 0.74 0.70 0.69 0.70 0.70 0.64 Current 1/2 pk+/30-Day 0.49 0.49 0.51 0.51 0.48 0.47 0.46 0.47 0.46 0.42 Current 1/2 pk+/Current Daily 0.67 0.67 0.67 0.68 0.65 0.67 0.67 0.67 0.65 0.66 Smoked Regularly/Lifetime — 0.43 0.43 0.42 0.40 0.36 0.34 0.35 0.34 0.31 30-Day/Smoked Regularly — 1.19 1.18 1.15 1.17 1.18 1.22 1.22 1.25 1.34 Current Daily/Smoked Regularly — 0.88 0.88 0.86 0.86 0.83 0.84 0.86 0.88 0.85 Current 1/2 pk+/Smoked Regularly — 0.59 0.59 0.59 0.56 0.55 0.56 0.58 0.57 0.56 
Table 2-4 (continued) 

Percentage Who Used 

Class of: 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 

Approx. N: 16300 16300 16700 15200 15000 15800 16300 15400 15400 14300 1

Lifetime 67.2 66.4 65.7 64.4 63.1 61.8 61.9 62.0 64.2 63.5 Thirty-Day 29.4 28.7 28.6 29.4 28.3 27.8 29.9 31.2 33.5 34.0 Current Daily 18.7 18.1 18.9 19.1 18.5 17.2 19.0 19.4 21.6 22.2 Current 1/2 Pack or More per Day 11.4 10.6 11.2 11.3 10.7 10.0 10.9 11.2 12.4 13.0 Ever Smoked Regularly 21.3 20.6 21.6 22.0 21.6 20.4 22.2 22.6 24.0 25.1 Ratios: 

30-Day/Lifetime 0.44 0.43 0.44 0.46 0.45 0.45 0.48 0.50 0.52 0.54 

Current Daily/Lifetime 0.28 0.27 0.29 0.30 0.29 0.28 0.31 0.31 0.34 0.35 

Current 1/2 pk+/Lifetime 0.17 0.16 0.17 0.18 0.17 0.16 0.18 0.18 0.19 0.20 

Current Daily/30-Day 0.64 0.63 0.66 0.65 0.65 0.62 0.64 0.62 0.64 0.65 

Current 1/2 pk+/30-Day 0.39 0.37 0.39 0.38 0.38 0.36 0.36 0.36 0.37 0.38 

Current 1/2 pk+/Current Daily 0.61 0.59 0.59 0.59 0.58 0.58 0.57 0.58 0.57 0.59 

Smoked Regularly/Lifetime 0.32 0.31 0.33 0.34 0.34 0.33 0.36 0.36 0.37 0.39 

30-Day/Smoked Regularly 1.38 1.39 1.32 1.33 1.31 1.36 1.35 1.38 1.40 1.36 

Current Daily/Smoked Regularly 0.88 0.88 0.87 0.87 0.86 0.84 0.86 0.86 0.90 0.89 

Current 1/2 pk+/Smoked Regularly 0.54 0.51 0.52 0.51 0.49 0.49 0.49 0.50 0.52 0.52 

Notes: Level of significance of difference between the two most recent classes: s =0.05, ss =0.01, sss =0.001. 

Source: The Monitoring the Future Study, University of Michigan. 

29 
30 Table 2-5 

Trends in the Transition from Lifetime Cigarette Use to Use in the Past 30 Days: Twelfth Graders, 1976–1998 

Transition Rate 

Class of: 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 

Total 0.49 0.51 0.51 0.49 0.48 0.43 0.42 0.43 0.44 0.42 0.44 0.44 Sex 

Male 0.50 0.48 0.47 0.43 0.38 0.39 0.40 0.41 0.39 0.42 0.42 0.41 Female 0.52 0.53 0.50 0.50 0.47 0.43 0.45 0.44 0.45 0.45 0.44 0.46 

College Plans 

0 or <4 Years 0.57 0.57 0.56 0.54 0.51 0.49 0.51 0.50 0.50 0.53 0.51 0.53 Complete 4 Years 0.43 0.42 0.40 0.38 0.34 0.33 0.34 0.35 0.35 0.36 0.38 0.39 

Region 

Northeast 0.53 0.56 0.53 0.49 0.48 0.44 0.45 0.47 0.47 0.48 0.50 0.49 North Central 0.54 0.52 0.51 0.48 0.43 0.44 0.45 0.45 0.43 0.48 0.47 0.47 South 0.52 0.50 0.47 0.48 0.44 0.41 0.43 0.42 0.42 0.39 0.40 0.40 

West 0.41 0.39 0.40 0.37 0.33 0.33 0.32 0.34 0.35 0.39 0.36 0.39 

Population Density 

Large MSA 0.54 0.53 0.50 0.46 0.43 0.43 0.46 0.43 0.45 0.45 0.45 0.44 Other MSA 0.49 0.49 0.46 0.46 0.43 0.40 0.41 0.42 0.41 0.42 0.42 0.42 Non-MSA 0.53 0.51 0.51 0.48 0.43 0.42 0.43 0.44 0.41 0.45 0.45 0.46 

Parental Education 

1.0–2.0 (Low) 0.56 0.51 0.49 0.50 0.45 0.45 0.46 0.46 0.46 0.46 0.42 0.43 2.5–3.0 0.53 0.53 0.52 0.47 0.47 0.43 0.45 0.44 0.45 0.46 0.47 0.45 3.5–4.0 0.49 0.49 0.46 0.45 0.40 0.40 0.41 0.40 0.40 0.43 0.43 0.43 4.5–5.0 0.48 0.46 0.44 0.42 0.38 0.37 0.37 0.40 0.38 0.41 0.40 0.42 5.5–6.0 (High) 0.42 0.46 0.44 0.44 0.37 0.34 0.37 0.39 0.37 0.36 0.42 0.46 

Race (2-year avg.) 

White — 0.51 0.50 0.48 0.46 0.42 0.43 0.44 0.44 0.45 0.46 0.46 

Black — 0.49 0.46 0.43 0.38 0.36 0.34 0.32 0.32 0.30 0.30 0.26 Hispanic — 0.46 0.45 0.39 0.34 0.34 0.37 0.36 0.38 0.38 0.37 0.36 
Table 2-5 (continued) 

Transition Rate 

Class of: 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 

Total 0.44 0.44 0.46 0.48 0.46 0.47 0.49 0.49 0.55 0.51 0.56 

Sex 

Male 0.43 0.43 0.45 0.46 0.46 0.48 0.52 0.53 0.54 0.57 0.54 Female 0.43 0.44 0.45 0.44 0.43 0.48 0.48 0.50 0.52 0.55 0.53 

College Plans 

0 or <4 Years 0.51 0.52 0.52 0.54 0.53 0.52 0.57 0.60 0.62 0.62 0.62 Complete 4 Years 0.39 0.39 0.42 0.40 0.41 0.46 0.47 0.49 0.51 0.53 0.50 

Region 

Northeast 0.47 0.45 0.48 0.47 0.46 0.51 0.51 0.53 0.58 0.60 0.56 North Central 0.45 0.50 0.50 0.51 0.49 0.53 0.56 0.55 0.59 0.58 0.59 South 0.43 0.41 0.42 0.42 0.43 0.47 0.50 0.52 0.52 0.55 0.52 

West 0.37 0.35 0.41 0.39 0.40 0.41 0.42 0.47 0.43 0.49 0.48 

Population Density 

Large MSA 0.42 0.41 0.44 0.43 0.43 0.49 0.49 0.53 0.52 0.55 0.52 Other MSA 0.42 0.43 0.46 0.46 0.44 0.48 0.50 0.51 0.53 0.56 0.53 Non-MSA 0.46 0.46 0.46 0.45 0.48 0.48 0.53 0.53 0.57 0.57 0.56 

Parental Education 

1.0–2.0 (Low) 0.42 0.39 0.40 0.48 0.43 0.43 0.43 0.47 0.50 0.48 0.51 2.5–3.0 0.44 0.46 0.47 0.45 0.47 0.48 0.51 0.53 0.55 0.55 0.54 3.5–4.0 0.42 0.44 0.45 0.45 0.45 0.48 0.51 0.51 0.51 0.55 0.55 4.5–5.0 0.43 0.42 0.46 0.44 0.44 0.51 0.52 0.53 0.56 0.58 0.53 5.5–6.0 (High) 0.45 0.42 0.46 0.43 0.43 0.50 0.49 0.53 0.53 0.59 0.53 

Race (2-year avg.) 

White 0.47 0.47 0.48 0.49 0.49 0.51 0.53 0.54 0.57 0.58 0.60 

Black 0.24 0.25 0.25 0.23 0.20 0.21 0.26 0.27 0.31 0.31 0.31 Hispanic 0.33 0.32 0.35 0.37 0.39 0.39 0.39 0.39 0.40 0.40 0.43 

Source: The Monitoring the Future Study, University of Michigan. 

31 
Smoking and Tobacco Control Monograph No. 14 

SUMMARY Over the 23-year interval covered by the Monitoring the Future study 

so far, there have been important changes in the patterns and trends of cigarette smoking by American adolescents. Overall, there was a decline in 

smoking rates early in the study interval and an equally substantial increase 

late in that same interval. These changes were attributable not only to 

changes in the rate at which young people were initiating cigarette smoking, but also to changes in the rates at which they were moving on to subsequent stages of use. 

Although nearly all demographic subgroups showed an overall decline 

and subsequent overall increase in smoking rates, there have been some 

important changes in both the nature and extent of the subgroup differences in various demographic dimensions. In particular, racial/ethnic differences expanded substantially, while social class differences diminished considerably. At the lower (8th and 10th) grades, however, these differences did 

not disappear completely. Gender differences reversed twice during the 

study interval, whereas differences associated with college plans became less 

pronounced, though they are still large. There were also interesting changes 

associated with population density, in that the increase in teen smoking 

rates in the 1990s was greatest in the non-urban areas. 

Substantial shifts in the demographic composition of the youth population occurred over this 23-year interval, with an increase in minority populations, particularly the Hispanic population. Substantial increases in the 

average educational level of parents and in the educational aspirations of 

the students themselves were also observed; some increase in the proportional concentration of the population in the Southern and Western regions 

of the country; and a continued concentration of the population in urban 

areas. 

Given the general associations between youth smoking and most of 

these factors, one might have expected that these shifts in demographic 

composition of the national population would have led to decreases in the 

overall rate of youth smoking over the past 23 years. However, this has not 

been the case for most of the 1980s and 1990s, which suggests either (1) 

that cultural influences that have encouraged increased smoking rates have 

had their effects partially “masked” or were offset by those substantial 

demographic shifts, or (2) that the nature of the relationships between 

demographics and smoking rates is more complex than it appears to be on 

the surface. 

32

Chapter 2 

REFERENCES


Bachman, J.G., O’Malley, P.M., Johnston, J. Youth in 

Transition: Vol. 6 Adolescence to Adulthood: Change 

and Stability in the Lives of Young Men. Ann Arbor, 

MI: Institute for Social Research, 1978. 

Burns, D.L., Lee, L., Shen, L.Z., Gilpin, E., Tolley, 

H.D., Vaughn, J., Shanks, T.G. Cigarette smoking 

behavior in the United States. In: Changes in 

Cigarette-Related Disease Risks and Their 

Implication for Prevention and Control. Smoking 

and Tobacco Control Monograph No. 8. Burns, 

D., Garfinkel, L., Samet, J. (Editors). Bethesda, 

MD: U.S. Department of Health and Human 

Services, Public Health Service, National 

Institutes of Health, National Cancer Institute. 

NIH Publication No. 97-4213, 1997. 

Johnston, L.D. Drugs and American Youth. Ann Arbor, 

MI: Institute for Social Research, 1973. 

Johnston, L.D., Bachman, L.D., O’Malley, P.M. 

Monitoring the Future: Questionnaire Responses from 

the Nation’s High School Seniors, 1995. Ann Arbor, 

MI: Institute for Social Research, 1997. 

Johnston, L.D., O’Malley, P.M., Bachman, J.G. 

National Survey Results on Drug Use from the 

Monitoring the Future Study, 1975–1997. Volume I: 

Secondary School Students. NIH Publication No. 

98-4345. Rockville, MD: U.S. Department of 

Health and Human Services, Public Health 

Service, National Institutes of Health, National 

Institute on Drug Abuse, 1998. 

Johnston, L.D., O’Malley, P.M., Bachman, J.G., 

Schulenberg, J. Aims and Objectives of the 

Monitoring the Future Study and Progress Toward 

Fulfilling Them. Monitoring the Future 

Occasional Paper No. 34, Revised. Ann Arbor, 

MI: Institute for Social Research, 1996. 

National Cancer Institute. Changes in CigaretteRelated Disease Risks and Their Implication for 

Prevention and Control. Smoking and Tobacco 

Control Monograph No. 8. Bethesda, MD: U.S. 

Department of Health and Human Services, 

Public Health Service, National Institutes of 

Health, National Cancer Institute. NIH 

Publication No. 97-4213, 1997. 

O’Malley, P.M., Bachman, J.G., Johnston, L.D. 

Reliability and consistency of self-reports of drug 

use. International Journal of the Addictions 

18(6):805–824, 1983. 

O’Malley, P.M., Bachman, J.G., Johnston, L.D. 

Period, age, and cohort effects on substance use 

among young Americans: A decade of change, 

1976–1986. American Journal of Public Health 

78:1315–1321, 1988. 

U.S. Department of Health and Human Services. 

Preventing Tobacco Use Among Young People: A 

Report of the Surgeon General. Atlanta, GA: U.S. 

Department of Health and Human Services, 

Public Health Service, Centers for Disease 

Control and Prevention, National Center for 

Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 1994. 

33

Trends and Subgroup Differences in 

Tobacco Use among High School 

Students in the United States, 1991–1997 

Sherry A. Everett, Charles W. Warren 

INTRODUCTION Tobacco use is the single leading cause of death in the United 

States (McGinnis and Foege, 1993). National trends in adolescent tobacco 

use and characteristics of adolescents who use tobacco are essential data for 

planning and evaluating tobacco prevention efforts (Everett et al., 1998b). 

This analysis used national Youth Risk Behavior Survey (YRBS) data to 

examine changes in cigarette smoking that occurred among high school 

students in the United States from 1991 to 1997. This analysis also examined the relationship between demographic characteristics and tobacco use 

behavior among these students. 

METHODS The YRBS is a component of the Centers for Disease Control and 

Prevention’s (CDC) Youth Risk Behavior Surveillance System and measures 

the prevalence of health risk behaviors among adolescents through representative national, state, and local surveys conducted biennially. The 1991, 

1993, 1995, and 1997 national surveys used independent, three-stage cluster samples to obtain representative cross-sectional samples of students in 

grades 9 through 12 in each of the 50 states and the District of Columbia. 

In 1991, 1993, 1995, and 1997, the respective sample sizes were 12,272, 

16,296, 10,904, and 16,262; the respective school response rates were 75, 

78, 70, and 79 percent; the respective student response rates were 90, 90, 

86, and 87 percent; and the respective overall response rates were 68, 70, 

60, and 69 percent. 

For each of the four cross-sectional surveys, students completed a selfadministered questionnaire that included questions about cigarette smoking, smokeless tobacco use, and cigar smoking. The following tobacco use 

behaviors were examined: 

1) lifetime cigarette smoking 

(ever smoked cigarettes, even one or two puffs); 

2) ever daily smoking 

(ever smoked at least 1 cigarette every day for 30 days); 

3) current cigarette smoking 

(smoked cigarettes on 1 or more of the 30 days preceding 

the survey); 

4) frequent cigarette smoking 

(smoked on 20 or more of the 30 days preceding the survey); 

35 
Smoking and Tobacco Control Monograph No. 14


5) smoking a whole cigarette before age 13; 

6) current smokeless tobacco use 

(used chewing tobacco or snuff on 1 or more of the 30 days 

preceding the survey); 

7) smoking cigarettes on school property 

(on 1 or more of the 30 days preceding the survey); 

8) using smokeless tobacco on school property 

(on 1 or more of the 30 days preceding the survey); and 

9) current cigar use 

(smoked cigars, cigarillos, or little cigars on 1 or more of the 30 days 

preceding the survey). 

To compare trends of current cigarette smoking with those of other 

drug use, data about students’ current use of alcohol, marijuana, and 

cocaine were also used. Students were identified as current users of alcohol, 

marijuana, or cocaine if they reported having used these substances on 1 or 

more of the 30 days preceding the survey. 

Demographic characteristics used in this study included sex, race/ethnicity, grade in school, and school location. In addition, as a proxy measure 

for socioeconomic status, students were asked to identify the highest educational level of their mothers and fathers (not included in the 1991 survey). 

“Parent education” was defined as the highest level of education of either 

parent and was categorized into one of four levels: did not finish high 

school, graduated from high school, some education after high school, or 

graduated from college. Students who reported that they were not sure of 

either parent’s educational level were excluded from analyses using this 

variable (n = 4,084 for 1993, 1995, and 1997 combined). School location 

(not included in the 1991 survey) was identified as urban, suburban, or 

rural based on the National Center for Health Statistics categories that use 

population and Metropolitan Statistical Area data and U.S. Bureau of the 

Census definitions (Quality Education Data, Inc., 1991). School locations 

were not identified for a total of 471 students in 1993, 1995, and 1997; 

thus, these students were excluded from analyses using school location. 

Data are presented only for non-Hispanic Black, non-Hispanic White, and 

Hispanic students because the numbers of students from other racial/ethnic 

groups were too small for meaningful analysis. 

Data were weighted to provide national estimates, and SUDAAN software was used for all data analysis. Secular trends were analyzed using logistic regression—controlling for sex, grade in school, and race/ethnicity—and 

simultaneously assessing linear and higher order time effects. Significant 

linear and quadratic trends were presented. These secular trends were also 

examined for each of the following subgroups: sex, race/ethnicity, school 

location, and parent education. Linear trends suggest a significant increase 

or decrease in data over time. Quadratic trends suggest a significant but 

nonlinear trend in data over time. When the trend includes significant linear and quadratic components, the data demonstrate some nonlinear variation (e.g., leveling off or change in direction) in addition to a linear effect. 

36 
Chapter 3


Because data on school location and parent education were not available 

for 1991, trend analyses were only conducted between 1993 and 1997 when 

using these variables. Trend analyses were not conducted for current smokeless tobacco use, smokeless tobacco use on school property, or cigar use 

because data for 3 or more years were not available. 

RESULTS	 Overall, the proportion of all high school students who 

reported that they had ever tried cigarette smoking Trends and Subgroup remained stable from 1991 to 1997; 70.2 percent report- Differences ed this behavior in 1997 (Table 3-1). The pattern was 

Lifetime Cigarette Smoking consistent across sex, race/ethnicity, and school location. 

Lifetime smoking remained stable in each parent education subgroup except among students whose parents had some education 

after high school. Among these students, lifetime smoking showed a significant linear increase. 

In 1997, lifetime smoking did not significantly differ by sex or school 

location, but was significantly more likely among Hispanic students than 

among White (t = 2.5, p < 0.05) and Black (t = 2.3, p < 0.05) students (Table 

3-2). Lifetime smoking was also significantly more likely among students 

whose parents had not finished high school (t = 5.3, p < 0.001), had graduated from high school (t = 4.3, p < 0.001), or had some education after high 

school (t = 3.9, p < 0.001) than among students whose parents had graduated from college. Students whose parents had not finished high school (t = 

2.3, p < 0.05) were significantly more likely to report lifetime smoking than 

were students whose parents had some education after high school. 

Ever Daily Cigarette Overall, ever daily smoking showed a significant linear 

Smoking increase from 1991 to 1997; 24.8 percent reported this behavior in 1997 (Table 3-3). Males, White students, Black students, and Black 

males showed significant linear increases from 1991 to 1997, and students 

in rural schools showed a significant linear increase from 1993 to 1997. 

Ever daily smoking was stable among females, Hispanic students, urban and 

suburban school locations, and all levels of parent education. 

In 1997, ever daily smoking did not significantly differ by sex, but was 

significantly more likely among White students than among Black (t = 12.3, 

p < 0.001) and Hispanic (t = 7.2, p < 0.001) students. Ever daily smoking 

also was significantly more likely among Hispanic students than among 

Black students (t = 4.0, p < 0.001) (Table 3-2). Students in suburban (t = 2.2, 

p < 0.05) and rural (t = 2.4, p < 0.05) schools were significantly more likely 

than students in urban schools to report this behavior. Similarly, students 

whose parents had not finished high school (t = 2.8, p < 0.01) and students 

whose parents had graduated from high school (t = 2.7, p < 0.01) were significantly more likely to report ever daily smoking than were students 

whose parents had graduated from college. 

37

Smoking and Tobacco Control Monograph No. 14


Table 3-1 

Percentage of High School Students who Reported Lifetime Cigarette Smoking, by Sex, 

Race/Ethnicity, School Location, and Parent Education—Youth Risk Behavior Survey, 

1991–1997 

Survey Year 

1991 1993 1995 1997 

Total 

Sex 

Female 

Male 

Race/Ethnicity 

White 

Female 

Male 

Black 

Female 

Male 

Hispanic 

Female 

Male 

School Location 

Urban 

Suburban 

Rural 

Parental Education† 

Did not finish high school 

Graduated high school 

Some education after HS 

Graduated college 

70.1 (±2.2)* 69.5 (±1.4) 71.3 (±1.7) 70.2 (±1.9) 

69.5 (±2.9) 68.7 (±1.8) 70.4 (±3.2) 69.3 (±2.6) 

70.7 (±2.0) 70.1 (±1.5) 72.1 (±2.0) 70.9 (±1.9) 

70.4 (±2.7) 70.2 (±1.5) 71.1 (±1.9) 70.4 (±2.3) 

69.4 (±3.9) 70.0 (±2.1) 71.1 (±3.2) 70.3 (±3.3) 

71.4 (±2.3) 70.4 (±1.7) 71.1 (±2.4) 70.4 (±2.4) 

67.2 (±3.3) 67.1 (±2.6) 66.0 (±3.7) 68.4 (±4.4) 

69.3 (±3.5) 66.7 (±3.7) 62.8 (±6.2) 66.8 (±5.2) 

64.8 (±5.3) 67.6 (±3.2) 70.6 (±4.8) 70.1 (±4.7) 

75.3 (±1.6) 71.8 (±2.2) 76.3 (±4.8) 75.0 (±2.7) 

75.0 (±4.1) 68.2 (±3.6) 74.8 (±5.1) 72.7 (±3.9) 

75.7 (±4.7) 75.1 (±3.6) 77.8 (±7.2) 76.9 (±3.6) 

— 68.8 (±2.3) 70.6 (±2.9) 69.4 (±3.3) 

— 70.2 (±2.0) 71.6 (±2.9) 69.5 (±2.9) 

— 67.0 (±2.8) 71.5 (±4.0) 74.6 (±6.1) 

— 77.8 (±4.4) 73.4 (±8.0) 79.1 (±4.0) 

— 76.1 (±3.1) 76.2 (±2.6) 75.2 (±2.6) 

— 67.7 (±2.5) 73.2 (±2.9) 72.9 (±3.4) § 

— 67.3 (±2.1) 68.0 (±2.8) 66.2 (±2.6) 

* Numbers in parentheses are 95% confidence intervals. † Highest level of education of either parent.
 § Significant linear effect (p < 0.05).


Note: Trend analyses were conducted using a logistic regression model controlling for sex, 


grade in school, race/ethnicity, and higher order time effects. 

38

Table 3-2 

Percentage of High School Students who Reported Tobacco Use in 1997, by Sex, Race/Ethnicity, School Location, and Par

Youth Risk Behavior Survey* 

Smokeless 

Smoked Smoked on Current Tobacco Us

Lifetime Ever Daily Current Frequent Before School Smokeless on Schoo

Smoking Smoking Smoking Smoking Age 13 Property Tobacco Use Property 

Total 70.2 (±1.9)† 24.8 (±2.1) 36.4 (±2.3) 16.7 (±1.9) 24.8 (±2.3) 14.6 (±1.5) 9.3 (±2.2) 5.1 (±1.4) 

Sex 

Female 69.3 (±2.6) 25.4 (±3.1) 34.7 (±2.8) 15.7 (±2.1) 20.9 (±2.4) 13.0 (±2.2) 1.5 (±0.7) 0.4 (±0.2) 

Male 70.9 (±1.9) 24.3 (±2.2) 37.7 (±2.7) 17.6 (±2.7) 28.0 (±3.3) 15.9 (±1.7) 15.8 (±3.7) 9.0 (±2.5) 

Race/Ethnicity 

White 70.4 (±2.3) 29.2 (±1.7) 39.7 (±2.4) 19.9 (±2.2) 25.6 (±3.0) 15.8 (±1.8) 12.2 (±2.5) 6.5 (±1.7) 

Female 70.3 (±3.3) 31.0 (±3.3) 39.9 (±3.2) 20.1 (±3.2) 22.0 (±3.4) 14.9 (±3.2) 1.6 (±0.9) 0.4 (±0.3) 

Male 70.4 (±2.4) 27.7 (±2.4) 39.6 (±3.8) 19.8 (±3.3) 28.5 (±3.8) 16.5 (±2.4) 20.6 (±4.0) 11.3 (±2.9

Black 68.4 (±4.4) 9.9 (±2.1) 22.7 (±3.8) 7.1 (±1.8) 17.4 (±2.4) 8.8 (±2.0) 2.2 (±1.1) 1.4 (±0.9) 

Female 66.8 (±5.2) 7.4 (±2.6) 17.4 (±3.9) 4.3 (±1.8) 15.3 (±3.5) 5.5 (±2.0) 1.3 (±1.2) 0.4 (±0.7) 

Male 70.1 (±4.7) 12.6 (±2.9) 28.2 (±5.5) 10.1 (±3.1) 19.5 (±4.0) 12.4 (±3.1) 3.2 (±1.7) 2.5 (±1.6) 

Hispanic 75.0 (±2.7) 18.0 (±2.9) 34.0 (±2.7) 10.9 (±2.6) 24.9 (±3.2) 11.9 (±2.5) 5.1 (±2.3) 3.3 (±1.6) 

Female 72.7 (±3.9) 18.0 (±3.4) 32.3 (±3.7) 8.1 (±2.7) 20.3 (±4.2) 7.7 (±1.8) 1.2 (±1.0) 0.3 (±0.2) 

Male 76.9 (±3.6) 17.9 (±4.0) 35.5 (±3.6) 13.2 (±3.7) 28.6 (±5.6) 15.3 (±3.7) 8.3 (±3.3) 5.8 (±2.6) 

School Location 

Urban 69.4 (±3.3) 21.0 (±3.7) 32.8 (±2.4) 13.4 (±1.7) 20.9 (±2.0) 13.0 (±2.1) 7.5 (±3.3) 3.6 (±1.8) 

Suburban 69.5 (±2.9) 26.1 (±2.9) 37.2 (±2.8) 17.1 (±2.7) 25.7 (±2.9) 15.1 (±2.1) 8.6 (±2.5) 5.0 (±2.0) 

Rural 74.6 (±6.1) 29.6 (±5.6) 42.2 (±6.6) 23.8 (±5.9) 30.7 (±5.6) 16.8 (±4.9) 14.1 (±4.3) 8.0 (±3.0) 

Parental Education§ 

Did not finish HS 79.1 (±4.0) 27.7 (±3.9) 39.3 (±4.6) 18.4 (±3.1) 35.4 (±3.7) 18.3 (±4.6) 8.1 (±3.0) 6.8 (±2.8) 

Graduated HS 75.2 (±2.6) 28.3 (±4.1) 40.2 (±3.8) 19.5 (±3.6) 30.3 (±2.6) 15.4 (±2.7) 8.7 (±3.0) 4.4 (±2.1) 

Some educ. after HS 72.9 (±3.4) 26.1 (±2.7) 37.7 (±3.0) 16.3 (±2.9) 25.3 (±3.5) 13.4 (±2.0) 8.9 (±2.3) 4.7 (±1.9) 

Graduated college 66.2 (±2.6) 22.9 (±2.7) 34.3 (±2.5) 15.5 (±2.3) 21.5 (±2.7) 14.4 (±1.9) 9.9 (±2.9) 5.1 (±1.7) 

39 

* Lifetime smoking = ever smoked cigarettes, even one or two puffs; ever daily smoking = ever smoked at least one cigarette every day for 30 days; current cigarette sm

cigarettes on 1 or more of the 30 days preceding the survey; frequent cigarette smoking = smoked on 20 or more of the 30 days preceding the survey; smoked before 

when first smoked a whole cigarette; current smokeless tobacco use = used chewing tobacco or snuff on 1 or more of the 30 days preceding the survey; smoked ciga

property = on 1 or more of the 30 days preceding the survey; used smokeless tobacco on school property = on 1 or more of the 30 days preceding the survey; and cu

smoked cigars, cigarillos, or little cigars on 1 or more of the 30 days preceding the survey. 

† Numbers in parentheses are 95% confidence intervals. § Highest level of education of either parent; HS = high school. 
Smoking and Tobacco Control Monograph No. 14


Table 3-3 

Percentage of High School Students who Reported Ever Smoking Daily, by Sex, Race/Ethnicity, 

School Location, and Parent Education—Youth Risk Behavior Survey, 1991–1997 

Survey Year 

1991 1993 1995 1997 

Total 

Sex 

Female 

Male 

Race/Ethnicity 

White 

Female 

Male 

Black 

Female 

Male 

Hispanic 

Female 

Male 

School Location 

Urban 

Suburban 

Rural 

Parental Education† 

21.3 (±2.2)* 24.7 (±2.0) 23.6 (±2.9) 24.8 (±2.1) § 

22.2 (±3.0) 24.5 (±2.5) 23.5 (±3.4) 25.4 (±3.1) 

20.4 (±1.9) 24.9 (±2.2) 23.7 (±3.2) 24.3 (±2.2) § 

25.0 (±2.8) 28.4 (±2.6) 27.6 (±3.7) 29.2 (±1.7) § 

27.2 (±4.0) 28.6 (±3.4) 28.9 (±3.9) 31.0 (±3.3) 

23.0 (±2.5) 28.2 (±2.9) 26.5 (±4.4) 27.7 (±2.4) 

7.1 (±1.7) 9.3 (±1.8) 9.1 (±2.4) 9.9 (±2.1) § 

5.6 (±1.8) 9.1 (±2.1) 5.6 (±3.2) 7.4 (±2.6) 

8.9 (±2.8) 9.4 (±3.2) 13.4 (±5.6) 12.6 (±2.9) § 

16.1 (±2.5) 18.6 (±2.7) 17.0 (±3.8) 18.0 (±2.9) 

16.5 (±3.1) 18.3 (±4.0) 15.8 (±3.7) 18.0 (±3.4) 

15.7 (±3.2) 19.0 (±3.4) 18.3 (±5.8) 17.9 (±4.0) 

— 21.0 (±4.4) 19.2 (±2.8) 21.0 (±3.7) 

— 27.3 (±2.8) 24.5 (±4.7) 26.1 (±2.9) 

— 19.1 (±2.9) 29.8 (±4.3) 29.6 (±5.6) § 

Did not finish high school — 30.5 (±4.3) 22.5 (±6.1) 27.7 (±3.9) 

Graduated high school — 27.7 (±4.1) 26.5 (±3.5) 28.3 (±4.1) 

Some education after high school — 24.0 (±2.2) 24.7 (±4.3) 26.1 (±2.7) 

Graduated college — 23.5 (±2.7) 22.1 (±3.6) 22.9 (±2.7) 

* Numbers in parentheses are 95% confidence intervals. † Highest level of education of either parent.
 § Significant linear effect (p < 0.5).


Note: Trend analyses were conducted using a logistic regression model controlling for sex, 


grade in school, race/ethnicity, and higher order time effects. 

Current Cigarette Smoking Current smoking showed a significant linear increase 

from 1991 to 1997; 36.4 percent of high school students reported this 

behavior in 1997 (Table 3-4). This significant linear increase was consistent 

across sex, race/ethnicity, school location, and parent education, except 

among students whose parents had not finished high school. Among these 

students, current cigarette smoking was stable from 1993 to 1997. 

In 1997, current smoking did not significantly differ by sex, but was significantly more likely among White students than among Black (t = 7.7, p < 

0.001) and Hispanic (t = 3.5, p < 0.001) students. Current smoking was also 

significantly more likely among Hispanic students than among Black students (t = 4.9, p < 0.001) (Table 3-2). Students in suburban (t = 2.4, p < 

0.05) and rural (t = 2.7, p < 0.05) schools were significantly more likely to 

report this behavior than were students in urban schools. Similarly, students whose parents had not finished high school (t = 2.3, p < 0.05), had 

40 
Chapter 3


Table 3-4 

Percentage of High School Students who Reported Current Cigarette Smoking,* by Sex, Race/ 

Ethnicity, School Location, and Parent Education—Youth Risk Behavior Survey, 1991–1997 

Survey Year 

1991 1993 1995 1997 

Total 

Sex 

Female 

Male 

Race/Ethnicity 

White 

Female 

Male 

Black 

Female 

Male 

Hispanic 

Female 

Male 

School Location 

Urban 

Suburban 

Rural 

Parental Education‡ 

27.5 (±2.7)† 30.5 (±1.9) 34.8 (±2.2) 36.4 (±2.3) § 

27.3 (±3.4) 31.2 (±2.1) 34.3 (±3.2) 34.7 (±2.8) § 

27.6 (±3.1) 29.8 (±2.3) 35.4 (±2.4) 37.7 (±2.7) § 

30.9 (±3.3) 33.7 (±2.2) 38.3 (±2.7) 39.7 (±2.4) § 

31.7 (±4.6) 35.3 (±2.6) 39.8 (±3.5) 39.9 (±3.2) § 

30.2 (±3.8) 32.2 (±2.7) 37.0 (±3.3) 39.6 (±3.8) § 

12.6 (±2.5) 15.4 (±2.5) 19.2 (±3.2) 22.7 (±3.8) § 

11.3 (±2.3) 14.4 (±2.7) 12.2 (±3.1) 17.4 (±3.9) § 

14.1 (±4.5) 16.3 (±4.2) 27.8 (±5.5) 28.2 (±5.5) § 

25.3 (±2.8) 28.7 (±2.9) 34.0 (±5.3) 34.0 (±2.7) § 

22.9 (±3.8) 27.3 (±3.9) 32.9 (±5.6) 32.2 (±3.7) § 

27.9 (±3.6) 30.2 (±3.4) 34.9 (±8.7) 35.5 (±3.6) § 

— 26.6 (±3.6) 31.1 (±3.3) 32.8 (±2.4) § 

— 32.6 (±2.7) 35.7 (±3.8) 37.2 (±2.8) § 

— 27.9 (±3.3) 39.6 (±1.9) 42.2 (±6.6) § 

Did not finish high school — 36.8 (±4.4) 33.1 (±4.5) 39.3 (±4.6) 

Graduated high school — 32.8 (±3.5) 37.6 (±3.9) 40.2 (±3.8) § 

Some education after high school — 28.9 (±2.5) 36.3 (±3.7) 37.7 (±3.0) § 

Graduated college — 29.7 (±2.5) 33.6 (±2.7) 34.3 (±2.5) § 

* Smoked Cigarettes on 1 or more of the 30 days preceding the survey. † Numbers in parentheses are 95% confidence intervals. ‡ Highest level of education of either parent.
 § Significant linear effect (p < 0.05).


Note: Trend analyses were conducted using a logistic regression model controlling for sex, 


grade in school, race/ethnicity, and higher order time effects. 

graduated from high school (t = 2.9, p < 0.01), or had some education after 

high school (t = 2.1, p < 0.05) were significantly more likely to report current smoking than students whose parents had graduated from college. 

Frequent Cigarette Smoking Frequent smoking showed a significant linear increase 

from 1991 to 1997; 16.7 percent of students reported this behavior in 1997 

(Table 3-5). This pattern was consistent among males, females, White, 

Black, and Hispanic students overall as well as White females, White males, 

Black males, and Hispanic males. Among students in rural schools, frequent 

cigarette smoking showed both significant linear and quadratic time effects; 

frequent smoking more than doubled between 1993 and 1995, then leveled 

off between 1995 and 1997. Frequent smoking remained stable among students in both urban and suburban schools. Among students whose parents 

had some education after high school and among students whose parents 

had graduated from college, frequent cigarette smoking significantly 

41 
Smoking and Tobacco Control Monograph No. 14


Table 3-5 

Percentage of High School Students who Reported Frequent Cigarette Smoking,* by Sex, Race/ 

Ethnicity, School Location, and Parent Education—Youth Risk Behavior Survey, 1991–1997 

Survey Year 

1991 1993 1995 1997 

Total 

Sex 

Female 

Male 

Race/Ethnicity 

White 

Female 

Male 

Black 

Female 

Male 

Hispanic 

Female 

Male 

School Location 

Urban 

Suburban 

Rural 

Parental Education‡ 

12.7 (±2.2) † 13.8 (±1.7) 16.1 (±2.6) 

12.4 (±2.9) 13.5 (±2.1) 15.9 (±3.0) 

13.0 (±1.9) 14.0 (±1.7) 16.3 (±2.9) 

15.4 (±2.8) 16.1 (±2.1) 19.5 (±3.6) 

15.8 (±3.9) 16.1 (±2.8) 20.8 (±4.1) 

15.0 (±2.1) 16.0 (±2.2) 18.4 (±3.8) 

3.1 (±1.1) 4.6 (±1.6) 4.5 (±1.8) 

1.9 (±1.0) 4.3 (±1.8) 1.3 (±0.8) 

4.5 (±2.1) 4.9 (±2.5) 8.5 (±3.4) 

6.8 (±1.5) 7.7 (±2.0) 10.0 (±3.3) 

5.7 (±2.3) 6.9 (±3.2) 9.3 (±3.8) 

8.0 (±1.6) 8.5 (±2.3) 10.7 (±4.5) 

— 11.7 (±3.4) 13.0 (±2.4) 

— 15.3 (±2.4) 16.3 (±4.3) 

— 9.9 (±1.7) 22.2 (±3.5) 

Did not finish high school — 19.0 (±4.5) 15.4 (±3.7) 

Graduated high school — 16.1 (±3.0) 18.8 (±3.5) 

Some education after high school — 13.1 (±2.3) 18.2 (±4.0) 

Graduated college — 12.6 (±1.7) 14.0 (±3.0) 

16.7 (±1.9) § 

15.7 (±2.1) § 

17.6 (±2.7) § 

19.9 (±2.2) § 

20.1 (±3.2) § 

19.8 (±3.3) § 

7.2 (±1.8) § 

4.3 (±1.8) 

10.1 (±3.1) § 

10.9 (±2.6) § 

8.1 (±2.7) 

13.2 (±3.7) § 

13.4 (±1.7) § 

17.1 (±2.7) 

23.8 (±5.9) §,§§ 

18.4 (±3.1) 

19.5 (±3.6) 

16.3 (±2.9) § 

15.5 (±2.3) § 

* Smoked Cigarettes on 20 or more of the 30 days preceding the survey. † Numbers in parentheses are 95% confidence intervals. ‡ Highest level of education of either parent.
 § Significant linear effect (p < 0.05).
 §§ Significant quadratic effect (p < 0.05).


Note: Trend analyses were conducted using a logistic regression model controlling for sex, 


grade in school, race/ethnicity, and higher order time effects. 

increased; however, frequent smoking remained stable among students 

whose parents had not finished high school or had graduated from high 

school. 

In 1997, frequent smoking did not significantly differ by sex, but was 

significantly more likely among White students than among Black (t = 7.9, 

p < 0.001) and Hispanic (t = 5.6, p < 0.001) students. Frequent smoking also 

was significantly more likely among Hispanic students than among Black 

students (t = 2.2, p < 0.05). Frequent smoking among students in suburban 

(t = 2.4, p < 0.05) and rural schools (t = 3.2, p < 0.05) was significantly more 

likely than among students in urban schools. It was also significantly more 

likely among students in rural schools (t = 2.0, p < 0.05) than among students in suburban schools. 

42 
Chapter 3


Smoked Cigarettes Overall, the proportion of high school students who reported 

Before Age 13 that they had smoked their first whole cigarette before age 13 

years remained stable from 1991 to 1997; 24.8 percent of students reported 

this behavior in 1997 (Table 3-6). Similarly, there were no significant linear 

effects among males, females, White, Black, and Hispanic students overall, 

among students in suburban and rural schools, and across parent education. Students in urban schools showed a significant linear decrease in 

smoking before age 13. Hispanic males showed significant linear and quadratic effects with increases between 1991 and 1995 and then a decrease 

from 1995 to 1997. Among Hispanic students overall, there was a significant quadratic trend with smoking before age 13 years peaking in 1993. 

Among students whose parents had not finished high school, there was a 

significant quadratic trend with the lowest prevalence occurring in 1995. 

In 1997, males were significantly more likely than females to smoke 

before age 13 (t = 4.3, p < 0.001) (Table 3-2). This behavior also was significantly more likely among White students than among Black students (t = 

4.6, p < 0.001) and significantly more likely among Hispanic students than 

among Black students (t = 3.6, p < 0.001). Students in suburban (t = 2.5, p < 

0.05) and rural (t = 3.1, p < 0.01) schools were significantly more likely 

than students in urban schools to smoke before age 13. Similarly, students 

whose parents had not finished high school (t = 7.5, p < 0.001), had graduated from high school (t = 4.9, p < 0.001), or had some education after high 

school (t = 2.3, p < 0.05) were significantly more likely to report smoking 

before age 13 than were students whose parents had graduated from college. Students whose parents had not finished high school were significantly more likely to report smoking before age 13 than students whose parents 

had graduated from high school (t = 2.6, p < 0.05) or whose parents had 

some education after high school (t = 3.9, p < 0.001). 

Smoked Cigarettes on Smoking on school property remained stable from 1991 to 

School Property 1997; 14.6 percent of students reported this behavior in 

1997 (Table 3-7). This pattern was consistent among females, males, White 

female and male students, Black females, and among students whose parents had not graduated high school, had graduated high school, and students whose parents had graduated from college. Smoking on school property showed a significant linear increase among Black students overall, 

Black males, Hispanic males, and students in rural schools, and showed a 

significant linear decrease among Hispanic females. Among Hispanic 

females and students in rural schools, there were also significant quadratic 

trends with peaking in smoking on school property in 1995 and declines 

from 1995 to 1997. Among Hispanic females, after the decline from 1995 to 

1997, the prevalence in 1997 was lower than in 1993, whereas, among students in rural schools, smoking on school property remained higher in 

1997 than in 1993 even with these declines. Among students whose parents 

had some education after high school, there was only a quadratic trend 

with smoking on school property peaking in 1995. 

In 1997, males were significantly more likely than females to report 

smoking on school property (t = 2.5, p < 0.05; Table 3-2). White students 

were significantly more likely than Black (t = 4.9, p < 0.001) and 

43

Smoking and Tobacco Control Monograph No. 14


Table 3-6 

Percentage of High School Students who Reported Smoking Their First Whole Cigarette before 

Age 13 Years, by Sex, Race/Ethnicity, School Location, and Parent Education—Youth Risk 

Behavior Survey, 1991–1997 

Survey Year 

1991 1993 1995 1997 

Total 23.8 (±1.5)* 26.9 (±1.4) 24.9 (±2.7) 24.8 (±2.3) 

Sex 

Female 22.1 (±1.9) 23.3 (±2.1) 21.8 (±3.7) 20.9 (±2.4) 

Male 25.4 (±2.2) 30.1 (±1.7) 27.8 (±2.8) 28.0 (±3.3) 

Race/Ethnicity 

White 25.1 (±2.1) 28.5 (±1.9) 25.9 (±2.9) 25.7 (±3.0) 

Female 23.1 (±2.7) 24.6 (±2.7) 23.7 (±4.3) 22.1 (±3.4) 

Male 26.9 (±3.1) 31.9 (±2.3) 27.9 (±3.4) 28.5 (±3.8) 

Black 18.0 (±2.2) 18.9 (±1.8) 17.2 (±3.1) 17.4 ±(2.4) 

Female 18.5 (±3.2) 17.4 (±2.5) 14.8 (±4.2) 15.3 (±3.5) 

Male 17.4 (±2.7) 20.5 (±2.3) 20.1 (±3.1) 19.5 (±4.0) 

Hispanic 22.0 (±2.6) 27.3 (±2.0) 26.6 (±3.2) 24.9 (±3.2) §§ 

Female 22.9 (±3.8) 23.5 (±3.6) 20.2 (±5.4) 20.3 (±4.2) 

Male 20.9 (±3.0) 31.0 (±4.2) 33.0 (±5.5) 28.6 (±5.6) §,§§ 

School Location 

Urban — 26.1 (±3.1) 22.8 (±2.3) 20.9 (±2.0) § 

Suburban — 27.5 (±2.0) 25.4 (±3.7) 25.7 (±2.9) 

Rural — 25.0 (±4.0) 27.5 (±4.6) 30.7 (±5.6) 

Parental Education† 

Did not finish high school — 36.3 (±5.3) 29.1 (±5.6) 35.4 (±3.7) §§ 

Graduated high school — 30.1 (±3.3) 26.0 (±4.9) 30.3 (±2.6) 

Some education after HS — 25.4 (±1.7) 26.3 (±2.7) 25.3 (±3.5) 

Graduated college — 25.1 (±2.5) 22.6 (±2.8) 21.5 (±2.7) 

* Numbers in parentheses are 95% confidence intervals. † Highest level of education of either parent.
 § Significant linear effect (p < 0.05).
 §§ Significant quadratic effect (p < 0.05).


Note: Trend analyses were conducted using a logistic regression model controlling for sex, 


grade in school, race/ethnicity, and higher order time effects. 

44

Chapter 3


Table 3-7 

Percentage of High School Students who Reported Smoking on School Property,* by Sex, 

Race/Ethnicity, School Location, and Parent Education—Youth Risk Behavior Survey, 

1993–1997 

Survey Year 

1991 1993 1995 1997 

Total — 13.2 (±1.8)† 16.0 (±2.1) 14.6 (±1.5) 

Sex 

Female — 12.9 (±1.8) 15.1 (±2.4) 13.0 (±2.2) 

Male — 13.5 (±2.1) 16.8 (±2.6) 15.9 (±1.7) 

Race/Ethnicity 

White — 14.6 (±2.4) 17.6 (±3.0) 15.8 (±1.8) 

Female — 14.5 (±2.3) 17.7 (±3.3) 14.9 (±3.2) 

Male — 14.7 (±2.8) 17.5 (±3.2) 16.5 (±2.4) 

Black — 5.9 (±1.6) 7.6 (±2.2) 8.8 (±2.0) § 

Female — 4.5 (±1.7) 4.5 (±2.4) 5.5 (±2.0) 

Male — 7.3 (±2.8) 11.6 (±2.3) 12.4 (±3.1) § 

Hispanic — 11.1 (±2.5) 14.9 (±3.3) 11.9 (±2.5) 

Female — 11.6 (±3.1) 13.6 (±3.9) 7.7 (±1.8) §,,§§ 

Male — 10.6 (±2.7) 16.2 (±3.9) 15.3 (±3.7) § 

School Location 

Urban — 11.8 (±2.4) 14.3 (±1.7) 13.0 (±2.1) 

Suburban — 14.8 (±2.1) 16.4 (±3.9) 15.1 (±2.1) 

Rural — 6.8 (±3.2) 18.3 (±2.1) 16.8 (±4.9) §,§§ 

Parent Education‡ 

Did not finish high school — 16.3 (±4.1) 16.9 (±3.5) 18.3 (±4.6) 

Graduated high school — 14.3 (±3.4) 17.8 (±2.5) 15.4 (±2.7) 

Some education after HS — 12.7 (±2.0) 17.1 (±4.0) 13.4 (±2.0) §§ 

Graduated college — 12.7 (±1.9) 14.3 (±2.6) 14.4 (±1.9) 

* Smoked on school property on 1 or more of the 30 days preceding the survey (question not asked in 1991). † Numbers in parentheses are 95% confidence intervals. ‡ Highest level of education of either parent.
 § Significant linear effect (p < 0.05).
 §§ Significant quadratic effect (p < 0.05).


Note: Trend analyses were conducted using a logistic regression model controlling for sex, 


grade in school, race/ethnicity, and higher order time effects. 

45

Smoking and Tobacco Control Monograph No. 14


Hispanic (t = 2.4, p < 0.05) students to report this behavior. Students whose 

parents had not finished high school were significantly more likely to have 

smoked on school property than were students whose parents had some 

education after high school (t = 2.4, p < 0.05). 

Current Smokeless In 1997, 9.3 percent of students reported current use of 

Tobacco Use and smokeless tobacco and 5.1 percent reported using smokeless 

Smokeless Tobacco Use tobacco on school property (Table 3-2). 

on School Property Males were significantly more likely than females to report 

current smokeless tobacco use (t = 7.9, p < 0.001) and smokeless tobacco 

use on school property (t = 6.9, p < 0.001). White students were significantly more likely than Black (t = 9.4, p < 0.001) and Hispanic (t = 5.8, p < 

0.001) students, and Hispanic students were significantly more likely than 

Black students (t = 2.3, p < 0.05), to report current smokeless tobacco use. 

Similarly, White students were significantly more likely than Black (t = 6.5, 

p < 0.001) and Hispanic (t = 3.5, p < 0.001) students, and Hispanic students 

were significantly more likely than Black students (t = 2.0, p < 0.05), to 

report smokeless tobacco use on school property. Students in rural schools 

were significantly more likely than students in suburban (t = 2.0, p < 0.05) 

and urban (t = 2.8, p < 0.01) schools to report current smokeless tobacco 

use. In addition, students in rural schools were significantly more likely 

than students in urban schools (t = 2.4, p < 0.05) to report smokeless tobacco use on school property. Parental educational level was not associated 

with current smokeless tobacco use; however, smokeless tobacco use on 

school property was significantly more likely among students whose parents had not finished high school than among students whose parents had 

graduated from high school (t = 2.0, p < 0.05). 

Current Cigar Use In 1997, 22.0 percent of students reported current cigar use. 

Overall, males were significantly more likely than females (t = 15.1, p < 

0.001) to report this behavior and these differences held across the 

racial/ethnic subgroups. Current cigar use did not vary significantly by 

race/ethnicity overall, by school location, or by parental education. 

Trends in Current Overall, current alcohol use remained stable from 1991 to 

Smoking Compared 1997 (50.8 ±2.8 percent in 1997); however, significant linear 

with Other Drug Use increases were seen for both current marijuana use (from 14.7 

±2.2 percent in 1991 to 26.2 ±2.2 percent in 1997, p < 0.001) and current 

cocaine use (from 1.8 ±0.5 percent in 1991 to 3.3 ±0.5 percent in 1997, p < 

0.001). These increases were consistent with the significant linear increases 

in current cigarette smoking from 1991 to 1997 (Figure 3-1). This pattern 

was consistent among males and females, as well as among White and 

Hispanic students. Among Black students, however, cocaine use remained 

stable from 1991 to 1997. 

46

Chapter 3


Figure 3-1 

Current Smoking and Other Drug Use* among High-School Students, 1991-1997 

Alcohol Cigarettes Marijuana Cocaine

60

50

40

30

20

10

Prevalence (%)


0

1991 1993 1995

Survey Year 

* Used alcohol, smoked cigarettes, used marijuana, or used cocaine on 1 or more 

of the 30 days preceding the survey. 

Source: Youth Risk Behavior Survey, 1991-1997. 

1997

DISCUSSION This study found that lifetime cigarette smoking remained stable 

among high school students from 1991 to 1997; 70 percent of students 

reported this behavior in 1997. However, both current and frequent cigarette smoking significantly increased from 1991 to 1997. With the current 

patterns of tobacco use among youths, an estimated 5 million persons aged 

0 to 17 years in 1995 will die prematurely from a smoking-related illness 

(CDC, 1996). 

Approximately 80 percent of tobacco use occurs for the first time 

among youths aged less than 18 years (U.S. DHHS, 1994). Schools are ideal 

settings to influence tobacco use patterns among young people because 

educators can reach almost all school-aged youths and can provide prevention education when children are at the highest risk of experimenting with 

tobacco. To be most effective, school-based programs must target young 

persons before they initiate tobacco use or drop out of school (CDC, 1994). 

For this prevention to occur, programs must begin to reach youths at an 

early age. This study found that, from 1991 to 1997, the proportion of students who reported smoking their first whole cigarette before age 13 was 

stable—one in four students reported this behavior in 1997. 

47 
Smoking and Tobacco Control Monograph No. 14


To assist schools in providing the most effective tobacco-use prevention 

programs, the CDC (1994) developed Guidelines for School Health 

Programs to Prevent Tobacco Use and Addiction. These guidelines recommend that schools provide tobacco-use prevention education from kindergarten through 12th grade, with especially intensive instruction in junior 

high or middle school. However, this level of instruction is not occurring as 

recommended. Slightly more than one-half (55 percent) of middle and junior-high school teachers and fewer than half (47 percent) of senior high 

school teachers taught tobacco-use prevention as a major topic in their 

courses in 1994 (Crossett et al., in press). Only 21 percent of teachers who 

included tobacco-use prevention as a major topic spent six or more class 

periods on the topic. Few teachers are dedicating the instructional time that 

research trials indicate is needed to effectively prevent tobacco use (NCI, 

1990; Dusenbury et al., 1997; Botvin et al., 1995). 

This study revealed that, overall, cigarette smoking on school property 

remained stable from 1993 to 1997, but increased significantly among Black 

students overall, Black males, Hispanic males, and students in rural schools. 

In 1997, 14.6 percent of students reported smoking cigarettes on school 

property and 5.1 percent (11.3 percent of White males) used smokeless 

tobacco on school property. The CDC guidelines recommend that school 

buildings, school property, school vehicles, and school-sponsored functions 

be tobacco-free. In addition, the Pro-Children Act of 1994 (1994) requires 

smoke-free environments in all schools supported by federal funds. Most 

schools have smoke-free building policies in place, but lack more comprehensive prohibitions (Crossett et al., in press) that, if enforced, might 

reduce smoking on school property. 

School-based tobacco-use prevention programs are most effective when 

supported by community-wide programs involving families, peers, and 

community organizations (CDC, 1994). Other critical components of a 

comprehensive tobacco control program include reducing youth access 

(e.g., by implementing and adequately enforcing restrictions on minors’ 

access) (U.S. DHHS, 1994), reducing the appeal of tobacco products (U.S. 

DHHS, 1994), conducting youth-oriented mass media campaigns (U.S. 

DHHS, 1994; FDA, 1996), and increasing excise taxes on tobacco products 

(U.S. DHHS, 1994; Hamilton et al., 1997; Ohsfeldt et al., 1997). 

Rates of cigar smoking, although significantly higher among males than 

females, did not significantly vary across any other subgroups. However, as 

in other investigations (Najem et al., 1997; Nelson et al., 1995), differences 

emerged in other tobacco-use patterns among students of different 

racial/ethnic backgrounds. In this study, White students were significantly 

more likely than Hispanic students and Hispanic students were more likely 

than Black students to report ever daily smoking, current smoking, frequent 

smoking, current smokeless tobacco use, and smokeless tobacco use on 

school property. Further, White students and Hispanic students were significantly more likely than Black students to report smoking before age 13, and 

White students were significantly more likely than Black and Hispanic students to have smoked on school property. 

48 
Chapter 3


Parental education and school location were also associated with tobacco use. As parents’ education increased, students’ current cigarette smoking 

decreased, although frequent smoking and current smokeless tobacco use 

were consistent across parental education subgroups. Students in urban 

schools were generally less likely to use tobacco than students in rural 

schools. These differences partly reflect differences in the racial/ethnic distributions found across school locations. For example, urban schools in 

1997 were comprised of 45 percent of White students, 23 percent of Black 

students, and 15 percent of Hispanic students. However, in suburban 

schools, 67 percent of students were White, 9 percent were Black, and 8 

percent were Hispanic. In rural schools, 84 percent of students were White, 

4 percent were Black, and 5 percent were Hispanic. Urban schools have a 

higher proportion of Black and Hispanic students than other school locations and these students are generally less likely than White students to 

report cigarette use. 

Increasing trends in current cigarette smoking were consistent with significant increases in current marijuana and cocaine use from 1991 to 1997. 

This was expected given the strong association between cigarette smoking 

and other drug use found in other investigations (Everett et al., 1998a; 

Escobedo et al., 1997; Parra-Medina et al., 1995). Programs designed to prevent tobacco use should consider other substance use because rarely is one 

substance used in isolation (CDC, 1994; Everett et al., 1998a). 

The findings in this report are subject to at least two limitations. First, 

these data apply only to adolescents who attend high school. However, in 

1996, only 5 percent of persons aged 14 to 17 were not enrolled in school 

(Snyder, 1997). Second, the extent of underreporting or overreporting cannot be determined, although the survey questions demonstrate good testretest reliability (Brener et al., 1995). 

CONCLUSIONS Despite national efforts to reduce tobacco use among American 

youths, cigarette smoking increased among high school students nationwide from 1991 to 1997. In addition, smokeless tobacco use and cigar use 

were high in 1997. Continued efforts are needed to reduce all forms of 

tobacco use among youths. 

REFERENCES 

Botvin, G.J., Baker, E., Dusenbury, L., Botvin, E.M., 

Diaz, T. Long-term follow-up results of a randomized drug abuse prevention trial in a white 

middle-class population. Journal of the American 

Medical Association 273(14):1106-1112, 1995. 

Brener, N.D., Collins, J.L., Kann, L., Warren, C.W., 

Williams, B.I. Reliability of the Youth Risk 

Behavior Survey Questionnaire. American Journal 

of Epidemiology 141(6):575-580, 1995. 

Centers for Disease Control and Prevention. 

Guidelines for school health programs to prevent 

tobacco use and addiction. Morbidity and 

Mortality Weekly Report 43(RR-2):1-18, 1994. 

Centers for Disease Control and Prevention. 

Projected smoking-related deaths among youth— 

United States. Morbidity and Mortality Weekly 

Report 45(44):971–974, 1996. 

Crossett, L.S., Everett, S.A., Brener, N.D., Fishman, 

J.A., Pechacek, T.F. Adherence to the CDC 

Guidelines for School Health Programs to 

Prevent Tobacco Use and Addiction. Journal of 

Health Education (in press). 

Dusenbury, L., Falco, M., Lake, A. A review of the 

evaluation of 47 drug abuse prevention curricula 

available nationally. Journal of School Health 

67(4):127-132, 1997. 

49

Smoking and Tobacco Control Monograph No. 14


Escobedo, L.G., Reddy, M., DuRant, R.H. 

Relationship between cigarette smoking and 

health risk and problem behaviors among US 

adolescents. Archives of Pediatric and Adolescent 

Medicine 151(1):66-71, 1997. 

Everett, S.A., Giovino, G.A., Warren, C.W., Crossett, 

L., Kann, L. Other substance use among high 

school students who use tobacco. Journal of 

Adolescent Health 23(5):289-296 1998a. 

Everett, S.A., Husten, C.G., Warren, C.W., Crossett, 

L., Sharp, D. Trends in tobacco use among high 

school students in the United States, 1991–1995. 

Journal of School Health 68(4):137-140, 1998b. 

Food and Drug Administration. Regulations restricting the sale and distribution of cigarettes and 

smokeless tobacco to children and adolescents; 

final rule. Federal Register 61:44395-44618, 1996. 

Hamilton, V.H., Levinton, C., St-Pierre, Y., Grimard, 

F. The effect of tobacco tax cuts on cigarette 

smoking in Canada. Canadian Medical Association 

Journal 156(2):187-191, 1997. 

McGinnis, J.M., Foege, W.H. Actual causes of death 

in the United States. Journal of the American 

Medical Association 270(18):2207-2212, 1993. 

Najem, G.R., Batuman, F., Smith, A.M., Feuerman, 

M. Patterns of smoking among inner-city 

teenagers: smoking has a pediatric age of onset. 

Journal of Adolescent Health 20(3):226-231, 1997. 

National Cancer Institute. School Programs to Prevent 

Smoking: The National Cancer Institute Guide to 

Strategies that Succeed. Rockville, MD: U.S. 

Department of Health and Human Services, 

Public Health Service, National Institutes of 

Health, National Cancer Institute. DHHS 

Publication No. (NIH) 90-500, 1990. 

Nelson, D.E., Giovino, G.A., Shopland, D.R., 

Mowery, P.D., Mills, S.L., Eriksen, M.P. Trends in 

cigarette smoking among US adolescents, 

1974–1991. American Journal of Public Health 

85(1):34-40, 1995. 

Ohsfeldt, R.L., Boyle, R.G., Capilouto, E. Effects of 

tobacco excise taxes on the use of smokeless 

tobacco products in the USA. Health Economics 

6(5):525-531, 1997. 

Parra-Medina, D.M., Talavera, G., Elder, J.P., 

Woodruff, S.I. Role of cigarette smoking as a 

gateway drug to alcohol use in Hispanic junior 

high school students. Journal of the National 

Cancer Institute 18:83-86, 1995. 

Pro-Children Act of 1994. Public Law No. 103-227 

Title X § C, 1044, 108 Stat. 274. 1994. 

Quality Education Data, Inc. (WED) Data User Guide 

(version 2.7). Denver, CO: Quality Education 

Data, Inc., 1991. 

Snyder, T.D. Digest of Education Statistics, 1997. 

Washington, D.C.: U.S. Department of 

Education, Office of Educational Research and 

Improvement, National Center for Education 

Statistics, 1997. 

U.S. Department of Health and Human Services. 

Preventing Tobacco Use Among Young People: A 

Report of the Surgeon General. Atlanta, GA: U.S. 

Department of Health and Human Services, 

Public Health Service, Centers for Disease 

Control and Prevention, National Center for 

Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 1994. 

50

Trends in Adolescent Smoking in the 

United States: Data from the National 

Household Survey on Drug Abuse, 

1994 through 1998 

Andrea N. Kopstein 

INTRODUCTION It is well documented that most smokers begin cigarette use in 

their adolescent years (U.S. DHHS, 1999). The prevalence of both past-year 

and past-month smoking increases dramatically throughout adolescence 

and young adulthood, peaking when people are in their late teens or early 

twenties. Beyond that point, the prevalence of current smoking declines. 

The steepest gradient for lifetime smoking is observed in the teenage years. 

In 1998, about 17 percent of 12- to 13-year-olds had ever smoked compared 

to 37 percent of 14- to 15-year-olds and 55 percent of adolescents ages 16 

and 17 (U.S. DHHS, 2000). 

This chapter uses data from the National Household Survey on Drug 

Abuse (NHSDA) to examine trends in cigarette and other tobacco product 

use among adolescents aged 12 to 17 (U.S. DHHS, 1998). Trends for variables associated with cigarette use were also examined for the same time 

period. 

The NHSDA was first conducted by the federal government in 1971. 

The survey was fielded periodically until 1990, at which time data collection became annual. Since October of 1992, the NHSDA has been conducted by the Substance Abuse and Mental Health Services Administration 

(SAMHSA). The target population is United States civilian residents 12 years 

of age and older living in households, noninstitutional group quarters (e.g., 

shelters, rooming houses, dormitories), and military bases. The survey collects data by administering questionnaires to a representative sample of this 

population at their place of residence. The NHSDA employs a multistage 

area probability sample, and data collection takes place continuously 

throughout the calendar year. From 1985 through 1998, Hispanics, Blacks, 

and adolescents were oversampled. The sample size of the NHSDA was 

expanded to 70,000 for the 1999 survey. The NHSDA uses self-administered 

answer sheets for the most sensitive portions of the survey. 

SAMHSA continues to invest substantial resources for improving measurement of substance use and related issues. A series of methodological 

studies was conducted between 1988 and 1992. Based on the results from 

these studies, and consultation with drug researchers and other data users, 

51 
Smoking and Tobacco Control Monograph No. 14 

an improved instrument was fielded in 1994. One of the changes made in 

1994 was putting cigarette use questions on self-administered answer sheets 

instead of having the interviewer administer them, as had been done prior 

to 1994. Therefore, the cigarette trends included in this paper will be limited to surveys conducted from 1994 through 1998. Estimates of adolescent 

cigarette use prior to 1994 are not comparable to the most recent years due 

to the change in data collection method (Brittingham et al., 1998). The 

sample sizes for adolescents aged 12 to 17 years were 4,698 in 1994, 4,595 

in 1995, 4,358 in 1996, 7,844 in 1997, and 6,788 in 1998. The adolescent 

interview response rate for each year was about 85 percent. 

DATA ANALYSIS Statistical analyses were performed using SAS version 6.12 (SAS 

Institute, 1997) and SUDAAN version 7.5 (Shah et al., 1997). Because of the 

sample design of the NHSDA, traditional methods of statistical analysis that 

assume simple random sampling are not applicable. It is necessary to use 

statistical methods that incorporate both survey weights and the complex 

sample design. SUDAAN was used to compute 95 percent confidence intervals and to test the difference between time periods at the critical level of p 

< 0.05. 

Point estimates considered to be unreliable were omitted from all tables 

and are noted by asterisks (**). An estimate was considered unreliable if the 

relative standard error was greater than 17.5 percent of the log transformation of the estimated proportion. 

Trend data are presented for cigarette use and smokeless tobacco use. 

Cigar use data are presented for the 1997 and 1998 survey years. 

Demographic characteristics used in this study included gender, age, and 

race/ethnicity. Data are presented for three major racial/ethnic groups: 

White non-Hispanic, Black non-Hispanic, and Hispanic. Tobacco use is also 

shown by population density, with large metropolitan areas being defined 

as Metropolitan Statistical Areas (MSAs) with populations of 1 million or 

more. Small metropolitan areas are MSAs with populations of less than 1 

million, and nonmetropolitan areas are outside MSAs. Cigarette data are 

also presented for four U.S. geographic regions: Northeast, North Central, 

South, and West. 

52

Chapter 4 

Table 4-1 

Proportion of Adolescents Reporting Cigarette Smoking in the Month prior to Survey, by Age 

Smoked during Previous Month 

1994 1995 1996 1997 1998 

Age (N = 4,698)* (N = 4,595)* (N = 4,538)* (N = 7,844)* (N = 6,788)* 

(Years) % CI % CI % CI % CI % CI 

12–17 18.9 (17.5-20.4) 20.2 (18.8-21.8) 18.3 (16.9-19.7) 19.9 (18.6-21.3) 18.2 (16.9-19.7) 

12–13 9.40 (7.6-11.5) 10.7 (8.8-12.9) 7.30 (5.7-9.3) 9.70 (8.1-11.6) 8.00 (6.5-9.9) 

14–15 19.7 (17.3-22.4) 20.5 (18.0-23.2) 18.4 (16.2-20.8) 19.5 (17.5-21.9) 18.2 (15.9-20.7) 

16–17 28.6 (25.8-31.7) 30.1 (27.3-33.2) 28.4 (25.9-31.3) 30.3 (27.8-33.1) 29.3 (26.6-32.3) 

*Total N for ages 12–17.


Note: CI = 95% confidence interval.


Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1994–1998.


Other variables investigated included those shown in the literature to 

be important predictors for tobacco use, including self-reported average 

grades in school and perceived risk for cigarette smoking (Brandon et al., 

1996; Pierce et al., 1996). The perceived risk question for cigarette use asks, 

“How much do you think people risk harming themselves physically and in 

other ways when they smoke one or more packs of cigarettes per day?” The 

four answer choices range from “no risk” to “great risk.” 

The NHSDA collects four different prevalence periods for substance use. 

The four time periods are lifetime use (at least once in one’s life), past year 

use (using a substance at least once in the 12 months prior to interview), 

past month use (using a substance at least once in the 30 days prior to survey), and daily use. An adolescent is considered a “current smoker” if he or 

she reported smoking at least once within the 30 days prior to the interview. 

RESULTS The steepest gradient for smoking prevalence is observed in the teenage 

years. In Table 4-1, trends for current smoking are shown by age. In the 

1998 NHSDA, 8.0 percent of 12- to 13-year-olds reported smoking in the 30 

days prior to the survey compared to 18.2 percent of 14- to 15-years-olds 

and 29.3 percent of 16- to 17-year-olds. For the time period of 1994 to 

1998, the prevalence of teen smoking was fairly stable for the two younger 

age groups. Among 16- to 17-year-olds, there was no statistically significant 

increase between 1994 and 1998, but the prevalence estimates went from 

28.6 percent of this age group reporting current smoking in 1994 to 29.3 

percent in 1998. 

Trends for current smoking among 12- to 17-year-olds by gender and 

race/ethnicity are shown in Table 4-2. Among White non-Hispanic males, 

the proportion reporting current cigarette use did not significantly change 

during the 4-year time period (22.5 percent in 1994 to 20.0 percent in 

1998). For White non-Hispanic females, current smoking has been relatively 

stable at about 21 to 23 percent since 1995. Current smoking among nonHispanic Black males increased from 11.2 percent reporting current smoking in 1994 to 16.9 percent in 1998, but this difference was not statistically 

53 
Smoking and Tobacco Control Monograph No. 14 

Table 4-2 

Proportion of Adolescents 12 to 17 Years of Age Reporting Cigarette Smoking in the Past 

Month, by Gender and Race/Ethnicity 

Race/ Smoked during Previous Month 

Ethnicity 1994 1995 1996 1997 1998 

& Gender % CI % CI % CI % CI % CI 

Non-Hispanic White 

Males 22.5 (20.0-25.4) 22.8 (20.2-25.7) 19.3 (16.9-22.0) 19.8 (17.5-22.4) 20.0 (17.6-22.8) 

Females 21.5 (19.0-24.4) 23.1 (20.4-26.1) 22.5 (19.9-25.4) 23.8 (21.4-26.4) 21.0(18.4-24.0) 

Non-Hispanic Black 

Males 11.2 (8.4-15.0) 13.4 (10.4-17.2) 15.0 (12.0-18.8) 17.1 (13.9-21.0) 16.9 (13.6-21.1) 

Females 11.9 (8.9-15.8) 10.3 (7.6-13.8) 8.70 (6.5-11.7) 12.8 (10.1-16.3) 10.6 (8.1-13.8) 

Hispanic 

Males 15.2 (11.8-19.6) 18.0 (14.2-22.7) 17.0 (13.7-21.0) 18.8 (15.6-22.6) 15.4 (12.6-18.8) 

Females 13.5 (10.1-18.2) 13.0 (9.8-17.3) 12.5 (9.8-15.9) 13.1 (10.4-16.3) 14.7 (11.9-18.3) 

Note: CI = 95% confidence interval.


Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1994–1998.


significant (p < 0.07). About 11 to 12 percent of non-Hispanic Black females 

have reported current smoking from 1994 to 1998. Current smoking has 

been reported by about 15 to 18 percent of Hispanic males since 1994. 

Among Hispanic females, current smoking has been relatively stable at 

about 13 to 15 percent since 1994. 

Past year smokeless tobacco use trends are displayed in Table 4-3. 

Among White non-Hispanic males, the proportion reporting past-year 

smokeless tobacco use declined significantly (p < 0.001) from 15.0 percent 

in 1994 down to 8.8 percent in 1998. For White non-Hispanic females, rates 

for past year smokeless tobacco have remained at around 1 to 2 percent for 

5 years. The use of smokeless tobacco remained at about 1 percent among 

non-Hispanic Black males during those 5 years and the level of use among 

non-Hispanic Black females has been so low that the estimates are statistically unreliable. Between 1994 and 1998, about 2 to 4 percent of Hispanic 

males were past-year smokeless tobacco users and less than 1 percent 

reported this behavior among Hispanic females. 

Past-month (current) cigar use is shown in Table 4-4. Almost 9 percent 

of non-Hispanic White males and Hispanic males reported current cigar use 

in the 1998 survey compared to 4.7 percent of non-Hispanic Black males. 

Among White non-Hispanic females, 4.2 percent were current cigar smokers 

in 1998 compared to 2.3 percent of non-Hispanic Black females and 3.9 

percent of Hispanic females. 

Attitudes are known to be strong predictors of behavior. The data in 

Table 4-5 provide trends for the proportion of adolescents who reported 

that smoking a pack or more of cigarettes per day was of “great risk” to 

their health. None of the differences between 1994 and 1998 were statistically significant among adolescent males for any of the three racial/ethnic 

54 
Chapter 4 

Table 4-3 

Proportion of Adolescents 12 to 17 Years of Age Reporting Smokeless Tobacco Use in the Past 

Year, by Gender and Race/Ethnicity 

Race/ Smoked during Previous Month 

Ethnicity 1994 1995 1996 1997 1998 

& Gender % CI % CI % CI % CI % CI 

Non-Hispanic White 

Males 15.0 (12.9-17.4) 13.6 (11.6-16.1) 11.1 9.4a (7.8-11.2) 8.8 (7.1-10.9) 

Females 2.1 (1.4-3.2) 2.0 (1.3-3.2) ** ( 2.2 (1.5-3.2) 0.9 (0.4-2.0) 

Non-Hispanic Black 

Males 1.5 (0.4-5.2) ** ( ** ( ** 1.2 (0.5-2.6) 1.3 (0.5-3.4) 

Females ** ( ** ( ** 0.4 (0.1-1.7) 0.5 (0.1-1.7) ** ( 

Hispanic 

Males (2.4-6.5) 3.8 (1.9-7.6) 0.9 (0.4-2.2) 4.5 (2.9-7.1) 2.1 (1.2-3.8) 

Females ** ( 0.7 (0.2-2.4) 0.2 (0.1-1.3) 0.7 (0.1-3.2) 0.9 (0.4-2.0) 

(9.2-13.4) 

** ) 

** ) ) 

** ) ) ** ) 

4.0 

** ) 

Note: CI = 95% confidence interval. a The difference between 1994 and 1997 is statistically different at p < 0.01. 

** Low precision, no estimate shown.


Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1994–1998.


Table 4-4 

Proportion of Adolescents 12 to 17 Years of Age Reporting Cigar Use in the Past Month, by 

Gender and Race/Ethnicity 

Race/ Smoked during Previous Month 

Ethnicity 1997 1998 

& Gender % CI % CI 

Non-Hispanic White 

Males 

Females 

Non-Hispanic Black 

Males 

Females 

Hispanic 

Males 

Females 

7.0 (5.6-8.8) 8.5 (6.8-10.5) 

3.9 (2.9-5.3) 4.2 (3.1-5.8) 

4.1 (2.8-6.2) 4.7 (3.0-7.4) 

3.5 (2.1-5.7) 2.3 (1.3-3.9) 

6.8 (4.9-9.4) 6.6 (4.7-9.3) 

2.2 (1.2- 4.0) 3.9 (2.5-5.9) 

Note: CI = 95% confidence interval.


Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1994–1998.


55

Smoking and Tobacco Control Monograph No. 14 

Table 4-5

Proportion of Adolescents 12 to 17 Years of Age Reporting Perceived “Great Risk” from

Smoking a Pack of Cigarettes a Day or More, by Gender and Race/Ethnicity

Race/ Perceived “Great Risk” from Smoking 

Ethnicity 1994 1995 1996 1997 1998 

& Gender % CI % CI % CI % CI % CI 

Non-Hispanic White 

Males 43.8 (40.7- 47.1) N/A N/A 47.8 (44.5-51.2) 47.5 (44.6-50.7) 49.2 (46.0-52.6) 

Females 56.8 (53.6-60.2) N/A N/A 56.2 (53.0-59.6) 56.2 (53.3-59.2) 55.3 (51.9-58.8) 

Non-Hispanic Black 

Males 51.1 (46.0-56.8) N/A N/A 57.3 (52.6-62.4) 56.2 (51.8-61.0) 54.1 (49.5-59.2) 

Females 60.3 (55.6-65.3) N/A N/A 58.8 (54.1-63.8) 61.1 (56.9-65.6) 63.2 (59.0-67.8) 

Hispanic 

Males 52.5 (47.5-58.0) N/A N/A 55.6 (50.9-60.7) 59.8 (55.7-64.2) 58.9 (54.8-63.3) 

Females 61.2 (56.1-66.7) N/A N/A 63.9 (59.5-68.6) 57.9 (53.8-62.3) 64.5 (60.6-68.7) 

Note: CI = 95% confidence interval.


Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1994–1998.


categories. Only 43.8 percent of White non-Hispanic males viewed this 

behavior as risky to their health in 1994, and 49.2 percent felt this way in 

1998. The change during this time period for Black non-Hispanic males was 

from 51.1 percent to 54.1 percent and, among Hispanic males, the proportion associating “great risk” with smoking a pack a day or more was 52.5 

percent in 1994 and 58.9 percent in 1998. Attitudes toward smoking were 

stable among female adolescents, with only about 56 percent of White nonHispanic females reporting “great risk” compared to 63 percent of Black 

non-Hispanic females and 65 percent of Hispanic females. 

Tables 4-6 and 4-7 show trends for cigarette smoking by population 

density and region of the country, respectively. For both genders and all 

three population density measures, there were no statistically significant 

changes in cigarette smoking prevalence between 1994 and 1998. As seen in 

Table 4-7, there were also no statistically significant changes in cigarette 

smoking prevalence between 1994 and 1998. In 1998, however, there was a 

difference by population density with significantly (p < 0.05) fewer adolescents smoking in large metropolitan statistical areas compared to nonmetropolitan statistical areas. 

Logistic regression analysis was used to examine the relationship 

between smoking cigarettes and self-reported academic achievement. The 

relative likelihood or odds ratio (by gender) is shown in Table 4-8. Using 

male and female adolescents who reported getting mostly As in school as 

reference categories in separate models, the data show the risk of smoking 

rises notably with decreasing grades, ranging from an odds ratio of about 2 

for students who get mostly Bs to 5.5 for male students who get mostly Ds 

and 11.5 for females who get mostly Ds. 

56

Chapter 4 

Table 4-6 

Proportion of Adolescents 12 to 17 Years of Age Reporting Cigarette Smoking in the Past 

Month, by Gender and Population Density 

Gender & Reported Smoking Cigarettes during Previous Month 

Population 1994 1995 1996 1997 1998 

Density % CI % CI % CI % CI % CI 

Large MSA 

Males 

Females 

Small MSA 

Males 

Females 

Non-MSA 

Males 

Females 

16.8 (14.1-20.1) 

16.0 (13.5-19.1) 

23.0 (19.4-27.3) 

19.7 (16.3-23.9) 

19.4 (15.9-23.7) 

20.0 (16.3-24.6) 

17.6 (14.5-21.2) 

18.0 (15.0-21.6) 

20.5 (17.3-24.4) 

20.0 (16.8-23.7) 

25.7 (21.9-30.1) 

22.1 (18.1-27.1) 

19.1 (16.3-22.3) 

15.5 (12.8-18.6) 

14.5 (11.9-17.7) 

20.0 (16.8-23.6) 

20.8 (17.0-25.5) 

22.6 (18.5-27.6) 

17.2 (14.8-20.2) 17.1 (14.4-20.1) 

17.6 (15.1-20.4) 14.2 (11.7-17.4)a 

19.9 (16.9-23.5) 17.8 (14.9-21.4) 

23.3 (20.0-27.1) 19.3 (16.1-23.1) 

21.1 (17.7-25.3) 23.0 (19.1-27.7) 

22.2 (18.6-26.5) 21.9 (17.9-26.9) 

Note: CI = 95% confidence interval.
 aThe difference between females in large metropolitan statistical areas and females in non-metropolitan statistical areas is signifi­


cantly different at p < 0.05.


Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1994–1998.


Table 4-7 

Proportion of Adolescents 12 to 17 Years of Age Reporting Cigarette Smoking in the Past 

Month, by Gender and Region 

Reported Smoking Cigarettes during Previous Month 

Gender & 1994 1995 1996 1997 1998 

Region % CI % CI % CI % CI % CI 

Northeast 

Males 15.5 (11.7-20.6) 16.7 (12.4-22.5) 14.7 (10.9-19.7) 15.0) (11.2-20.1) 17.4 (13.2-23.0) 

Females 20.0 (15.3-26.1) 19.8 (15.4-25.4) 16.7 (12.4-22.4) 17.2 (13.0-22.8) 18.8 (14.2-24.8) 

Northcentral 

Males 19.1 (15.5-23.5) 24.9 (20.5-30.1) 19.4 (15.8-23.9) 20.6 (16.9-25.2) 23.2 (19.0-28.3) 

Females 21.5 (17.6-26.3) 22.2 (18.0-27.4) 20.1 (16.4-24.6) 24.1 (20.3-28.7) 20.0 (15.9-25.2) 

South 

Males 23.0 (19.5-26.9) 21.4 (18.4-24.8) 20.1 (17.1-23.5) 20.2 (17.4-23.4) 17.8 (15.0-21.2) 

Females 17.2 (14.3-20.6) 17.9 (14.8-21.5) 19.8 (16.7-23.4) 21.0 (18.2-24.2) 18.1 (15.0-21.9) 

West 

Males 18.1 (14.2-23.1) 18.2 (14.4-22.9) 14.9 (11.6-19.1) 18.9 (15.5-22.9) 16.5 (13.7-19.8) 

Females 15.0 (11.4-19.7) 19.3 (15.4-24.3) 16.9 (13.4-21.3) 19.4 (15.9-23.7) 14.0 (11.5-17.1) 

Note: CI = 95% confidence interval.


Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1994–1998.


57

Smoking and Tobacco Control Monograph No. 14 

Table 4-8 

Odds of Being a Current Cigarette Smoker by Self-Reported Grades and Gender, 1997 

Average Grades Odds Ratio 

in School Males Females 

Mostly As 1.00 1.00 

Mostly Bs 2.38 1.85 

Mostly Cs 4.10 3.24 

Mostly Ds 5.54 11.5 

Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1994–1998. 

Tables 4-9, 4-10, and 4-11 include incidence estimates calculated from 

the NHSDA. The methodology used for computation of these estimates is 

included in the footnotes at the bottom of each table. In Table 4-9, the agespecific rates of first use (per 1,000 person-years of exposure) are given by 

age group. For adolescents (12 to 17 years of age), the age-specific rate of 

first use has increased from 101.3 in 1965 to 139.1 in 1995. The age-specific 

rates of first daily use of cigarettes (per 1,000 years of exposure) are shown 

in Table 4-10 by age group. For adolescents, the rates of daily use have 

almost doubled from 44.0 in 1965 to 77.8 in 1996. Table 4-11 shows the 

incidence rates for first daily use of cigarettes by gender and age. For 12- to 

17-year-old males, the rate of first daily use of cigarettes (per 1,000 years of 

exposure) increased from 56.2 in 1965 to 72.9 in 1996. For females, the 

increase has been more dramatic, with the rate going from 41.2 in 1965 to 

82.6 in 1996. Standard errors for these incidence estimates are shown in 

Tables 4-12 through 4-14, which follow the text of this chapter. 

DISCUSSION Although the prevalence of current cigarette smoking showed important differences by race/ethnicity and by age group, there were very few statistically significant changes between 1994 and 1998. White adolescents 

(both male and female) were more likely than Black or Hispanic teens to 

report current cigarette smoking in all five time periods. In general, adolescents living in non-metropolitan areas and small metropolitan areas reported higher rates of past month cigarette use than teens living in large metropolitan statistical areas. Teens in the South and North Central regions of the 

United States reported somewhat higher rates of current cigarette smoking 

in all five time periods, but, again, there were no significant changes over 

time. 

Although males are generally less likely than females to see “great risk” 

to their health associated with heavy smoking (one or more packs per day), 

there were no changes between 1994 and 1998. As would be expected from 

the reported levels of smoking by race/ethnicity, White adolescents were 

less likely than their Black or Hispanic peers to associate “great risk” to their 

health from heavy smoking. 

With the exception of White males, the prevalence of smokeless tobacco use is very low among adolescents. There was a significant decrease in 

past year smokeless tobacco use among White males (p < 0.001), with the 

58 
Chapter 4 

Table 4-9 

Estimated Number (in 1000s) of Persons who First Used a Cigarette during Each Year, 

1965–1995, Their Mean Age at First Use, and Annual Age-Specific Rates of First Use (per 1000 

Person-Years of Exposure), Based on 1994–1997 NHSDAs 

Initiates Mean Age Age-Specific Rate of First Use1 

Year (1000s) (Years) 12–17 18–25 26–34 

1965 2,974 16.0 101.3 112.9 19.8 

1966 2,843 16.2 88.3 125.4 13.8 

1967 3,229 15.6 112.9 114.6 9.5 

1968 3,166 15.4 101.6 114.6 16.8 

1969 3,362 15.5 111.0 122.3 8.3 

1970 3,574 15.7 113.7 112.9 21.0 

1971 3,472 15.2 119.3 102.1 9.4 

1972 3,794 15.3 129.6 107.9 22.4 

1973 3,395 15.5 114.8 87.2 16.8 

1974 3,708 15.0 132.2 84.3 7.9 

1975 3,650 15.2 125.0 95.7 7.3 

1976 3,492 15.5 124.8 87.6 9.8 

1977 3,428 15.7 126.9 87.8 14.6 

1978 3,031 15.6 112.0 72.7 8.4 

1979 2,997 15.7 111.0 83.8 9.7 

1980 2,753 15.6 105.1 70.0 6.5 

1981 2,735 15.6 107.0 66.7 7.0 

1982 2,750 15.5 102.4 67.2 11.2 

1983 2,739 15.1 106.0 64.5 4.5 

1984 2,679 15.5 99.4 71.1 7.7 

1985 2,816 15.5 111.3 69.4 7.8 

1986 2,782 15.5 107.0 77.2 5.4 

1987 2,566 16.1 98.6 66.1 12.6 

1988 2,484 15.3 107.0 58.6 7.1 

1989 2,503 16.3 99.5 60.9 8.5 

1990 2,645 15.5 101.6 71.3 7.9 

1991 2,567 16.0 100.5 66.4 11.1 

1992 2,707 15.7 115.0 64.7 9.2 

19932 2,897 16.1 121.4 70.1 6.7 

19943 3,178 16.0 131.0 82.0 4.6 

19954 3,263 15.6 139.1 85.8 7.6 

1 The numerator of each rate equals the number of persons who first used the drug in the year (times 1000). The denominator of 

each rate equals the number of persons who were exposed to risk of first use during the year, weighted by their estimated 

exposure time measured in years. For example, for the age group 12–17 in 1990, the denominator is the sum of three 

components: 

(1) those persons 12–17 years old in 1990 who first used the drug in 1989 or earlier, times a weight of zero. The weight 

is zero since they had zero exposure to the risk of first use in 1990. 

(2) those who first used the drug in 1990 times a weight of 0.5. The weight of 0.5 assumes that these people, on average, first used the drug at mid-year and consequently have a half year of exposure (i.e., the first half of the year.) 

(3) those who never used, or those who first used the drug in 1991 or later, times a weight of 1.0. The weight of 1.0 

assumes their exposure to the risk of first use during 1990 was for the whole year. 

Each person is also weighted by his/her sample weight. 

2 Estimated using 1995, 1996, and 1997 data only. 

3 Estimated using 1996 and 1997 data only. 

4 Estimated using 1997 data only.


Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1994–1997.


59

Smoking and Tobacco Control Monograph No. 14 

Table 4-10 

Estimated Number (in 1000s) of Persons who Began Daily Cigarette Use during Each Year, 

1965–1996, Their Mean Age at First Daily Use, and Annual Age-Specific Rates of First Daily 

Use (per 1000 Person-Years of Exposure), Based on 1994–1997 NHSDAs 

Initiates Mean Age Age-Specific Rate of First Use1 

Year (1000s) (Years) 12–17 18–25 26–34 

1965 1,606 17.9 44.0 106.2 7.9 

1966 1,716 17.9 42.6 117.0 6.0 

1967 1,741 18.7 48.1 100.8 14.8 

1968 2,268 18.5 49.7 155.2 6.4 

1969 2,055 18.0 57.1 116.4 18.0 

1970 1,910 17.3 52.5 101.9 6.5 

1971 2,175 18.0 58.0 117.9 15.0 

1972 2,004 17.9 57.7 95.4 25.4 

1973 2,276 17.9 65.3 106.5 25.6 

1974 2,403 18.9 66.2 109.2 23.7 

1975 1,811 18.4 49.4 87.1 14.5 

1976 1,976 18.1 54.8 93.1 17.6 

1977 2,284 18.4 66.8 108.0 12.9 

1978 1,984 18.3 59.6 88.1 14.4 

1979 1,955 19.0 54.7 92.5 16.7 

1980 1,704 18.7 51.6 81.7 10.5 

1981 1,757 19.1 56.4 73.3 14.1 

1982 1,586 18.7 49.2 73.3 11.9 

1983 1,527 18.3 43.8 73.9 13.3 

1984 1,547 18.4 52.3 65.4 11.1 

1985 1,497 18.7 50.2 66.2 10.8 

1986 1,561 18.0 56.7 69.5 10.0 

1987 1,482 18.4 51.8 68.0 10.4 

1988 1,384 18.5 51.2 60.8 11.4 

1989 1,436 18.7 53.8 61.4 7.1 

1990 1,503 18.3 57.8 63.6 13.9 

1991 1,464 18.1 57.6 58.0 13.3 

1992 1,651 18.2 61.9 69.1 11.9 

1993 1,578 18.8 58.7 60.0 12.6 

19942 1,747 17.9 67.7 68.9 10.4 

19953 1,797 17.8 71.8 62.3 11.3 

19964 1,851 17.3 77.8 68.4 7.5 

1 The numerator of each rate equals the number of persons who first used the drug in the year (times 1000). The denominator of 

each rate equals the number of persons who were exposed to risk of first use during the year, weighted by their estimated 

exposure time measured in years. For example, for the age group 12–17 in 1990, the denominator is the sum of three 

components: 

(1) those persons 12–17 years old in 1990 who first used the drug in 1989 or earlier, times a weight of zero. The weight 

is zero since they had zero exposure to the risk of first use in 1990. 

(2) those who first used the drug in 1990 times a weight of 0.5. The weight of 0.5 assumes that these people, on average, first used the drug at mid-year and consequently have a half year of exposure (i.e., the first half of the year.) 

(3) those who never used, or those who first used the drug in 1991 or later, times a weight of 1.0. The weight of 1.0 

assumes their exposure to the risk of first use during 1990 was for the whole year. 

Each person is also weighted by his/her sample weight. 

2 Estimated using 1995, 1996, and 1997 data only. 

3 Estimated using 1996 and 1997 data only. 

4 Estimated using 1997 data only.


Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1994–1997.


60

Chapter 4 

Table 4-11 

Annual Age-Specific Rates of First Daily Use (per 1000 Person-Years of Exposure) of Persons 

who Began Daily Cigarette Use during Each Year 1962-1996 among the Total U.S. Population 

by Gender, Based on 1994-1997 NHSDAs 

Age Specific Rate of First Use1 

Total Male Female 

Year 12–17 18–25 26–34 12–17 18–25 26–34 12–17 18–25 26–34 

1962 48.3 129.8 13.9 56.5 150.6 * 41.2 120.7 11.0 

1963 51.0 104.6 24.3 61.1 142.8 * 41.6 86.7 32.7 

1964 34.7 93.5 17.3 40.3 152.3 * 29.1 63.9 22.1 

1965 44.0 106.2 7.9 54.3 143.8 * 34.1 84.5 3.2 

1966 42.6 117.0 6.0 62.8 189.0 ** 22.4 76.8 8.4 

1967 48.1 100.8 14.8 55.3 139.3 11.6 41.2 79.4 16.2 

1968 49.7 155.2 6.4 64.7 202.0 4.7 35.4 127.7 7.1 

1969 57.1 116.4 18.0 67.2 166.0 24.2 47.3 84.8 15.5 

1970 52.5 101.9 6.5 68.6 136.3 10.0 38.1 78.2 5.2 

1971 58.0 117.9 15.0 58.6 175.4 12.5 57.4 79.3 15.9 

1972 57.7 95.4 25.4 63.5 117.5 9.8 52.5 80.2 31.3 

1973 65.3 106.5 25.6 76.5 154.2 24.1 55.5 74.3 26.3 

1974 66.2 109.2 23.7 68.4 119.9 20.7 64.3 101.8 25.1 

1975 49.4 87.1 14.5 47.2 114.8 25.5 51.3 66.8 9.5 

1976 54.8 93.1 17.6 45.9 101.6 18.5 62.9 86.7 17.1 

1977 66.8 108.0 12.9 75.7 106.4 7.8 58.7 109.3 15.4 

1978 59.6 88.1 14.4 56.8 108.4 15.4 62.1 72.2 13.8 

1979 54.7 92.5 16.7 56.3 89.2 14.4 53.2 95.1 18.0 

1980 51.6 81.7 10.5 52.0 90.7 12.3 51.3 74.3 9.3 

1981 56.4 73.3 14.1 52.5 78.1 18.2 59.9 69.1 11.6 

1982 49.2 73.3 11.9 49.1 84.6 19.8 49.3 63.4 7.0 

1983 43.8 73.9 13.3 42.1 91.9 10.8 45.2 58.5 14.9 

1984 52.3 65.4 11.1 52.9 81.9 10.6 51.8 51.4 11.5 

1985 50.2 66.2 10.8 60.3 81.3 4.6 41.7 53.4 15.3 

1986 56.7 69.5 10.0 52.0 82.6 8.6 60.7 58.8 11.1 

1987 51.8 68.0 10.4 55.7 74.3 14.4 48.5 62.8 7.5 

1988 51.2 60.8 11.4 57.2 76.4 14.4 45.8 48.3 9.0 

1989 53.8 61.4 7.1 58.6 79.4 6.9 49.4 47.4 7.2 

1990 57.8 63.6 13.9 59.6 84.5 14.2 56.0 48.1 13.6 

1991 57.6 58.0 13.3 60.5 68.7 19.5 54.8 50.2 8.4 

61

Smoking and Tobacco Control Monograph No. 14 

Table 4-11 (continued) 

Age Specific Rate of First Use1 

Total Male Female 

Year 12–17 18–25 26–34 12–17 18–25 26–34 12–17 18–25 26–34 

1992 61.9 69.1 11.9 61.9 77.5 14.4 61.9 62.9 10.0 

1993 58.7 60.0 12.6 56.1 71.4 17.4 61.3 51.5 9.0 

19942 67.7 68.9 10.4 71.9 93.5 11.2 63.6 50.0 9.7 

19953 71.8 62.3 11.3 78.4 81.1 8.9 65.1 48.0 13.0 

19964 77.8 68.4 7.5 72.9 84.8 9.9 82.6 55.9 5.8 

* Low Precision, no estimate reported. 

** Estimate rounds to zero. 1 The numerator of each rate equals the number of persons who first used the drug in the year (times 1000). The denominator of 

each rate equals the number of persons who were exposed to risk of first use during the year, weighted by their estimated 

exposure time measured in years. For example, for the age group 12–17 in 1990, the denominator is the sum of three 

components: 

(1) those persons 12–17 years old in 1990 who first used the drug in 1989 or earlier, times a weight of zero. The weight 

is zero since they had zero exposure to the risk of first use in 1990. 

(2) those who first used the drug in 1990 times a weight of 0.5. The weight of 0.5 assumes that these people, on average, first used the drug at mid-year and consequently have a half year of exposure (i.e., the first half of the year.) 

(3) those who never used, or those who first used the drug in 1991 or later, times a weight of 1.0. The weight of 1.0 

assumes their exposure to the risk of first use during 1990 was for the whole year. 

Each person is also weighted by his/her sample weight. 

2 Estimated using 1995, 1996, and 1997 data only. 

3 Estimated using 1996 and 1997 data only. 

4 Estimated using 1997 data only.


Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1994–1997.


past year rate dropping from 15 percent in 1994 to 8.8 percent in 1998. 

Table 4-4 includes the prevalence of cigar use by teens from the 1997 and 

1998 surveys (cigar questions were added to the NHSDA in 1997). Cigars 

have been increasing in popularity for the last few years. White and 

Hispanic males are the most likely adolescents to report this behavior (8.5 

and 6.6 percent, respectively). 

Although the prevalence of past month cigarette smoking (current use) 

among adolescents has been relatively stable over time for all age, 

racial/ethnic, and gender groups in the NHSDA between 1994 and 1998, 

incidence estimates from this survey indicate there may be cause for concern. The trends for initiation of cigarette smoking (shown in Tables 4-10 

through 4-12) indicate that an alarming number of adolescents become regular smokers each day. The incidence data included in this chapter indicate 

that more than 6,000 persons under the age of 18 try their first cigarette 

each day, and more than 3,000 persons under the age of 18 become daily 

smokers each day. Among persons 12 to 17 years of age, particularly the 

females, the incidence of first use of cigarettes and first daily use have been 

rising during the 1990s. Age-specific rates of regular smoking (first daily 

use) of cigarettes among 12- to 17-year-olds (per 1,000 years of exposure) 

have almost doubled in the last 30 years, from 44.0 in 1965 to 77.8 in 

1996. 

62

Chapter 4 

DATA LIMITATIONS An important potential source of bias is the underreporting 

of illicit behaviors such as cigarette use for persons less than 18 years of age 

(Bradburn et al., 1987). While there are no objective criteria for validating 

the self-reports in this study, inferential evidence of their validity is available. Examples of such evidence include the large proportion of respondents admitting to the use of the tobacco products included, the near universal completion of survey items concerning tobacco use (NIDA, 1997), 

and the finding of predictable relationships between cigarette use and such 

items as self-reported grades. Underreporting bias has been reduced by 

allowing respondents to answer sensitive questions on self-administered 

answer sheets. 

In a study published in 1998, Brittingham et al. analyzed data from the 

1994 NHSDA. The main interview in the 1994 NHSDA included two versions of the smoking items. In one version, the interviewer administered 

the smoking questions and, in the other, the questions were self-administered. Even though cigarette use is legal for adults, self-administered questions produced higher estimates for the prevalence of cigarette smoking 

than interviewer-administered questions for respondents of all ages 

(Brittingham et al., 1998). 

THE FOLLOWING PAGES CONTAIN 

TABLES 4-12 THROUGH 4-14, WHICH 

SHOW STANDARD ERRORS FOR 

TABLES 4-9 THROUGH 4-11 

63

Smoking and Tobacco Control Monograph No. 14 

Table 4-12 

Standard Errors of Estimated Number (in 1000s) of Persons who First Used a Cigarette during 

Each Year 1965–1995, Their Mean Age at First Use, and Annual Age-Specific Rates of First Use 

(per 1000 Person-Years of Exposure), Based on 1994–1997 NHSDAs 

Initiates Mean Age Age-Specific Rate of First Use1 

Year (1000s) (Years) 12–17 18–25 26–34 

1965 190 0.4 7.6 13.9 9.0 

1966 188 0.3 7.3 14.5 6.0 

1967 176 0.3 7.4 11.1 6.3 

1968 166 0.3 8.4 11.2 9.0 

1969 185 0.3 7.9 12.4 4.4 

1970 218 0.4 9.1 11.3 10.9 

1971 185 0.2 7.8 11.0 3.0 

1972 188 0.2 7.5 10.1 8.4 

1973 149 0.3 6.9 7.7 4.8 

1974 184 0.2 8.1 9.9 2.5 

1975 177 0.2 7.7 9.6 2.7 

1976 197 0.3 7.4 9.9 3.2 

1977 153 0.2 6.0 9.4 3.8 

1978 124 0.3 4.8 6.6 2.5 

1979 124 0.2 5.7 8.9 3.6 

1980 106 0.3 4.9 6.6 2.9 

1981 115 0.3 5.2 6.4 1.9 

1982 108 0.2 4.7 6.6 3.5 

1983 110 0.2 5.3 4.8 1.4 

1984 115 0.2 4.6 5.7 2.2 

1985 110 0.2 5.2 4.0 3.1 

1986 99 0.2 5.7 5.7 1.3 

1987 102 0.3 4.9 4.7 3.0 

1988 91 0.2 5.1 4.6 2.1 

1989 94 0.4 4.8 4.4 1.7 

1990 94 0.2 4.1 5.2 1.6 

1991 116 0.3 4.5 5.6 4.0 

1992 102 0.2 4.2 4.5 2.9 

19932 107 0.3 5.0 4.9 1.5 

19943 155 0.4 6.6 7.3 1.4 

19954 178 0.2 9.1 10.1 2.6 

1 The numerator of each rate equals the number of persons who first used the drug in the year (times 1000). The denominator of 

each rate equals the number of persons who were exposed to risk of first use during the year, weighted by their estimated 

exposure time measured in years. For example, for the age group 12–17 in 1990, the denominator is the sum of three 

components: 

(1) those persons 12–17 years old in 1990 who first used the drug in 1989 or earlier, times a weight of zero. The weight 

is zero since they had zero exposure to the risk of first use in 1990. 

(2) those who first used the drug in 1990 times a weight of 0.5. The weight of 0.5 assumes that these people, on average, first used the drug at mid-year and consequently have a half year of exposure (i.e., the first half of the year.) 

(3) those who never used, or those who first used the drug in 1991 or later, times a weight of 1.0. The weight of 1.0 

assumes their exposure to the risk of first use during 1990 was for the whole year. 

Each person is also weighted by his/her sample weight. 

2 Estimated using 1995, 1996, and 1997 data only. 

3 Estimated using 1996 and 1997 data only. 

4 Estimated using 1997 data only.


Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1994–1997.


64

Chapter 4 

Table 4-13 

Standard Errors of Estimated Number (in 1000s) of Persons who Began Daily Cigarette Use 

during Each Year 1965–1996, Their Mean Age at First Daily Use, and Annual Age-Specific 

Rates of First Daily Use (per 1000 Person-Years of Exposure), Based on 1994–1997 NHSDAs 

Initiates Mean Age Age-Specific Rate of First Use1 

Year (1000s) (Years) 12–17 18–25 26–34 

1965 141 0.5 7.2 11.6 4.5 

1966 139 0.3 4.9 13.9 2.7 

1967 145 0.5 5.9 12.9 7.1 

1968 162 0.5 5.9 14.5 2.7 

1969 150 0.3 6.2 12.4 8.7 

1970 128 0.3 5.1 10.5 3.2 

1971 160 0.4 5.6 12.1 7.2 

1972 141 0.3 5.1 9.0 8.7 

1973 160 0.3 6.7 9.9 8.1 

1974 167 0.6 6.0 10.7 5.5 

1975 122 0.5 4.0 9.2 4.3 

1976 124 0.3 4.2 8.4 4.4 

1977 151 0.4 5.1 11.5 3.2 

1978 109 0.5 3.9 7.7 3.3 

1979 108 0.4 3.1 7.0 3.8 

1980 94 0.5 3.4 6.9 3.2 

1981 117 0.6 3.9 7.4 3.7 

1982 101 0.7 3.4 7.8 4.6 

1983 85 0.3 3.2 6.1 3.9 

1984 73 0.4 3.6 4.0 2.5 

1985 92 0.5 3.8 5.1 3.8 

1986 67 0.3 3.9 4.6 2.5 

1987 78 0.3 4.7 5.0 2.5 

1988 70 0.5 3.8 4.5 1.9 

1989 78 0.6 3.5 4.5 1.4 

1990 71 0.3 3.6 4.4 2.5 

1991 82 0.3 3.8 4.3 3.6 

1992 83 0.3 4.0 4.2 2.2 

1993 79 0.7 3.2 4.3 2.7 

19942 78 0.5 3.7 5.9 2.2 

19953 113 0.3 4.5 6.5 2.3 

19964 139 0.4 7.0 7.8 3.4 

1 The numerator of each rate equals the number of persons who first used the drug in the year (times 1000). The denominator of 

each rate equals the number of persons who were exposed to risk of first use during the year, weighted by their estimated 

exposure time measured in years. For example, for the age group 12–17 in 1990, the denominator is the sum of three 

components: 

(1) those persons 12–17 years old in 1990 who first used the drug in 1989 or earlier, times a weight of zero. The weight 

is zero since they had zero exposure to the risk of first use in 1990. 

(2) those who first used the drug in 1990 times a weight of 0.5. The weight of 0.5 assumes that these people, on average, first used the drug at mid-year and consequently have a half year of exposure (i.e., the first half of the year.) 

(3) those who never used, or those who first used the drug in 1991 or later, times a weight of 1.0. The weight of 1.0 

assumes their exposure to the risk of first use during 1990 was for the whole year. 

Each person is also weighted by his/her sample weight. 

2 Estimated using 1995, 1996, and 1997 data only. 

3 Estimated using 1996 and 1997 data only. 

4 Estimated using 1997 data only.


Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1994–1997.


65

Smoking and Tobacco Control Monograph No. 14 

Table 4-14 

Standard Errors of Annual Age-Specific Rates of First Daily Use (per 1000 Person-Years of 

Exposure) of Persons who Began Daily Cigarette Use during Each Year, 1962–1996, among the 

Total U.S. Population by Gender, Based on 1994–1997 NHSDAs 

Age Specific Rate of First Use1 

Total Male Female 

Year 12–17 18–25 26–34 12–17 18–25 26–34 12–17 18–25 26–34 

1962 6.0 20.3 6.6 9.3 39.4 * 7.8 23.7 5.8 

1963 6.4 16.6 12.2 10.0 32.2 * 8.5 18.4 17.2 

1964 5.1 13.4 9.5 7.9 29.8 * 6.0 12.1 13.3 

1965 7.2 11.6 4.5 12.6 23.6 * 6.4 12.8 2.3 

1966 4.9 13.9 2.7 8.6 27.7 ** 4.8 14.3 3.8 

1967 5.9 12.9 7.1 10.0 25.6 6.2 6.3 13.3 9.6 

1968 5.9 14.5 2.7 9.7 29.1 3.4 6.9 16.0 3.5 

1969 6.2 12.4 8.7 9.3 24.8 14.9 8.8 12.7 10.7 

1970 5.1 10.5 3.2 10.9 20.4 7.9 5.6 10.6 3.2 

1971 5.6 12.1 7.2 9.4 24.8 6.1 7.1 10.2 9.5 

1972 5.1 9.0 8.7 8.1 16.7 7.3 6.6 9.0 11.9 

1973 6.7 9.9 8.1 11.1 21.5 11.1 7.2 10.5 10.5 

1974 6.0 10.7 5.5 8.7 18.3 9.3 7.7 12.7 6.9 

1975 4.0 9.2 4.3 5.8 16.2 10.6 6.1 9.7 3.7 

1976 4.2 8.4 4.4 6.0 13.0 8.5 6.3 10.4 5.3 

1977 5.1 11.5 3.2 10.2 15.1 3.4 5.3 15.0 4.4 

1978 3.9 7.7 3.3 6.8 14.2 5.1 4.4 9.3 4.3 

1979 3.1 7.0 3.8 5.8 11.1 5.8 4.2 9.8 5.6 

1980 3.4 6.9 3.2 5.6 12.7 6.8 3.9 7.9 3.2 

1981 3.9 7.4 3.7 5.2 12.3 7.1 5.4 7.9 4.2 

1982 3.4 7.8 4.6 4.9 12.3 10.9 4.8 7.0 3.0 

1983 3.2 6.1 3.9 4.6 10.3 4.1 4.1 5.8 5.6 

1984 3.6 4.0 2.5 6.1 7.2 4.4 4.4 4.5 3.6 

1985 3.8 5.1 3.8 7.4 8.3 2.0 3.3 5.2 6.4 

1986 3.9 4.6 2.5 5.4 7.6 3.5 5.2 5.1 3.2 

1987 4.7 5.0 2.5 6.4 8.0 5.2 5.2 5.8 2.0 

1988 3.8 4.5 1.9 5.7 8.1 5.2 4.3 4.5 2.5 

1989 3.5 4.5 1.4 4.8 7.5 2.2 4.5 5.0 1.7 

1990 3.6 4.4 2.5 5.6 7.5 3.4 4.5 4.9 3.7 

1991 3.8 4.3 3.6 5.2 7.8 7.7 4.8 5.3 1.7 

66

Chapter 4 

Table 4-14 (continued) 

Age Specific Rate of First Use1 

Total Male Female 

Year 12–17 18–25 26–34 12–17 18–25 26–34 12–17 18–25 26–34 

1992 4.0 4.2 2.2 5.4 7.1 3.6 4.8 5.6 3.1 

1993 3.2 4.3 2.7 4.5 7.0 6.0 4.3 4.7 1.4 

19942 3.7 5.9 2.2 5.6 11.5 3.1 4.8 5.4 3.3 

19953 4.5 6.5 2.3 6.4 9.7 3.3 6.7 7.7 3.1 

19964 7.0 7.8 3.4 9.6 14.7 5.4 9.2 10.0 4.2 

* Low Precision, no estimate reported. 

** Estimate rounds to zero. 1 The numerator of each rate equals the number of persons who first used the drug in the year (times 1000). The denominator of 

each rate equals the number of persons who were exposed to risk of first use during the year, weighted by their estimated 

exposure time measured in years. For example, for the age group 12–17 in 1990, the denominator is the sum of three 

components: 

(1) those persons 12–17 years old in 1990 who first used the drug in 1989 or earlier, times a weight of zero. The weight 

is zero since they had zero exposure to the risk of first use in 1990. 

(2) those who first used the drug in 1990 times a weight of 0.5. The weight of 0.5 assumes that these people, on average, first used the drug at mid-year and consequently have a half year of exposure (i.e., the first half of the year.) 

(3) those who never used, or those who first used the drug in 1991 or later, times a weight of 1.0. The weight of 1.0 

assumes their exposure to the risk of first use during 1990 was for the whole year. 

Each person is also weighted by his/her sample weight. 

2 Estimated using 1995, 1996, and 1997 data only. 

3 Estimated using 1996 and 1997 data only. 

4 Estimated using 1997 data only.


Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1994–1997.


REFERENCES 

Bradburn, N.M., Rips, L.J., Shevell, S.K. Answering 

autobiographical questions: the impact of memory and inference on surveys. Science 

236(4798):157-161, 1987. 

Brandon, T.H., Wetter, D.W., Baker, T.B. Affect, 

expectancies, urges, and smoking: do they conform to models of drug motivation and relapse? 

Experimental and Clinical Psychopharmacology 

4:29-36, 1996. 

Brittingham, A., Tourangeau, R., Kay, W. Reports of 

smoking in a national survey: data from screening and detailed interviews, and from self- and 

interviewer-administered questions. Annals of 

Epidemiology 8(6):393-401, 1998. 

Kann, L., Kinchen, S., Williams, B., Ross, J., Lowry, 

R., Hill, C., Grunbaum, J., Blumson, P., Collins, 

J., Kolbe, L. Youth Risk Behavior Surveillance— 

United States, 1997. Mortality and Morbidity 

Weekly Report Surveillance Summaries 47(No. SS3):1-89. U.S. Department of Health and Human 

Services, National Center for Chronic Disease 

Prevention and Health Promotion, Centers for 

Disease Control and Prevention, 1998 

National Institute on Drug Abuse. The Validity of SelfReported Drug Use: Improving the Accuracy of Survey 

Estimates. NIDA Research Monograph No. 167. 

U.S. Department of Health and Human Services, 

National 1, NIH Publication No. 97-4147, 1997. 

Pierce, J.P., Choi, W.S., Gilpin, EA., Farkas, A.J., 

Merritt, R. Validation of susceptibility as a predictor of which adolescents take up smoking in 

the United States. Health Psychology 15(5):355-

361, 1996. 

SAS Institute. SAS/STAT Software: Changes and 

enhancements through release 6.12. ISBN No. 1-

55544-873-9. SAS Institute, Cary, N.C., 1997. 

Shah, B.V., Barnwell, B.G., Bieler, G.S. SUDAAN: software for the statistical analysis of correlated data; 

user’s manual, release 7.5. Research Triangle Park, 

NC: Research Triangle Institute, 1997. 

67

Smoking and Tobacco Control Monograph No. 14 

U.S. Department of Health and Human Services. 

National Household Survey on Drug Abuse: Main 

Findings, 1997. U.S. Department of Health and 

Human Services, Substance Abuse and Mental 

Health Services Administration, Office of Applied 

Studies. U.S. DHHS Pub. No. (SMA ) 99-3295. 

Hyattsville, MD: U.S. Government Printing 

Office, 1999. 

U.S. Department of Health and Human Services. 

National Household Survey on Drug Abuse: Main 

Findings, 1998. U.S. Department of Health and 

Human Services, Substance Abuse and Mental 

Health Services Administration, Office of Applied 

Studies. U.S. DHHS Pub. No. (SMA ) 2000-xxxx. 

Hyattsville, MD: Government Printing Office, 

2000. 

U.S. Department of Health and Human Services. 

National Household Survey on Drug Abuse: 

Population Estimates, 1997. U.S. Department of 

Health and Human Services, Substance Abuse 

and Mental Health Services Administration, 

Office of Applied Studies. U.S. DHHS Pub. No. 

(SMA) 98-3250. Hyattsville, MD: Government 

Printing Office, 1998. 

68

Cigarette Smoking among Adolescents 

in California, 1990–1996 

David M. Burns, Jacqueline M. Major, Jerry W. Vaughn, 

Christy M. Anderson, Thomas G. Shanks 

INTRODUCTION Initiation of cigarette smoking occurs almost exclusively during 

adolescence (U.S. DHHS, 1994; Lynch and Bonnie, 1994; CDC, 1998a; 

Burns et al., 1997). Currently, if one becomes an adult without becoming a 

cigarette smoker, it is unlikely that one will ever smoke cigarettes. 

California has conducted three large surveys of smoking behavior among 

adolescents in 1990, 1993, and 1996 (Burns and Pierce, 1992; Pierce et al., 

1994 & 1998). During this period, there has been an increase in adolescent 

smoking behavior nationally (CDC, 1998b) and in California (Pierce et al., 

1998). In this chapter, we examine the increase in smoking prevalence over 

time in California to define its demographic distribution. We also examine 

several predictors of adolescent cigarette smoking to determine whether the 

increase in prevalence has been accompanied by an increase in the power 

of the predictors to identify current smokers or by an increase in the prevalence of these predictors among the current population of adolescents. 

Tracking changes in adolescent smoking prevalence over time provides 

important information in aiding current primary prevention efforts and in 

predicting future adult disease consequences. 

The California Tobacco Surveys are telephone surveys conducted periodically by the state of California and the methodology for these surveys is 

reported elsewhere (Pierce et al., 1998). The absolute values for prevalence 

of smoking in these telephone surveys differ from those of the school-based 

surveys reported in other chapters of this monograph, but the trends over 

time are consistent across the differences in survey methodology. 

DEFINITION OF Initiation of cigarette smoking among adolescents is a process 

SMOKING FOR that includes experimentation with smoking, intermittent use, 

ADOLESCENTS regular use, and addiction (U.S. DHHS, 1994; Lynch and 

Bonnie, 1994). Because the issue being examined is the start of smoking 

behavior among adolescents, the traditional adult definition of a smoker 

(Have you ever smoked 100 cigarettes in your lifetime?) would exclude 

many adolescents who are in the early stages of smoking initiation. As a 

result, the question used to define current smokers among the adolescents 

sampled in the California Tobacco Surveys was, “Think about the last 30 

days. On how many of these days did you smoke?” A current smoker was 

one who reported any smoking in the last 30 days. The question “Have you 

ever smoked a cigarette?” was also asked, and those who said yes were 

defined as ever-smokers. 

69

Smoking and Tobacco Control Monograph No. 14 

Figure 5-1 

Smoking Prevalence among 12- to 17-Year-Old Adolescents in California: 1990-1998 

14 

12 

10 

8 

6 

4 

2 

0 

1990 1991 1992 1993 1994 1995 1996 1997 1998 

9.1 8.7 9.1

10.9 

11.9 

11.2 10.9 10.7 

Survey Year 

1990, 1992-1993: California Tobacco Survey* (CTS), UCSD. 

1994-1998: California Youth Tobacco Survey* (CYTS), CDHS). 

* Telephone interviews. 

CHANGE IN ADOLESCENT National data on adolescent smoking behavior indiSMOKING BEHAVIORS, cate a substantial recent increase in smoking preva1990–1998 lence among adolescents, with most of the increase 

occurring after 1993 (CDC, 1998a). Similar changes have occurred in 

California. Figure 5-1 presents the prevalence of cigarette smoking among 

adolescents ages 12–17 for the period of 1990 to 1998 in California. These 

data are consistent with the national data showing a rise in prevalence over 

that period. This increase may have peaked and begun to decline after 

1996. 

The prevalence of current and ever smoking among 12- to 17-year-old 

adolescents is presented in Figure 5-2, with both ever smoking and current 

smoking estimates presented for 1990, 1993, and 1996 (Table 5-1). 

Between 1990 and 1993, there was a significant increase in the proportion of adolescents who had ever smoked cigarettes, but the prevalence of 

smoking in the last 30 days was unchanged. In contrast, between 1993 and 

1996, the prevalence of ever smoking increased only slightly, but there was 

Percent Prevalence 

70

Chapter 5 

Figure 5-2 

Change in Adolescent Cigarette Smoking: 1990-1996 

Have Smoked, 

but not in the 

Have Smoked in 

the Last 30 Days 

30


25


Last 30 Days 

16.16 18.81 16.66 

9.19 9.13 11.97 

Percentage Change 

20


15


10


5


0


1990 1993 1996 

Year 

1990, 1993, 1996 California Tobacco Survey (CTS), UCSD. 

* Telephone interviews. 

a significant increase in the prevalence of current smoking. The magnitude 

of the increase in smoking prevalence in California is smaller than that 

reported for school-based surveys nationally (CDC, 1998a), but it clearly 

reflects a move in the opposite direction from that anticipated by the public health community. This report examines the demographic distribution 

of this change in adolescent smoking prevalence and describes the relationships between some of the known correlates of smoking initiation and this 

change in initiation over time. 

Gender Figure 5-3 presents the prevalence of smoking among male and female 

adolescents for the years 1990, 1993, and 1996. Males have a slightly higher 

prevalence of smoking than females, but both genders have increased by 

similar amounts over the 6-year interval. The increase over time was largely 

between the years 1993 and 1996 and was statistically significant for both 

males and females. 

Age Figure 5-4 presents the current-smoking prevalence among adolescents 

for different age groups. The figure reveals that the increase in prevalence 

has occurred predominantly among those aged 14–15 and 16–17, with the 

71 
72 Table 5-1 

Cigarette Smoking Prevalence and Frequency of Use among Adolescents during the Last 30 Days: 1990, 1993, 1996 

Have Smoked in Last 30 Days Have Smoked, but Not in Last 30 Days Have Never S

Total: 1990 1993 1996 1990 1993 1996 1990 1993 

Statewide (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (C

Total 9.19 0.93 9.13 1.04 11.97 1.07 16.16 1.38 18.81 1.65 16.66 1.18 74.61 1.30 71.90 1.

Age (Years) 12–13 3.62 1.52 2.98 1.03 3.31 0.86 7.35 1.94 7.87 1.61 7.19 1.37 89.00 2.67 88.93 1.

14–15 7.98 1.47 9.13 1.55 10.86 1.38 16.94 2.62 20.97 2.68 18.52 2.05 75.08 3.12 69.81 2.

16–17 16.61 2.13 16.29 2.62 22.10 2.28 24.98 3.01 29.18 3.87 24.34 1.94 58.33 3.11 54.37 3.

Race/Ethnicity Non-Hispanic White 10.95 1.24 11.33 1.31 13.67 1.28 19.04 1.86 21.22 1.75 18.08 1.58 69.96 1.72 67.38 2.

Hispanic 8.83 1.87 8.24 1.82 11.52 2.04 15.73 2.67 19.60 3.48 16.32 1.75 75.41 2.52 71.79 3.

African-American 5.55 3.12 5.08 3.53 6.17 2.68 9.55 2.60 11.45 4.32 15.01 3.78 84.89 3.96 83.46 5.

Asian/PI 4.70 2.55 5.09 3.44 8.96 2.76 9.16 3.51 10.25 2.85 12.60 2.76 86.14 4.19 84.66 4.

Native American 8.65 5.10 8.73 5.38 18.25 10.48 18.28 8.59 18.17 8.86 19.44 8.09 73.07 9.97 73.10 8.

Other . . . . . . 2.45 5.01 . . . . . . . 

Educational Performance Above average 5.86 1.08 5.94 1.20 8.88 1.15 14.10 2.04 16.94 2.26 14.69 1.42 80.04 1.93 77.00 2.

Average 11.33 1.78 10.78 1.58 13.94 1.73 19.01 2.47 20.02 2.34 19.58 1.95 69.60 2.33 68.96 2.

Below average 39.08 11.60 30.51 8.97 36.94 7.73 18.98 7.53 28.88 8.62 20.26 6.93 41.66 9.95 40.61 8.

Unknown 4.28 6.78 . . 28.90 10.78 2.98 6.09 . . 18.60 9.35 92.74 9.42 . 

Family Income (Dollars) <10k 11.19 4.67 7.46 3.46 12.94 3.89 10.88 4.84 16.86 3.86 12.80 3.20 77.93 5.64 75.43 4.

10k–20k 8.77 2.87 10.18 3.78 13.12 3.21 15.75 3.77 17.57 3.70 14.20 3.15 75.48 3.85 72.25 4.

20k–30k 9.30 2.64 11.22 3.94 11.40 2.44 15.99 4.65 20.25 4.96 16.43 2.45 74.71 5.30 68.46 4.

30k–50k 9.04 2.75 9.53 1.88 12.77 2.51 15.96 2.90 19.62 2.44 19.20 2.66 74.89 3.51 70.71 2.

50k–75k 7.89 2.32 8.85 2.23 11.42 2.16 15.43 3.56 19.56 2.59 18.49 2.70 76.68 3.47 71.38 3.

>75k 10.45 2.95 9.11 2.53 10.79 1.91 22.13 4.48 18.01 4.22 15.74 1.98 67.42 4.35 72.88 4.

Unknown 8.26 3.01 6.69 2.86 12.03 3.01 16.96 5.11 18.53 5.24 15.94 3.61 74.69 5.61 74.23 5.
Table 5-1 (continued) 

Have Smoked in Last 30 Days Have Smoked, but Not in Last 30 Days Have Never S

Males: 1990 1993 1996 1990 1993 1996 1990 1993 

Statewide (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (C

Total 9.72 1.53 10.14 1.72 12.64 1.40 17.77 2.01 19.85 2.58 17.32 1.61 72.44 2.39 69.91 2.

Age (Years)
12–13 4.30 2.85 3.28 1.37 4.20 1.33 8.21 3.40 8.40 2.30 8.23 2.04 87.44 4.40 88.21 2.

14–15 7.04 1.87 9.34 2.30 9.34 2.29 19.30 4.14 20.11 2.97 19.26 2.69 73.66 4.12 70.55 3.

16–17 18.69 3.49 18.88 4.37 24.75 3.06 26.57 3.35 32.71 5.67 24.36 3.27 54.57 4.82 48.18 5.

Race/Ethnicity Non-Hispanic White 10.23 1.58 12.00 1.98 13.37 1.75 19.54 3.03 20.11 2.70 18.74 2.02 70.11 3.30 67.73 3.

Hispanic 10.92 3.05 9.74 2.74 13.31 2.76 19.37 4.55 23.04 5.67 16.88 2.74 69.65 4.31 67.11 5.

African-American 6.51 5.80 6.65 4.82 5.86 3.20 10.51 4.76 14.31 6.92 16.09 4.91 82.98 9.25 79.03 8.

Asian/PI 5.18 4.42 4.98 3.48 10.50 3.91 9.57 5.97 11.73 4.27 12.42 4.28 85.26 6.74 83.29 5.

Native American 11.12 9.57 11.17 8.44 17.06 13.74 13.68 12.50 16.12 9.35 23.73 11.47 . . 72.71 9.

Other . . . . . . . . . . . . . . . 

Educational Performance Above average 5.32 1.28 6.82 1.93 8.97 1.44 15.84 3.32 18.40 4.08 15.00 1.90 78.84 3.48 74.79 3.

Average 11.29 2.36 11.46 2.47 14.92 2.21 20.86 3.40 19.91 2.96 20.47 2.70 67.72 3.54 68.36 2.

Below average 48.25 14.17 29.02 12.35 33.91 8.41 14.59 8.85 30.01 11.35 20.86 8.94 36.74 10.90 40.97 10.

Unknown . . . . . . . . . . . . . . . 

Family Income (Dollars) <10k 14.64 8.37 7.95 4.64 14.57 5.10 17.71 10.26 18.18 7.25 14.68 4.54 67.65 11.53 73.87 8.

10k–20k 8.67 3.90 10.52 4.93 16.96 4.90 17.30 6.89 21.11 4.98 12.52 4.50 74.03 7.99 68.37 6.

20k–30k 9.27 3.31 14.33 5.14 11.14 3.27 17.25 6.23 21.11 6.65 15.62 4.14 73.47 6.79 64.56 7.

30k–50k 9.43 4.67 9.50 2.57 13.97 3.78 16.62 4.13 19.59 3.30 19.51 3.32 73.73 4.90 70.73 3.

50k–75k 7.85 2.52 11.02 3.67 12.20 2.67 15.82 4.59 18.38 3.65 19.17 3.78 76.34 4.81 70.19 5.

>75k 11.03 4.67 10.35 3.84 9.10 2.40 26.35 6.69 16.93 4.83 17.73 2.84 62.62 6.61 72.72 5.

Unknown 9.09 5.47 5.94 4.48 12.92 3.89 14.82 6.17 25.12 9.53 18.59 5.67 75.90 8.33 68.94 9.

73 
74 Table 5-1 (continued) 

Have Smoked in Last 30 Days Have Smoked, but Not in Last 30 Days Have Never S

Females: 1990 1993 1996 1990 1993 1996 1990 1993 

Statewide (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (C

Total 8.67 1.49 8.15 1.47 11.25 1.42 14.59 1.74 17.80 1.72 15.94 1.32 76.74 2.05 73.85 1.

Age (Years) 12–13 2.98 1.66 2.70 1.36 2.37 1.05 6.52 1.93 7.37 1.90 6.10 1.42 90.50 2.80 89.61 2.

14–15 8.93 2.41 8.92 2.48 12.51 2.19 14.57 2.66 21.82 3.78 17.72 2.54 76.50 3.84 69.08 4.

16–17 14.62 2.99 13.74 3.12 19.20 2.64 23.45 4.58 25.71 4.06 24.31 2.56 61.93 4.92 60.46 4.

Race/Ethnicity Non-Hispanic White 11.67 2.15 10.67 2.03 14.02 2.10 18.53 2.61 22.30 2.64 17.33 2.00 69.81 3.08 67.04 2.

Hispanic 6.80 2.27 6.75 2.25 9.71 2.41 12.21 3.24 16.19 3.15 15.75 2.29 80.99 3.76 76.45 4.

African-American 4.78 4.27 3.63 3.89 6.47 4.23 8.77 5.24 8.80 4.43 13.98 4.92 86.46 6.33 87.58 5.

Asian/PI 4.19 3.38 5.20 5.82 7.32 3.42 8.74 4.17 8.86 3.48 12.78 3.85 87.07 4.79 85.94 6.

Native American 5.98 5.86 5.61 6.48 19.77 11.29 . . . . 14.00 7.82 . . . 

Other . . . . . . 2.76 5.67 . . . . . . . 

Educational Performance Above average 6.36 1.87 5.17 1.47 8.80 1.56 12.49 2.03 15.67 2.19 14.39 1.85 81.15 2.38 78.93 2.

Average 11.37 2.53 10.06 2.17 12.78 2.31 17.13 3.35 20.14 3.42 18.52 3.05 71.50 3.20 69.60 3.

Below average 21.48 11.43 32.81 12.28 42.10 15.46 27.41 11.51 27.14 11.78 19.23 10.46 . . 40.05 12.

Unknown 4.44 9.38 . . . . 4.41 9.31 . . . . . . . 

Family Income (Dollars) <10k 8.56 5.29 7.04 5.48 11.30 4.97 5.69 3.10 15.74 6.22 10.90 4.25 85.76 5.60 76.76 7.

10k–20k 8.85 4.61 9.80 5.17 9.17 3.56 14.33 5.07 13.69 5.23 15.93 3.82 76.82 5.93 76.50 6.

20k–30k 9.34 4.29 7.84 3.87 11.65 3.73 14.44 5.81 19.32 5.42 17.19 4.09 76.21 6.99 72.70 5.

30k–50k 8.66 2.92 9.56 3.20 11.53 2.44 15.30 4.51 19.65 3.60 18.87 4.02 76.04 5.89 70.69 4.

50k–75k 7.93 3.20 6.68 2.36 10.51 3.12 15.06 4.96 20.75 4.48 17.70 3.65 77.01 5.27 72.58 4.

>75k 9.89 4.70 7.91 3.45 12.87 2.81 18.07 4.89 19.06 5.60 13.27 2.86 72.04 6.65 73.03 6.

Unknown 7.46 3.73 7.35 3.68 11.07 4.02 19.00 8.45 12.81 4.38 13.05 4.74 73.54 8.56 78.82 4.

Note: The column Unknown has been eliminated from this table; CI = 95% confidence interval. 

Source: 1990, 1993, 1996 California Tobacco Surveys, UCSD. Telephone interviews. 
Chapter 5 

Figure 5-3 

Prevalence of Smoking at Least One Cigarette in the Last 30 Days among Male and 

Female Adolescents: 1990, 1993, 1996 

15 

12 

9 

6 

3 

0 

1990 1993 1996 

Male Female 

1990, 1993, 1996 California Tobacco Survey* (CTS), UCSD. 

* Telephone interviews. 

prevalence for the 12- to 13-year-old group remaining unchanged. This pattern of increasing prevalence for the two older age groups with no change 

for the youngest age group is present for both males and females. 

Number of the Last 30 Use of cigarettes among adolescents is commonly 

Days that Cigarettes episodic and progresses to a greater prevalence of daily 

Were Used smoking as the adolescent increases in age and adopts 

more adult—and addictive—patterns of smoking. This change in frequency 

of smoking with increasing age is presented in Figure 5-5 and Tables 5-2a 

and 5-2b, which show that an increasing percentage of adolescents report 

smoking in the last 30 days as they age. With each age group, smoking on 

1–19 days out of the last 30 is the most common frequency of smoking 

reported, but the change in prevalence of daily smoking with advancing 

age is particularly dramatic. 

It is useful to know how each category of number of days smoked has 

contributed to the observed increase in smoking prevalence among adolescents between 1990 and 1996. Figure 5-6 shows the increase (or decrease) in 

prevalence of each frequency of smoking between 1990 and 1996 for each 

age group. The increase in smoking prevalence between 1990 and 1996 is 

confined to the two older age groups, as noted earlier. The largest contribuPrevalence (%) 

75

Smoking and Tobacco Control Monograph No. 14 

Figure 5-4 

Prevalence of Current Cigarette Smoking among Adolescent Californians of Different 

Ages: 1990, 1993, 1996 

25


Current Cigarette Smoking (%) 20


15


10


5


I990 1993 1996

0


12—13 Years 14—15 Years 16—17 Years 

Age Group 

1990, 1993, 1996 California Tobacco Survey* (CTS), UCSD. 

* Telephone interviews. 

tion to the increased prevalence is made by the change in the prevalence of 

adolescents smoking 1–19 days out of the last 30. This category is the 

largest category of smokers among all adolescents, but it also increases by 

more than 40 percent between 1990 and 1996, in contrast to the increase of 

less than 20 percent in daily smoking. These data suggest that a large fraction of the increase in smoking prevalence among California adolescents is 

composed of less-frequent smokers who may not yet be addicted and who 

may, therefore, still be able to easily stop smoking if they can be reached 

and appropriately motivated. 

Race and Ethnicity White adolescents have a higher smoking prevalence than 

adolescents in other racial and ethnic populations, with the possible exception of Native Americans, for whom the small sample size in the survey 

leads to a wide confidence interval. The increase in smoking prevalence 

between 1990 and 1996 among all adolescents is replicated for each of the 

racial and ethnic groups, with the exception of African Americans (Figure 5-

7). The pattern of increasing prevalence in all racial and ethnic groups, 

except African Americans, is present for both males and females. 

76 
Chapter 5 

Figure 5-5 

Percentage of Adolescents who Have Smoked Different Numbers of Days Out of the 

Last 30 in 1996 

15 

12 

9 

6 

3 

0 

12— 13 Years 14— 15 Years 16— 17 Years 

1— 19 Days 

20— 29 Days 

All 30 Days 

Age Group 

1996 California Tobacco Survey* (CTS), UCSD. 

* Telephone interviews. 

Income No change in smoking prevalence over time is evident among adolescents whose families earn incomes over $75,000. Adolescents whose families earn less than $10,000 may have an increase in smoking prevalence 

between 1993 and 1996, but are unchanged from 1990. The bulk of the 

increase in smoking prevalence seems to occur among adolescents from 

families in the middle range of incomes of $10,000–$75,000. 

In contrast to adults, who show marked declines in smoking prevalence 

with increasing family income, adolescent smoking does not appear to be 

strongly influenced by family income. Moreover, there is no clear trend 

over time by family income. Figure 5-8 presents adolescent smoking prevalence by levels of family income for 1990, 1993, and 1996. 

PREDICTORS OF A number of factors, including family smoking behaviors and 

ADOLESCENT peer influence, are recognized as predictors of adolescent 

INITIATION smoking initiation. In examining the increase in smoking 

prevalence among adolescents in California, it is useful to explore whether 

the impact of some of these predictors has changed over time. Three patPercentage 

77

Smoking and Tobacco Control Monograph No. 14 

Table 5-2a 

Cigarette Smoking Prevalence and Frequency of Use among Adolescents in the 

Last 30 Days: 1990 

Number of Days Smoked Cigarette(s) in Past 30 Days 

None in Past 

Total: All 30 Days 20–29 Days 1–19 Days 30 Days Never Smoked 

Statewide (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) 

Total 2.30 0.60 0.87 0.43 6.02 0.83 16.16 1.38 74.61 1.30 

Age (Years) 

12–13 0.16 0.20 0.05 0.07 3.42 1.52 7.35 1.94 89.00 2.67 

14–15 1.64 0.73 0.50 0.48 5.84 1.40 16.94 2.62 75.08 3.12 

16–17 5.37 1.55 2.17 1.02 9.07 1.83 24.98 3.01 58.33 3.11 

Race/Ethnicity 

Non-Hispanic White 3.82 1.18 1.21 0.49 5.92 1.05 19.04 1.86 69.96 1.72 

Hispanic 0.99 0.53 0.36 0.38 7.48 1.91 15.73 2.67 75.41 2.52 

African-American . . 1.08 2.21 4.48 2.73 9.55 2.60 84.89 3.96 

Asian/PI 1.54 1.73 0.77 1.05 2.39 1.86 9.16 3.51 86.14 4.19 

Native American 2.55 3.03 1.32 1.84 4.78 3.55 18.28 8.59 73.07 9.97 

Other . . . . . . 2.45 5.01 . . 

Educational Performance 

Above average 1.26 0.56 0.59 0.31 4.01 0.94 14.10 2.04 80.04 1.93 

Average 3.20 1.07 0.82 0.45 7.31 1.45 19.01 2.47 69.60 2.33 

Below average 8.51 4.32 6.02 6.83 24.55 12.15 18.98 7.53 41.66 9.95 

Unknown 3.00 6.14 . . 1.28 2.59 2.98 6.09 92.74 9.42 

Family Income (Dollars) 

<10k 1.91 1.38 0.89 1.84 8.39 4.14 10.88 4.84 77.93 5.64 

10k–20k 2.07 1.72 0.34 0.34 6.36 2.59 15.75 3.77 75.48 3.85 

20k–30k 2.52 1.28 0.94 0.87 5.85 2.07 15.99 4.65 74.71 5.30 

30k–50k 2.14 1.15 1.00 0.64 5.90 2.18 15.96 2.90 74.89 3.51 

50k–75k 2.34 1.44 0.88 0.74 4.68 1.37 15.43 3.56 76.68 3.47 

>75k 2.94 2.09 1.26 1.04 6.24 1.89 22.13 4.48 67.42 4.35 

Unknown 2.22 1.46 0.58 0.91 5.45 2.53 16.96 5.11 74.69 5.61 

78

Chapter 5 

Table 5-2a (continued) 

Number of Days Smoked Cigarette(s) in Past 30 Days 

None in Past 

Males: All 30 Days 20–29 Days 1–19 Days 30 Days Never Smoked 

Statewide (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) 

Total 2.41 0.87 1.04 0.74 6.27 1.35 17.77 2.01 72.44 2.39 

Age (Years) 

12–13 0.08 0.16 0.06 0.12 4.15 2.85 8.21 3.40 87.44 4.40 

14–15 1.20 0.74 0.73 0.75 5.12 1.52 19.30 4.14 73.66 4.12 

16–17 6.33 2.57 2.48 1.78 9.88 2.68 26.57 3.35 54.57 4.82 

Race/Ethnicity 

Non-Hispanic White 3.79 1.53 1.22 0.78 5.23 1.27 19.54 3.03 70.11 3.30 

Hispanic 1.22 0.83 0.56 0.75 9.14 2.96 19.37 4.55 69.65 4.31 

African-American . . 2.40 4.90 4.11 3.87 10.51 4.76 82.98 9.25 

Asian/PI 1.76 2.53 0.52 0.66 2.90 3.48 9.57 5.97 85.26 6.74 

Native American 3.41 5.47 2.55 3.77 5.17 5.61 13.68 12.50 . . 

Other . . . . . . . . . . 

Educational Performance 

Above average 0.88 0.56 0.57 0.53 3.88 1.28 15.84 3.32 78.84 3.48 

Average 3.67 1.59 0.84 0.69 6.78 2.07 20.86 3.40 67.72 3.54 

Below average 9.54 7.35 8.55 10.53 30.16 17.24 14.59 8.85 36.74 10.90 

Unknown . . . . . . . . . . 

Family Income (Dollars) 

<10k 3.13 2.60 2.06 4.26 9.45 6.21 17.71 10.26 67.65 11.53 

10k–20k 1.41 1.35 0.15 0.30 7.11 3.86 17.30 6.89 74.03 7.99 

20k–30k 2.41 1.56 1.49 1.59 5.37 2.50 17.25 6.23 73.47 6.79 

30k–50k 3.14 2.07 0.94 1.10 5.35 4.13 16.62 4.13 73.73 4.90 

50k–75k 1.13 1.00 0.93 1.08 5.78 2.09 15.82 4.59 76.34 4.81 

>75k 3.36 2.94 1.51 1.97 6.16 3.00 26.35 6.69 62.62 6.61 

Unknown 2.01 1.56 0.24 0.36 6.84 4.98 14.82 6.17 75.90 8.33 

79

Smoking and Tobacco Control Monograph No. 14 

Table 5-2a (continued) 

Number of Days Smoked Cigarette(s) in Past 30 Days 

None in Past 

Females: All 30 Days 20–29 Days 1–19 Days 30 Days Never Smoked 

Statewide (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) 

Total 2.19 0.76 0.70 0.32 5.78 1.25 14.59 1.74 76.74 2.05 

Age (Years) 

12–13 0.23 0.36 0.03 0.06 2.72 1.58 6.52 1.93 90.50 2.80 

14–15 2.09 1.18 0.27 0.28 6.57 2.48 14.57 2.66 76.50 3.84 

16–17 4.45 2.00 1.87 0.97 8.29 2.34 23.45 4.58 61.93 4.92 

Race/Ethnicity 

Non-Hispanic White 3.85 1.47 1.20 0.61 6.62 1.81 18.53 2.61 69.81 3.08 

Hispanic 0.77 0.72 0.17 0.23 5.87 2.23 12.21 3.24 80.99 3.76 

African-American . . . . 4.78 4.27 8.77 5.24 86.46 6.33 

Asian/PI 1.31 2.38 1.04 2.08 1.84 1.64 8.74 4.17 87.07 4.79 

Native American 1.63 3.28 . . 4.35 6.03 . . . . 

Other . . . . . . 2.76 5.67 . . 

Educational Performance 

Above average 1.61 1.01 0.61 0.42 4.14 1.18 12.49 2.03 81.15 2.38 

Average 2.73 1.22 0.80 0.57 7.84 2.21 17.13 3.35 71.50 3.20 

Below average 6.53 5.40 1.18 2.42 13.76 10.23 27.41 11.51 . . 

Unknown 4.44 9.38 . . . . 4.41 9.31 . . 

Family Income (Dollars) 

<10k 0.98 1.09 . . 7.58 5.04 5.69 3.10 85.76 5.60 

10k–20k 2.67 2.46 0.51 0.63 5.66 4.40 14.33 5.07 76.82 5.93 

20k–30k 2.65 2.27 0.27 0.37 6.43 4.17 14.44 5.81 76.21 6.99 

30k–50k 1.16 0.86 1.05 0.77 6.45 2.91 15.30 4.51 76.04 5.89 

50k–75k 3.50 2.26 0.82 1.10 3.61 2.19 15.06 4.96 77.01 5.27 

>75k 2.54 3.13 1.03 1.11 6.32 2.99 18.07 4.89 72.04 6.65 

Unknown 2.43 2.53 0.91 1.79 4.12 2.14 19.00 8.45 73.54 8.56 

Note: The column “Unknown” has been eliminated from this table.


CI = 95% confidence interval.


Source: 1990, 1993, 1996 California Tobacco Surveys, UCSD. Telephone interviews.


80

Chapter 5 

Table 5-2b 

Cigarette Smoking Prevalence and Frequency of Use among Adolescents in the 

Last 30 Days: 1996 

Number of Days Smoked Cigarette(s) in Past 30 Days 

None in Past 

Total: All 30 Days 20–29 Days 1–19 Days 30 Days Never Smoked 

Statewide (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) 

Total 2.70 0.48 1.65 0.43 7.62 0.76 16.66 1.18 71.36 1.38 

Age (Years) 

12–13 0.14 0.16 0.35 0.43 2.82 0.73 7.19 1.37 89.50 1.61 

14–15 1.82 0.67 1.57 0.63 7.47 1.16 18.52 2.05 70.58 2.33 

16–17 6.30 1.19 3.06 0.97 12.74 1.71 24.34 1.94 53.56 2.66 

Race/Ethnicity 

Non-Hispanic White 3.74 0.63 1.73 0.53 8.20 0.99 18.08 1.58 68.25 1.80 

Hispanic 1.82 0.81 1.40 0.72 8.30 1.55 16.32 1.75 72.12 2.23 

African-American 1.00 0.87 0.99 0.91 4.18 1.94 15.01 3.78 78.82 4.36 

Asian/PI 1.79 1.14 2.09 1.32 5.08 1.93 12.60 2.76 78.44 3.32 

Native American 6.01 5.16 3.82 4.34 8.43 4.90 19.44 8.09 62.31 10.44 

Other . . . . . . . . . . 

Educational Performance 

Above average 1.94 0.47 1.09 0.43 5.85 0.87 14.69 1.42 76.42 1.61 

Average 2.94 0.68 1.51 0.66 9.49 1.56 19.58 1.95 66.44 2.24 

Below average 9.26 4.53 10.04 4.83 17.65 5.58 20.26 6.93 42.80 5.79 

Unknown 12.85 8.39 6.17 6.39 9.88 7.68 18.60 9.35 . . 

Family Income (Dollars) 

<10k 4.55 2.18 1.73 1.69 6.67 2.74 12.80 3.20 74.26 5.07 

10k–20k 3.37 1.44 1.12 0.87 8.63 2.45 14.20 3.15 72.68 3.64 

20k–30k 2.96 1.48 1.58 1.19 6.87 2.23 16.43 2.45 72.05 3.56 

30k–50k 2.44 0.91 1.69 0.88 8.63 1.91 19.20 2.66 68.04 3.52 

50k–75k 2.38 1.02 1.51 0.95 7.53 1.88 18.49 2.70 70.09 3.04 

>75k 2.09 0.91 1.90 0.86 6.80 1.42 15.74 1.98 73.48 2.89 

Unknown 2.22 1.26 2.03 1.40 7.79 2.53 15.94 3.61 72.02 4.43 

81

Smoking and Tobacco Control Monograph No. 14 

Table 5-2b (continued) 

Number of Days Smoked Cigarette(s) in Past 30 Days 

None in Past 

Males: All 30 Days 20–29 Days 1–19 Days 30 Days Never Smoked 

Statewide (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) 

Total 2.66 0.69 1.73 0.56 8.25 1.09 17.32 1.61 70.00 2.08 

Age (Years) 

12–13 0.11 0.21 0.48 0.58 3.62 1.22 8.23 2.04 87.56 2.67 

14–15 1.86 0.88 1.09 0.74 6.39 1.74 19.26 2.69 71.32 3.39 

16–17 6.11 1.76 3.69 1.46 14.95 2.55 24.36 3.27 50.89 3.83 

Race/Ethnicity 

Non-Hispanic White 3.10 0.83 1.98 0.80 8.29 1.42 18.74 2.02 67.89 2.45 

Hispanic 2.29 1.15 1.19 0.81 9.83 2.14 16.88 2.74 69.72 3.63 

African-American 0.44 0.63 0.31 0.62 5.11 3.03 16.09 4.91 78.05 5.20 

Asian/PI 2.36 2.01 2.56 2.05 5.59 2.94 12.42 4.28 77.07 4.19 

Native American 7.29 6.05 4.81 6.66 4.96 4.87 23.73 11.47 . . 

Other . . . . . . . . . . 

Educational Performance 

Above average 1.89 0.72 1.13 0.58 5.95 1.13 15.00 1.90 76.03 2.20 

Average 2.72 0.97 1.70 0.99 10.51 1.89 20.47 2.70 64.53 3.18 

Below average 8.28 5.13 7.45 4.34 18.18 7.17 20.86 8.94 45.24 8.34 

Unknown . . 9.30 12.04 11.13 12.52 . . . . 

Family Income (Dollars) 

<10k 5.25 3.22 1.52 2.08 7.80 3.88 14.68 4.54 70.76 5.65 

10k–20k 4.41 2.46 1.56 1.46 10.98 3.48 12.52 4.50 70.52 5.68 

20k–30k 2.92 1.90 1.53 1.53 6.69 2.98 15.62 4.14 73.00 5.32 

30k–50k 2.35 1.48 1.61 0.94 10.01 2.86 19.51 3.32 66.52 4.96 

50k–75k 1.94 1.45 2.31 1.65 7.95 2.32 19.17 3.78 68.62 4.47 

>75k 1.65 1.07 1.76 1.10 5.69 2.06 17.73 2.84 73.16 3.80 

Unknown 2.03 1.57 1.44 1.83 9.45 3.52 18.59 5.67 68.50 6.55 

82

Chapter 5 

Table 5-2b (continued) 

Number of Days Smoked Cigarette(s) in Past 30 Days 

None in Past 

Females: All 30 Days 20–29 Days 1–19 Days 30 Days Never Smoked 

Statewide (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) 

Total 2.75 0.61 1.55 0.54 6.95 1.09 15.94 1.32 72.81 1.62 

Age (Years) 

12–13 0.18 0.26 0.21 0.34 1.99 0.92 6.10 1.42 91.53 1.47 

14–15 1.79 0.83 2.09 1.00 8.63 1.92 17.72 2.54 69.78 3.33 

16–17 6.52 1.59 2.38 1.07 10.30 1.99 24.31 2.56 56.50 3.09 

Race/Ethnicity 

Non-Hispanic White 4.48 1.11 1.44 0.59 8.10 1.55 17.33 2.00 68.66 2.64 

Hispanic 1.35 0.82 1.61 1.09 6.75 1.86 15.75 2.29 74.54 2.73 

African-American 1.53 1.63 1.64 1.62 3.29 2.57 13.98 4.92 79.55 6.03 

Asian/PI 1.19 1.19 1.59 1.63 4.54 2.54 12.78 3.85 79.90 4.82 

Native American 4.38 6.00 2.56 3.76 12.83 9.59 14.00 7.82 . . 

Other . . . . . . . . . . 

Educational Performance 

Above average 1.99 0.66 1.06 0.55 5.75 1.23 14.39 1.85 76.81 2.19 

Average 3.21 0.99 1.28 0.84 8.28 2.22 18.52 3.05 68.70 3.31 

Below average 10.92 7.16 14.44 9.50 16.75 8.41 19.23 10.46 38.66 11.77 

Unknown 9.57 10.92 2.77 3.87 8.51 9.40 . . . . 

Family Income (Dollars) 

<10k 3.84 2.30 1.93 2.04 5.52 3.29 10.90 4.25 77.80 6.68 

10k–20k 2.30 1.46 0.67 0.79 6.20 2.95 15.93 3.82 74.90 4.41 

20k–30k 2.99 1.84 1.62 1.40 7.04 3.28 17.19 4.09 71.16 5.57 

30k–50k 2.53 1.15 1.78 1.13 7.22 1.85 18.87 4.02 69.60 4.64 

50k–75k 2.87 1.48 0.60 0.52 7.04 2.65 17.70 3.65 71.78 4.00 

>75k 2.63 1.47 2.08 1.26 8.16 2.35 13.27 2.86 73.86 3.90 

Unknown 2.42 1.70 2.67 2.20 5.98 3.19 13.05 4.74 75.88 5.67 

Note: The column “Unknown” has been eliminated from this table.


CI = 95% confidence interval.


Source: 1990, 1993, 1996 California Tobacco Surveys, UCSD. Telephone interviews.


83

Smoking and Tobacco Control Monograph No. 14 

Figure 5-6 

Change Between 1990 and 1996 in the Percentage of Adolescents who Smoked 

Different Numbers of Days Out of the Last 30 

4.0 

3.5 

3.0 

2.5 

2.0 

1.5 

1.0 

0.5 

0.0 

-0.5 

-1.0 

12— 13 Years 14— 15 Years 16— 17 Years 

1— 19 Days 

20— 29 Days 

All 30 Days 

# of Days Smoked 

Age Group 

1990 and 1996 California Tobacco Survey* (CTS), UCSD. 

* Telephone interviews. 

terns defining the increase in adolescent prevalence may emerge. First, the 

predictor of smoking initiation may have increased in frequency in the 

population (for example, the number of adolescents who report that their 

friends smoke may have increased), but the impact of the predictor on initiation may not have changed. This pattern would show no change between 

1990 and 1996 in adolescent smoking prevalence at each level of the predictor, but more adolescents would be in the category that predicts higher 

initiation. A second pattern would result if the impact of the predictor on 

initiation has become more powerful over time. This pattern would show 

an increase in adolescent smoking prevalence between 1990 and 1996 in 

those levels of the predictor associated with high smoking initiation. A final 

pattern could occur in which the increase in smoking prevalence between 

1990 and 1996 would be uniformly spread across the levels of the predictor, 

indicating that the predictor had not changed in the intensity of its effect 

on cessation. This last pattern would suggest that the predictor did not contribute to the observed increase in adolescent smoking between 1990 and 

1996. 

Percentage 

84

Chapter 5 

Figure 5-7 

Current Cigarette Smoking Prevalence among Adolescent Californians of Different 

Race and Ethnic Groups: 1990, 1993, and 1996 

30


Current Cigarette Smoking (%) 25


20


15


10


1990 1993 1996

5


0


Non-Hispanic Hispanic 

White 

African- Asian/PI 

American 

Native 

American 

1990, 1993, and 1996 California Tobacco Survey* (CTS), UCSD. 

* Telephone interviews. 

School Performance One of the most powerful predictors of adolescent smoking 

behavior is self-described school performance. Figure 5-9, as well as Tables 

5-1, 5-2a, and 5-2b, present adolescent smoking prevalence in 1990, 1993, 

and 1996 for each of the school performance groups. For male and female 

adolescents combined, there are statistically significant increases in smoking prevalence for both the above-average and average school performance 

groups; the largest part of the increase appears to have occurred between 

1993 and 1996. There was no increase in prevalence with adolescents who 

described their school performance as being below average, with 3 to 5 percent of adolescents describing their school performances as being in this 

category. This suggests that a substantial part of the recent increase in adolescent smoking prevalence occurred among those school performance 

groups in which prevention efforts have traditionally been most successful 

rather than among adolescents in the group that is at greatest risk (those 

with below-average performance). 

When males and females are combined, there is an absence of change 

between 1990 and 1996 in the smoking prevalence of adolescents who 

report that they have below-average school performance. This masks an 

85 
Smoking and Tobacco Control Monograph No. 14 

Figure 5-8 

Prevalence of Current Cigarette Smoking among Adolescent Californians of Different 

Family Incomes: 1990, 1993, and 1996 

18


16


I990 1993 1996

Current Cigarette Smoking (%) 14


12


10


8


6


4


2


0


† 10,000 10,001—


20,000


20,001—


30,000


30,001—


50,000


50,001— 75,000+ 

75,000 

Income ($) 

1990, 1993, and 1996 California Tobacco Survey* (CTS), UCSD. 

* Telephone interviews. 

important gender-related difference between 1990 and 1996 for this school 

performance category. When smoking prevalence trends are examined separately for male and female adolescents, both males and females show similar increases in smoking prevalence between 1990 and 1996 for the aboveaverage and average school performance categories. However, males and 

females with below-average school performance change in opposite directions during the 1990–1996 period. Male adolescents with below-average 

school performance had a statistically significant decline in smoking prevalence between 1990 and 1993, and this decline was maintained in the 

1993–1996 period. In contrast, adolescent females who reported below-average school performance almost doubled their smoking prevalence between 

1990 and 1996, and the increase in prevalence seems to occur evenly across 

both the 1990–1993 and 1993–1996 time periods. These data suggest that 

there may be a strong gender-based change in the environmental influences 

and messages that are influencing smoking behavior in this high-risk target 

population of adolescents. 

86 
Chapter 5 

Figure 5-9 

Cigarette Smoking Prevalence among Adolescents with Different Self-Defined School 

Performance: 1990, 1993, and 1996 

60


50
 1990 1993 1996

Prevalence (%) 40


30


20


10


0


Above Average Average Below Average 

Self-Defined School Performance 

1990, 1993, and 1996 California Tobacco Survey* (CTS), UCSD. 

* Telephone interviews. 

Parental and 

Sibling Smoking 

Smoking behavior of parents or siblings has a profound effect 

on the prevalence of smoking among adolescents. This effect is 

clearly demonstrated in Table 5-3 for each of the survey years. The questions asked about parental and sibling smoking status differed among the 

survey years. The answers were collapsed to “at least one parent smokes” 

and “at least one older sibling smokes” for this analysis. 

There is a doubling of adolescent smoking prevalence among children 

of smoking parents, and having an older sibling who smokes triples the 

likelihood of adolescent smoking. However, across the three surveys, 

changes in the fraction of adolescents who are cigarette smokers within 

each category of parental or sibling smoking are less dramatic. Among adolescents aged 12–13, there is no significant change across the three survey 

years in the effect of parental or sibling smoking on adolescent smoking. 

That is, there is no significant change in the prevalence of smoking over 

time within each category of parental or sibling smoking. This age group 

also had no significant increase in smoking prevalence across the three surveys. 87

88 

Table 5-3 Prevalence of Adolescents Who Have Smoked in the Last 30 Days: 1990, 1993, and 1996 

Years of Age 

12 - 13 14 - 15 16 - 17

1990 1993 1996 1990 1993 1996 1990 1993 

(%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (C

Total 3.62 1.52 2.98 1.03 3.31 0.86 7.98 1.47 9.13 1.55 10.86 1.38 16.61 2.13 16.29 2.6

Male 4.30 2.85 3.28 1.37 4.20 1.33 7.04 1.87 9.34 2.30 9.34 2.29 18.69 3.49 18.88 4.3Female 2.98 1.66 2.70 1.36 2.37 1.05 8.93 2.41 8.92 2.48 12.51 2.19 14.62 2.99 13.74 3.1Parents Only 

Parent(s) Smoke 5.42 2.40 5.00 2.25 5.28 1.53 11.27 3.38 12.19 3.27 16.25 2.36 22.50 4.68 23.18 4.2

Don’t Smoke 2.68 2.02 1.98 1.22 2.34 0.99 6.02 1.95 7.28 1.83 8.04 1.62 13.06 2.66 12.53 2.9

Unknown . . . . . . . . . . . . . . . 

Older Siblings Only 

Sibling(s) Smoke 7.86 5.50 11.17 5.71 12.20 4.02 21.22 8.47 26.52 7.61 25.15 4.46 29.06 8.28 31.86 7.4

Nonsmoking/ 

No Siblings 3.31 1.64 1.96 0.98 2.27 0.79 6.28 1.49 6.52 1.47 8.48 1.33 14.73 1.95 12.24 2.7

Unknown . . . . 3.17 6.38 . . . . 5.12 10.43 . . . 

Parents and Older Siblings 

Neither Smoke 2.51 2.13 1.75 1.28 1.88 0.91 5.45 1.92 6.30 1.94 6.85 1.67 12.04 2.64 10.54 3.2

Parent(s) Only 4.86 2.51 2.67 1.81 3.20 1.65 7.83 2.95 7.02 2.60 11.80 2.20 19.74 4.71 16.49 4.3

Siblings Only 5.67 5.60 4.62 4.25 7.99 5.84 13.21 9.61 17.68 8.14 17.35 5.44 22.69 9.87 23.52 8.4

Both Smoke 9.47 8.99 16.87 9.37 15.81 6.05 26.56 13.49 32.72 11.78 32.95 8.02 34.77 12.85 41.55 10.4

Note: CI = 95% confidence interval.
Source: 1990, 1993, 1996 California Tobacco Surveys, UCSD. Telephone interviews.

Chapter 5 

For 15- to 16-year-old adolescents, there is a statistically significant 

increase in the prevalence of smoking among those adolescents who have a 

smoking parent (from 7.83 percent ± 2.95 percent to 11.80 percent ± 2.20 

percent), but the increase in prevalence among those with a smoking sibling is not statistically significant (from 13.21 percent ± 9.61 percent to 

17.35 percent ± 5.44 percent). The opposite pattern is evident for 16- to 17-

year-old adolescents, for whom the increase in smoking prevalence with 

older sibling smoking is statistically significant (from 22.69 percent ± 9.87 

percent to 36.21 percent ± 6.82 percent), but the increase with parental 

smoking is not (from 19.74 percent ± 4.71 percent to 22.94 percent ± 4.19 

percent). 

As might be expected from the increased prevalence of smoking among 

adolescents, there was also an increase in the fraction of adolescents who 

reported having an older sibling who smokes—from 10.5 percent in 1990 to 

14.4 percent in 1996. There was no change, or a slight decline, in the frequency with which adolescents reported having a parent who smoked over 

this same time interval. It would appear that the changes in smoking prevalence that occurred between 1990 and 1996 from the effect of having a parent or sibling who smokes have been modest. These modest changes may 

be due to a combination of a small increase in the effect of parental or sibling smoking on the likelihood of adolescent smoking and a small increased 

prevalence of having a sibling who smokes. 

Friends’ Smoking The association between prevalence of adolescent smoking and 

self-reported number of friends who smoke is dramatic, is evident in each 

age group and present for both male and female friends, and is consistent 

across all three surveys (Table 5-4a). There is approximately a 10-fold 

increase in adolescent smoking prevalence among adolescents who report 

having three or more friends who smoke compared to adolescents who 

report having no friends who smoke. 

However, there does not appear to be any increase across the survey 

years in the likelihood of smoking within each category of number of 

friends who smoke. For example, the prevalence of smoking goes from 4.4 

percent in 1990 to 3.8 percent in 1996 among 16- to 17-year-old adolescents who have no male friends who smoke and from 41.0 percent in 1990 

to 36.4 percent in 1996 among those who have three or more male friends 

who smoke. This would suggest that the power of perceived adolescent peer 

smoking in predicting—and possibly influencing—adolescent smoking 

prevalence has not increased between 1990 and 1996. What has changed is 

the fraction of adolescents who report having multiple friends who smoke 

(Table 5-4b). For example, the percentage of 14- to 15-year-old adolescents 

who report that none of their male friends smoked declined from 61.7 percent in 1990 to 38.1 percent in 1996, while the percentage who reported 

that three or more of their male friends smoked increased from 13.1 percent in 1990 to 38.0 percent in 1996. This shift in reporting friends who 

smoke was evident for all age groups and for both male and female friends. 

A similar pattern emerges when peer influence is examined with a question that measures qualitatively how many of the adolescent’s age group 

peers smoke (none, a few, some, or most). The prevalence of 

89 
90 

Table 5-4a Prevalence of Smoking among Adolescents of Different Ages by Reported Number of Friends who Smoke: 1990, 1993, and 

Years of Age 

12 - 13 14 - 15 16 - 17

1990 1993 1996 1990 1993 1996 1990 1993 

(%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (C

Total 3.62 1.52 2.98 1.03 3.31 0.86 7.98 1.47 9.13 1.55 10.86 1.38 16.61 2.13 16.29 2.6

# Male 0 2.36 1.90 0.81 0.53 1.00 0.59 3.35 1.38 3.91 1.63 1.37 0.74 4.41 1.42 2.61 1.2

Friends 1 7.43 5.58 5.80 4.44 1.35 2.11 10.90 7.03 10.57 5.12 5.54 3.65 24.20 8.88 17.26 8.1Who 2 9.62 6.12 13.26 9.95 3.66 3.62 17.47 8.80 10.55 4.56 11.38 3.61 26.67 9.50 23.15 7.5Smoke 3+ 24.81 16.01 15.68 8.15 16.37 4.49 26.13 7.59 25.48 6.74 21.80 3.33 41.05 6.51 35.52 5.7

# Female 0 1.80 0.98 1.30 0.85 1.39 0.58 4.11 1.33 3.36 1.13 1.82 0.69 8.30 2.06 6.10 2.4

Friends 1 4.43 3.42 5.65 4.78 2.44 2.07 15.13 5.85 13.11 4.74 9.58 3.60 19.78 7.41 19.55 5.6Who 2 . . 9.63 9.97 12.20 6.80 17.94 9.74 22.02 10.03 13.23 5.78 33.15 10.68 29.41 10.0Smoke 3+ 12.61 8.87 19.28 10.36 16.88 6.82 29.54 11.51 26.29 8.59 28.17 4.11 38.63 8.24 39.96 7.2

Male Subjects 4.30 2.85 3.28 1.37 4.20 1.33 7.04 1.87 9.34 2.30 9.34 2.29 18.69 3.49 18.88 4.3# Male 0 3.28 3.43 1.11 0.91 1.37 0.98 3.02 1.48 3.62 2.60 1.43 1.20 3.94 1.84 2.69 1.9

Friends 1 2.93 4.41 4.00 4.86 1.71 3.42 6.04 4.85 8.93 7.08 6.69 4.27 26.58 11.10 19.23 12.0Who 2 . . 13.51 11.00 4.68 5.85 16.88 14.81 11.70 7.61 6.34 4.12 31.58 14.02 18.68 9.3Smoke 3+ . . 13.34 10.08 21.84 6.00 22.95 10.40 29.60 7.80 21.45 5.77 42.23 9.05 39.83 8.8

# Female 0 2.44 1.66 1.54 1.30 2.12 1.06 4.49 1.81 4.17 1.91 2.30 1.14 11.00 3.09 9.51 4.3

Friends 1 2.82 4.31 11.60 11.44 4.68 4.35 14.35 7.59 11.47 5.89 4.75 3.96 22.29 10.61 25.43 10.0Who 2 . . . . . . . . . . 15.04 9.68 . . 31.04 16.6Smoke 3+ . . 13.89 14.10 22.68 11.84 18.81 18.26 34.60 13.65 28.33 7.37 41.31 12.35 39.29 11.2
Table 5-4a (continued) 

Years of Age 

12 - 13 14 - 15 

1990 1993 1996 1990 1993 1996 1990 1993 

(%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (CI) (%) (C

16 - 17 

Female Subjects 2.98 1.66 2.70 1.36 2.37 1.05 8.93 2.41 8.92 2.48 12.51 2.19 14.62 2.99 13.74 3.1

# Male 0 1.25 1.27 0.45 0.56 0.61 0.73 3.76 2.00 4.25 2.31 1.30 0.98 4.84 2.29 2.53 1.3

Friends 1 . . 7.89 8.01 0.79 1.57 15.17 12.94 12.37 7.56 3.03 3.52 22.39 12.14 15.56 9.5Who 2 9.47 7.84 12.92 20.41 2.41 3.55 17.88 9.03 9.53 6.89 17.84 7.73 22.49 14.74 26.72 12.4Smoke 3+ . . 19.57 14.85 11.20 6.18 30.63 13.18 22.05 9.59 22.07 4.01 39.28 10.96 29.26 8.3

# Female 0 1.23 1.15 1.11 1.22 0.57 0.63 3.72 2.23 2.45 1.46 1.14 0.86 5.53 2.71 2.80 1.8

Friends 1 5.22 4.65 1.46 2.11 0.58 1.14 15.52 7.81 14.53 7.19 12.99 6.14 18.18 8.95 15.41 8.5Who 2 . . 4.42 7.20 7.99 7.29 14.48 10.54 16.69 10.84 11.54 7.11 33.00 15.99 27.99 10.6Smoke 3+ . . 24.04 14.74 13.27 7.23 37.88 13.74 21.77 9.78 28.06 5.61 36.24 11.39 40.66 10.1

Note: CI = 95% confidence interval.
Source: 1990, 1993, 1996 California Tobacco Surveys, UCSD. Telephone interviews.


91 
92 

Table 5-4b Percentage of Adolescents who Are in Each Category of Reported Number of Friends who Smoke: 1990, 1993, and 1996 

Years of Age 

12 - 13 14 - 15 16 - 

1990 1993 1996 1990 1993 1996 1990 199

Overall-Groups-etc. 

No Male Friends Smoke 75.1% 65.8% 67.8% 61.7% 54.6% 38.1% 52.8% 43.41 Male Friend Smokes 4.3% 5.7% 7.3% 9.7% 11.2% 9.6% 15.2% 16.82 Male Friends Smoke 3.5% 4.9% 6.4% 5.6% 8.6% 10.7% 11.0% 9.43+ Male Friends Smoke 4.2% 8.3% 13.5% 13.1% 17.7% 38.0% 17.1% 25.8No Female Friends Smoke 78.0% 73.6% 74.7% 69.6% 62.1% 51.2% 59.2% 54.61 Female Friend Smokes 6.3% 6.5% 8.9% 9.9% 13.4% 9.9% 13.6% 14.12 Female Friends Smoke 3.7% 3.3% 4.2% 6.4% 7.1% 10.2% 8.3% 9.43+ Female Friends Smoke 2.5% 5.9% 8.8% 7.4% 12.8% 26.7% 14.5% 17.2

Note: CI = 95% confidence interval.
Source: 1990, 1993, 1996 California Tobacco Surveys, UCSD. Telephone interviews.

Chapter 5 

smoking increases in each age group with increasing proportion of peers 

who are reported to be smokers (Table 5-5). For example, the 1996 prevalence of smoking among 16- to 17-year-old adolescents is only 4.4 percent 

for those who reported that none of their peers smoke and 12.6 percent for 

those who reported that a few of their peers smoke, but the prevalence of 

smoking among those who reported most of their peers smoke is 42.8 percent. However, the prevalence of smoking within each category of reported 

peer smoking (none, a few, some, or most) did not change substantially 

between 1990 and 1996. What changed is the likelihood that an adolescent 

reported that most of his friends smoke. Figure 5-10 presents the percentage 

of adolescents in each age group who reported that most of their age group 

peers smoked in the 1990, 1993, and 1996 California Tobacco Survey (CTS). 

There was approximately a doubling between 1990 and 1996 in the fraction 

of adolescents who reported that most of their age group peers smoked, 

with almost 30 percent of 16- to 17-year-old adolescents reporting that 

most of their age group peers smoked (up from 16.7 percent in 1990). 

Both of these questions about smoking behavior among friends and 

peers demonstrate a dramatic rise in adolescents’ perception of the number 

of their peers and friends who smoke. Part of this change in perception is 

likely to be based on an accurate assessment of the increase in adolescent 

smoking prevalence that has occurred in California between 1993 and 

1996, but the magnitude of the increases in perception of adolescent smoking (a tripling of friends and doubling of peers) is vastly out of proportion 

with the real change in prevalence (from 9.2 percent in 1990 to 12 percent 

in 1996). This suggests that a change may have occurred over this interval 

in adolescents’ perception about how common smoking is among their 

peers. Tobacco industry advertising and promotional efforts may have been 

successful in convincing adolescents that smoking is the norm for their 

peer group. Certainly, the public health efforts to de-normalize tobacco use 

among adolescents have not been successful in altering the perceptions of 

these adolescents. 

93

Smoking and Tobacco Control Monograph No. 14 

Table 5-5 

Smoking Prevalence among Adolescents of Different Ages by Self-Reported Number of AgeGroup Peers who Smoke: 1990, 1993, 1996 

Has Smoked in Has Smoked, but 

Last 30 Days Not in Last 30 Days Never Smoked 

Year (%) CI (%) CI (%) CI 

Number of Peers Who Smoke: Ages 12–13 

Total 1990 3.62 1.52 7.35 1.94 89.00 2.67 

1993 2.98 1.03 7.87 1.61 88.93 1.99 

1996 3.31 0.86 7.19 1.37 89.50 1.61 

None 1990 0.64 0.64 5.40 2.52 93.96 2.50 

1993 0.45 0.55 2.12 1.04 97.43 1.23 

1996 0.64 0.53 2.76 1.19 96.61 1.23 

A Few 1990 5.56 3.03 10.44 3.40 83.89 4.81 

1993 2.66 1.43 13.30 4.16 83.47 4.56 

1996 2.37 1.44 10.31 3.20 87.32 3.29 

Some 1990 7.55 5.20 10.32 5.53 82.13 7.58 

1993 8.60 4.78 12.98 4.84 78.42 6.42 

1996 7.19 3.19 16.78 4.83 76.04 5.45 

Most 1990 . . 10.44 10.25 . . 

1993 15.52 9.97 21.47 11.50 61.87 14.58 

1996 22.07 7.59 14.33 6.18 63.59 9.26 

Total 1990 7.98 1.47 16.94 2.62 75.08 3.12 

1993 9.13 1.55 20.97 2.68 69.81 2.87 

1996 10.86 1.38 18.52 2.05 70.58 2.33 

None 1990 2.45 2.10 8.92 4.10 88.64 4.44 

1993 0.25 0.36 6.23 3.23 93.53 3.27 

1996 2.28 1.59 6.52 2.78 91.20 3.15 

A ew 1990 5.26 2.26 17.21 3.57 77.54 4.07 

1993 4.37 2.36 23.22 3.69 72.23 4.12 

1996 4.98 2.26 20.51 3.95 74.52 4.58 

Some 1990 10.58 3.34 23.77 7.51 65.65 8.04 

1993 7.61 2.34 25.83 5.98 66.57 6.11 

1996 9.53 3.02 20.55 3.49 69.75 3.88 

Most 1990 32.03 9.57 25.11 8.70 42.86 10.74 

1993 33.86 6.14 23.89 6.11 42.13 6.67 

1996 29.78 4.42 23.90 4.10 46.32 5.23 

Number of Peers Who Smoke: Ages 14–15

F

Number of Peers Who Smoke: Ages 16–17 

Total 1990 16.61 2.13 24.98 3.01 58.33 3.11 

1993 16.29 2.62 29.18 3.87 54.37 3.85 

1996 22.10 2.28 24.34 1.94 53.56 2.66 

None 1990 2.11 2.87 13.04 5.47 84.85 5.83 

1993 . . 6.89 5.65 93.11 5.65 

1996 4.41 4.08 12.32 5.59 83.27 6.98 

A Few 1990 9.51 2.75 28.36 5.12 62.13 5.81 

1993 8.91 3.10 28.93 5.79 62.15 6.39 

1996 12.58 2.75 25.18 3.29 62.24 4.34 

Some 1990 21.34 5.36 27.70 6.80 50.63 7.01 

1993 15.12 4.76 33.48 6.33 51.34 6.01 

1996 17.20 4.36 26.19 4.21 56.61 4.23 

Most 1990 40.21 7.46 22.12 6.27 37.67 8.32 

1993 38.47 6.90 31.93 6.63 28.93 5.91 

1996 42.77 4.41 25.32 4.66 31.91 4.43 

Note: CI = 95% confidence interval.


Source: 1990, 1993, 1996 California Tobacco Survey (CTS), UCSD. Telephone interviews.


94 
Chapter 5 

Figure 5-10 

Percentage of Adolescents of Different Ages who Report that Most of Their Friends 

Smoke Cigarettes: 1990, 1993, and 1996 

30 

25 

20 

15 

10 

5 

0 

12— 13 Years 14— 15 Years 16— 17 Years 

1990 1993 1996 

Age Group 

1990, 1993, and 1996 California Tobacco Survey* (CTS), UCSD. 

* Telephone interviews. 

Response of a The response of a non-smoking adolescent to the question, “If 

Nonsmoking one of your best friends were to offer you a cigarette, would 

Adolescent to a you smoke it?” has been suggested as a measure of the 

Best Friend’s Offer strength of an adolescent’s resolve not to smoke, and any 

of a Cigarette response except “definitely no” is felt to suggest that the adolescent is at risk for subsequent initiation. The response to this question is 

also likely to reflect adolescent norms about smoking and the social acceptability of smoking among adolescent non-smokers. Table 5-6 presents the 

responses of adolescent non-smokers in the 1990, 1993, and 1996 CTS to 

this question. The frequency with which adolescent non-smokers report 

that they definitely would not smoke if offered a cigarette by their best 

friend remained constant between 1990 and 1993, but declined precipitously in 1996 (from 87.9 percent in 1993 to 78.6 percent in 1996). This decline 

is evident for each of the three age groups, including 16- to 17-year-old 

adolescents, whose resistance to friends’ offers of cigarettes had been high 

(over 90 percent). This trend again suggests that the effort to de-normalize 

cigarette smoking has lost ground between 1993 and 1996, and this change 

may have contributed to the rise in adolescent smoking in California. 

Percentage 

95

Smoking and Tobacco Control Monograph No. 14 

Intention to Quit Table 5-7 presents the responses of adolescents who have 

smoked in the last 30 days to the question, “Have you ever thought seriously about quitting?” Approximately 70 percent of adolescents who smoke 

have thought about quitting, but there have not been significant changes 

in this response across the three surveys. There were no significant differences across age groups or between male and female adolescents. 

Access to Cigarettes Non-smoking adolescents were asked whether they thought 

it would be easy or hard to get cigarettes if they wanted to, and the results 

for the 1990, 1993, and 1996 surveys are presented in Table 5-8. The percentage of adolescents who thought that it would be easy to obtain cigarettes increased substantially with age, but there was no significant change 

in the perceived difficulty of obtaining cigarettes over the period 1990–1996 

among non-smoking adolescents. The absence of a change in perceived difficulty of obtaining cigarettes between 1990 and 1996—a period during 

which a substantial improvement occurred in the refusal of adolescent 

attempts to purchase cigarettes—suggests two possible explanations. One 

possibility is that the restrictions on the availability of cigarettes to adolescents have not yet become extensive enough to actually reduce access of 

adolescents to cigarettes. The second possibility is that the perceived availability of cigarettes among non-smoking adolescents may be influenced by 

factors other than the actual availability of cigarettes. 

COMPARISON OF The Current Population Survey (CPS) for 1992/1993 and 

CALIFORNIA WITH 1995/1996 asked all individuals over the age of 15 years 

OTHER STATES about their smoking behavior (those 15 years of age and 

USING CURRENT older were not included in the January 1996 survey). These 

POPULATION surveys can be used to compare the prevalence of smoking 

SURVEY DATA among 15- to 17-year-old adolescents in California to the rest 

of the nation. Table 5-9 presents the prevalence of smoking in California 

and the rest of the nation using the adult definition of smoking (has 

smoked at least 100 lifetime cigarettes and reports smoking all of the last 30 

days or only some days). An additional category of those who have smoked 

at least 100 cigarettes, but who have not smoked in the last 30 days, is 

included to improve comparability with the adolescent definition tables. 

Adolescent current smoking prevalence was significantly lower in California 

than in the remaining states in both the 1992/1993 and 1995/1996 CPS. 

There are increases in adolescent smoking prevalence between 1992/1993 

and 1995/1996 for both California adolescents and adolescents in the rest 

of the nation. The difference in the smoking prevalence of California and 

the rest of the nation is not statistically significant, since California’s prevalence is proportionately similar to the prevalence of the rest of the nation. 

These data suggest that California remains below the rest of the nation in 

adolescent initiation, but that California has seen an increase in smoking 

initiation between 1992/1993 and 1995/1996 that is similar to that of the 

rest of the nation. 

96

Chapter 5 

Table 5-6

Response of Adolescents who Have Never Smoked to the Question, “Would You Smoke if Your

Best Friend Offered You a Cigarette?”: 1990, 1993, 1996

Definitely Yes Probably Yes Probably No Definitely No Unknown 

(%) CI (%) CI (%) CI (%) CI (%) CI 

Total 

1990 0.18 0.16 0.86 0.36 12.05 1.81 86.87 1.86 0.04 0.05 

1993 0.06 0.12 1.39 0.52 10.57 1.34 87.90 1.43 0.09 0.13 

1996 0.20 0.16 2.16 0.50 18.74 1.06 78.65 1.18 0.25 0.15 

Males 

1990 0.09 0.10 0.88 0.52 12.09 2.89 86.89 3.00 0.05 0.08 

1993 . . 1.62 0.96 11.76 1.92 86.44 1.98 0.19 0.27 

1996 0.08 0.13 2.55 0.73 19.43 1.91 77.53 1.99 0.42 0.29 

Females 

1990 0.26 0.30 0.85 0.56 12.00 2.62 86.86 2.64 0.04 0.07 

1993 0.12 0.23 1.17 0.62 9.47 1.94 89.25 1.99 . . 

1996 0.32 0.29 1.76 0.64 18.02 1.49 79.82 1.71 0.08 0.11 

12–13 

1990 0.02 0.04 0.60 0.54 11.58 2.44 87.76 2.53 0.05 0.09 

1993 0.14 0.27 1.31 1.00 11.32 1.74 87.17 1.93 0.06 0.10 

Age in 

Years 

1996 0.11 0.16 1.62 0.62 17.03 1.46 80.98 1.54 0.26 0.25 

14–15 

1990 0.42 0.45 1.40 0.84 15.36 3.26 82.75 3.47 0.07 0.10 

1993 . . 1.54 0.85 11.80 2.42 86.46 2.33 0.19 0.38 

1996 0.28 0.28 3.32 1.08 22.62 2.28 73.57 2.48 0.22 0.22 

16–17 

1990 0.09 0.18 0.55 0.66 8.17 3.06 91.18 3.14 . . 

1993 . . 1.30 1.15 7.39 2.37 91.31 2.90 . . 

1996 0.23 0.37 1.41 0.93 16.03 2.45 82.04 2.66 0.29 0.42 

Note: CI = 95% confidence interval.


Source: 1990, 1993, 1996 California Tobacco Surveys, UCSD. Telephone interviews.


97

Smoking and Tobacco Control Monograph No. 14 

Table 5-7 

Self-Reported Interest in Quitting among Adolescents who Have Smoked in the 

Last 30 Days: 1990, 1993, 1996 

Quitting Quitting Never 

Considered Not Considered Smoked Regularly Unknown 

Year (%) CI (%) CI (%) CI (%) CI 

Overall	 1990 

1993 

1996 

Age in Years: 

12–13	 1990 

1993 

1996 

14–15	 1990 

1993 

1996 

16–17	 1990 

1993 

1996 

68.56 5.62 13.13 4.06 18.00 4.41 0.31 0.39 

72.66 4.83 13.53 3.25 13.50 3.99 0.31 0.61 

70.47 3.10 12.99 2.76 16.32 2.72 0.21 0.29 

. . 14.82 17.16 . . . . 

. . 7.90 10.50 17.61 12.63 . . 

. . 12.78 9.94 26.39 12.30 . . 

64.14 10.04 12.30 6.27 22.69 8.51 0.87 1.30 

71.85 9.38 11.02 5.36 17.12 8.03 . . 

67.09 5.84 16.36 6.08 16.55 5.12 . . 

74.97 5.82 13.17 5.71 11.78 4.00 0.09 0.17 

72.77 5.87 16.27 4.57 10.40 5.34 0.56 1.12 

73.79 4.15 11.21 3.70 14.65 3.69 0.36 0.49 

Note: CI = 95% confidence interval.


Source: 1990, 1993, 1996 California Tobacco Surveys, UCSD. Telephone interviews.


Table 5-8 

Self-Reported Ease of Obtaining Cigarettes among Adolescents of 

Different Ages: 1990, 1993, 1996 

Do You Think it would be Easy or Hard for You to Get Cigarettes if You Wanted Some? 

Easy Hard Unknown 

Age Group (%) CI (%) CI (%) CI 

12–13 Years 

1990 

1993 

1996 

14–15 Years 

1990 

1993 

1996 

16–17 Years 

1990 

1993 

1996 

38.86 3.82 58.02 3.39 3.12 0.99 

37.08 3.25 58.93 3.15 3.99 1.27 

37.00 2.61 59.41 2.55 3.59 0.91 

65.28 3.80 32.87 3.76 1.85 0.90 

67.89 2.79 29.61 2.89 2.50 1.14 

67.11 2.69 30.53 2.70 2.36 0.84 

85.64 2.71 13.75 2.86 0.61 0.60 

84.96 3.29 12.55 2.77 2.49 1.93 

82.72 2.96 16.53 2.93 0.76 0.49 

Note: CI = 95% confidence interval.


Source: 1990, 1993, 1996 California Tobacco Surveys, UCSD. Telephone interviews.


98

Chapter 5 

Table 5-9 

Current Smoking Status among Respondents Ages 15 to 17 Years: 1992/1993 and 1995/1996 

CPS: California Compared to the Rest of the Nation 

Smoked at Least 100 Lifetime Cigarettes 

Number of Days Smoked in the None in 

Current Years Last 30 Days the Last Smoked 

Smoking of All Some 30 Days <100 Cigarettes 

Status Age (%) CI (%) CI (%) CI (%) CI 

California 

1992/1993 

Total 15–17 4.43 1.60 1.40 0.91 1.85 1.04 92.32 2.07 

Male 15–17 4.40 2.21 0.90 1.02 1.98 1.50 92.72 2.80 

Female 15–17 4.47 2.31 1.94 1.54 1.71 1.45 91.88 3.05 

Overall 15 2.65 2.17 0.71 1.13 0.59 1.03 96.06 2.63 

Overall 16–17 5.31 2.12 1.74 1.24 2.47 1.47 90.49 2.78 

1995/1996* 

Total 15–17 6.76 1.82 2.31 1.09 2.26 1.08 88.66 2.3 

Male 15–17 8.9 2.88 1.75 1.32 1.87 1.37 87.48 3.35 

Female 15–17 4.51 2.15 2.9 1.74 2.68 1.67 89.91 3.12 

Overall 15 3.27 2.28 2.61 2.05 2.42 1.97 91.69 3.54 

Overall 16–17 8.39 2.43 2.17 1.28 2.19 1.28 87.25 2.93 

Nation Minus California 

1992/1993 

Total 15–17 7.07 0.60 2.33 0.35 1.89 0.32 88.70 0.74 

Male 15–17 7.19 0.84 2.74 0.53 2.07 0.46 88.00 1.05 

Female 15–17 6.95 0.85 1.91 0.46 1.70 0.43 89.44 1.02 

Overall 15 4.03 0.79 1.60 0.50 1.49 0.48 92.88 1.03 

Overall 16–17 8.62 0.80 2.70 0.46 2.09 0.41 86.58 0.97 

1995/1996 

Total 15–17 8.23 0.62 3.46 0.41 1.99 0.31 86.33 0.77 

Male 15–17 9.25 0.90 4.06 0.61 1.79 0.41 84.91 1.11 

Female 15–17 7.12 0.83 2.80 0.53 2.20 0.47 87.88 1.06 

Overall 15 4.63 0.81 2.78 0.63 1.28 0.43 91.30 1.08 

Overall 16–17 10.08 0.83 3.81 0.53 2.35 0.42 83.76 1.02 

Note: CI = 95% confidence interval. 

*January, 1996 CPS did not include 15-year-olds. 

99

Smoking and Tobacco Control Monograph No. 14 

SUMMARY Cigarette smoking prevalence among adolescents in California is lower 

than that among the adolescents in the rest of the United States. However, 

it has increased between 1993 and 1996 and the extent of this increase in 

California is similar to that for the rest of the nation. The increase between 

1993 and 1996 in California is largely among older adolescents and has 

occurred among each of the racial and ethnic groups, with the exception of 

African American adolescents. When examined by family income and level 

of school performance, the increase in adolescent smoking prevalence is 

predominantly among those groups with moderate to high family incomes 

and school performance—groups in which prior prevention efforts had 

been most successful. Analyses of the predictors of adolescent smoking initiation suggest that two of the principal changes were occurring between 

1993 and 1996. One change was in adolescents’ perception of the number 

of their friends and peers who smoke and the other was in the willingness 

of non-smoking adolescents to smoke if offered a cigarette by a close friend. 

These observations suggest that the effort to de-normalize smoking behavior among adolescents in California has not successfully altered their perceptions of the prevalence of smoking by adolescents or of the social 

acceptability of smoking among their peer group. 

REFERENCES 

Burns, D., Pierce, J.P. Tobacco Use in California. 

Sacramento, CA: California Department of 

Health Services, 1992. 

Burns, D., Lee, L., Shen, L., Gilpin, L., Tolley, H., 

Vaughn, J., Shanks, T. Cigarette smoking behavior in the United States. In: Burns, D., Garfinkel, 

L., Samet, J. (Editors). Changes in Cigarette-Related 

Disease Risks and Their Implication for Prevention 

and Control. Smoking and Tobacco Control 

Monograph No. 8. U.S. Department of Health 

and Human Services, Public Health Service, 

National Institutes of Health, National Cancer 

Institute, pp. 13-112, NIH Publication No. 97-

4213, 1997. 

Center for Disease Control and Prevention. Tobacco 

use among high school students—United States, 

1997. Mortality and Morbidity Weekly Report 

47(12):229-233, 1998a. 

Center for Disease Control and Prevention. 

Incidence of initiation of cigarette smoking— 

United States, 1965–1996. Mortality and Morbidity 

Weekly Report 47(39):837-840, 1998b 

Lynch, B.S., Bonnie, R.J. (Editors). Growing Up 

Tobacco Free: Preventing Nicotine Addiction in 

Children and Youth. Washington, DC: National 

Academy Press, 1994. 

Pierce, J.P., Evans, N., Farkas, A.J., Cavin, S.W., Berry, 

C., Kramer, M., Kealey, S., Rosbrook, B., Choi, 

W., Kaplan, R.M. Tobacco use in California: An 

evaluation of the Tobacco Control Program 

1989–1993. La Jolla, CA: University of California, 

San Diego, 1994. 

Pierce, J.P., Gilpin, E.A., Emery, S.L., Farkas, A.J., Zhu, 

S.H., Choi, W.S., Berry, C.C., Distefan, J.M., 

White, M.M., Soroko, S., Navarro, A. Tobacco 

Control in California: Who’s Winning the War? An 

Evaluation of the Tobacco Control Program, 

1989–1996. La Jolla, CA: University of California, 

San Diego, 1998. 

U.S. Department of Health and Human Services. 

Preventing Tobacco Use Among Young People: A 

Report of the Surgeon General. Atlanta, GA: U.S. 

Department of Health and Human Services, 

Public Health Service, Centers for Disease 

Control and Prevention, National Center for 

Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 1994. 

100

Changing Social Norms to Decrease 

Adolescent Tobacco Use: Massachusetts, 

1993–1996 

Carolyn Celebucki, Diane M. Turner-Bowker 

BACKGROUND The Massachusetts Tobacco Control Program (MTCP) was fundAND OVERVIEW ed by a 25-cent cigarette tax increase in January of 1993. The 

program developed counter-tobacco media coverage in the summer of 1993 

and began community programming early in 1994. By altering the social 

norms pertaining to tobacco use, the MTCP seeks to protect the residents of 

Massachusetts from environmental tobacco smoke, to assist smokers in successfully quitting their habit, and to reduce the rates of initiation and progression to habitual use of tobacco products among youths and younger 

adults. This chapter assesses the progress of the MTCP through 1997 by 

examining prevalence rates among adolescents in Massachusetts and 

changes in the direction and strength of factors associated with youth 

smoking. It will also compare smoking prevalence rates for Massachusetts to 

those of the nation as a whole. 

Data are presented from four representative in-school surveys. Two were 

conducted within Massachusetts—the Massachusetts Prevalence Survey 

(MPS) of junior high and high school students (Briton et al., 1997), and the 

Massachusetts Youth Risk Behavior Survey (MYRBS) of high school students 

(Massachusetts Department of Education, 1998). Selected items from two 

national surveys—the Monitoring the Future study (MTF), which follows 

8th-, 10th-, and 12th-grade students (Johnston et al., 1999), and the national Youth Risk Behavioral Survey (YRBS) of high school students (CDC, 

1998)—are presented for comparison. 

Information is presented on both lifetime and current1 smoking, but 

only current smoking (“smoked at least once in the past 30 days”) is 

defined in a consistent manner across all surveys and years. The MYRBS 

and YRBS define lifetime use as “ever smoked a cigarette, even one or two 

puffs,” while the MTF defines it as “ever smoked cigarettes,”2 and the MPS 

defines lifetime use as “ever smoked a whole cigarette” (U.S. DHHS, 1994). 

This chapter examines changes among junior high as well as high 

school youths and, therefore, relies most heavily on the MPS. These data 

must be interpreted in the context of program intervention, as 

1. Or recent in the YRBS and MYRBS. 

2. Those who reported that they had tried cigarettes at least once or twice were classified as 

ever smokers. 

101

Smoking and Tobacco Control Monograph No. 14 

Massachusetts youths in the 7th and 8th grades in 1996 would have had 

the benefit of 1 to 2 years’ exposure to prevention programming prior to 

the average age (12.2 years) of smoking initiation (MPS, Briton et al., 1997). 

In following with Worden et al. (1998), who detected a 50 percent reduction in smoking uptake among a cohort of middle school youths after 4 

years of comprehensive tobacco control program exposure, we would 

expect to see preliminary evidence of the effectiveness of the MTCP in this 

younger group. 

A series of analyses were conducted using MPS data to examine differences from 1993 to 1996 for males, females, individual grade, and for all 

grades combined (7 through 12) on current and lifetime smoking and specific correlates of smoking behavior—i.e., peer influences (friends who 

smoke, friends who disapprove) and educational status (performance, plans 

after high school). Results were obtained by chi-square analyses using SPSS 

version 8.0 (SPSS, 1998). 

TRENDS IN The MTCP began at a time when tobacco use (cigarettes and 

MASSACHUSETTS smokeless tobacco) was increasing among youths both 

AND THE NATION nationally and in Massachusetts (MTF—Johnston et al., 1999; 

PRIOR TO MTCP MPS—Briton et al., 1997). Massachusetts evidenced this 

increase 2 to 4 years before it was apparent in the nation as a whole 

(1987–1990 as compared with 1991–1992, respectively)3. 

At MTCP baseline, the 1993 MPS (Briton et al., 1997) assessed 5,321 

public school students in grades 7 through 12 and found lifetime use of cigarettes among 9th through 12th graders (63.6 percent) to be virtually 

unchanged since 1990 (62.7 percent); however, lifetime use of smokeless 

tobacco significantly increased from 1990 (19.3 percent) to 1993 (24.6 percent). From 1990 to 1993, rates for current cigarette use across grades 9 

through 12 increased from 29.2 percent to 33.6 percent; likewise, rates for 

current smokeless tobacco use increased from 6.4 percent to 9.3 percent‡

. 

Alarmingly, the greatest increase in tobacco use from 1990 to 1993 occurred 

in the lower grades, with lifetime use of cigarettes for 7th and 8th graders 

increasing from 36.6 percent to 45.4 percent and current use almost doubling from 12.8 percent to 22.6 percent. For smokeless tobacco, lifetime use 

among 7th and 8th graders increased fourfold, from 4.1 percent to 16.4 percent, and current use increased threefold, from 1.7 percent to 5.7 percent. 

3. Nationally, 12th graders reached their lowest levels on lifetime and current measures in 

1992, as did 10th graders on lifetime use. Lifetime use among 8th graders and current use 

among 8th and 10th graders increased since the first recording in 1991. In Massachusetts, 

lowest levels of lifetime and current smoking among 7th, 9th, 10th, and 11th grade students 

were recorded in 1990, with 8th and 12th grade current rates lowest in 1987. There were 

similar increases in Massachusetts in smokeless rates, with lifetime use for all but the 11th 

grade at lowest levels in 1990, the first year asked of junior high school students. Lifetime 

use of smokeless tobacco in 11th grade and current use in grades 9 through 12 were lowest 

in 1987, the first year data were collected from high school students. Nationally, current 

rates for smokeless were lowest in 1993 for 8th grade and 12th grade, and 1996 for 10th 

grade. 

‡ Data not shown. 

102

Chapter 6 

Prior to 1993, junior high school youths had not been exposed to a 

comprehensive, coordinated anti-smoking media campaign or any schoolor community-based prevention programs, but they both knew and liked 

Joe Camel (DiFranza et al., 1991). It is probable that they could purchase 

their own cigarettes and could receive free samples from cigarette manufacturers at neighborhood events or through the mail. The brands they favored 

were heavily advertised in the magazines they read (King et al., 1998) and 

many youths owned tobacco-branded merchandise (Biener et al., 1994). 

Local provisions (ordinances and regulations) pertaining to youth access or 

reduction of environmental tobacco smoke had been passed in only a 

handful of cities and towns in Massachusetts, and there were few places 

where smoking was strictly prohibited. In 1994, close to half of all purchase 

attempts by underage youths resulted in illegal sales of tobacco products 

(Hamilton, 1998). Cigarettes were affordable, as the impact of the 1993 

January tax increase was all but obliterated by the price reduction of premium brands by cigarette manufacturers in the months following the excise 

tax (Harris et al., 1997). In 1993, not surprisingly, about one-third of youths 

surveyed reported that they would probably smoke in the next year—and 

they did. 

TRENDS SINCE 1993 Increases in rates of smoking initiation and progression to 

regular use for those in lower grades (as documented by increased lifetime 

and current smoking rates for 1993) were reflected in the higher rates of 

current smoking by 9th and 10th grade youths in the 1995 MYRBS, and by 

10th and 11th grade youths in the 1996 MPS (Table 6-1). Data from the 

1996 MPS (Briton et al., 1997) were collected from 6,844 public school students in grades 64 through 12 during November and December of 1996 and 

early January of 1997. Significant increases were found for current smoking 

among a combined sample of 10th, 11th, and 12th graders, from 33.3 percent in 1993 to 37.5 percent in 1996, X2(1) = 10.27, p < 0.002. In contrast, 

there were significant decreases in current smoking for a combined sample 

of 7th, 8th, and 9th graders, from 26.4 percent in 1993 to 24.2 percent in 

1996, X2(1) = 3.87, p = 0.04. Students in a 7th, 8th, and 9th grade combined sample reported significantly lower lifetime cigarette use in 1996 

(53.8 percent) than in 1993 (57.7 percent), X2(1) = 9.00, p < 0.003. Likewise, 

lifetime rates decreased for boys [63 percent to 55.4 percent, X2(1) = 16.82, 

p < 0.001] and for Hispanic youths [63 percent to 52 percent, X2(1) = 15.4, 

p < 0.001] in this group. Current rates also declined among boys [28.1 percent to 21.6 percent, X2(1) = 16.0, p < 0.001] and African American youths 

[27.1 percent to 16.1 percent, X2(1) = 23.48, p < 0.001] in this combined 

sample. 

Respondents in the overall sample (grades 7 through 12) who identified 

themselves as Asian/Pacific Islanders were significantly more likely to have 

ever smoked in 1996 than in 1993, while African American youths were 

4. Sixth graders were first included in the MPS during the 1996 survey. Analyses comparing the 

results from the 1996 MPS to other MPS surveys focus on grades 7 through 12 only. 

103

Smoking and Tobacco Control Monograph No. 14 

Table 6-1

Prevalence of Current§ Tobacco Use among Massachusetts Youths by Grade, 1987–1999

Year: 1987 1990 1993 1993 1995 1996 1997 1999 1999 

Survey: MPS** MPS** MYRBS* MPS** MYRBS* MPS** MYRBS* MYRBS* MPS** 

Grade 

6 18.1††† N/A


7 11.6 7.5 18.5† 16.2††† N/A


8 15.5 19.6 26.5†† 26.0††† N/A


9 32.0 24.9 28.9 34.5††† 32.3†† 30.3††† 27.8 25.1 N/A


10 28.1 26.6 25.2 28.5 34.8††† 36.6††† 35.8† 29.2 N/A


11 34.9 31.6 31.0 33.1 37.7 38.9††† 35.5†† 31.4 N/A


12 31.7 33.0 35.9 37.8 39.1 40.6††† 40.2††† 36.9† N/A


13 N/A††


14 N/A†††


15


16


§ Current cigarette use defined as having smoked at least once in the past month. 

Surveys: MPS—Massachusetts Prelavence Survey conducted by Health & Addictions Research, Inc.; 

MYRBS—Massachusetts Youth Risk Behavior Survey conducted by the Department of 

Education. 

* Data Collected in November, December, January (NDJ). 

** Data Collected in April, May, June (AMJ). 

Cohort progression (e.g., using data from MPS): 

Seventh†, 8th††, 9th††† grades at MTCP baseline in NDJ of 1993; advance to 10th†, 11th††, 

12th††† grades in NDJ of 1996. 

N/A: Data not assessed. 

significantly less likely to have smoked in the past 30 days in 1996 than in 

1993 (Table 6-2). Tables 6-3 and 6-4 present changes in cigarette use from 

1993 to 1996 for females and males, respectively. There were significant 

increases in current cigarette use for males in grade 12; however, there were 

declines in overall male and White male lifetime use, with 7th grade males 

significantly less likely to smoke (lifetime and current) in 1996 than in 

1993 (Table 6-4). All grades experienced declines from 1993 to 1996 on lifetime and current use of smokeless tobacco and, with the exception of 10th 

grade (lifetime), 11th grade (current), and 12th grade youths, these declines 

were significant‡

. 

The 1993 MYRBS (Massachusetts Department of Education, 1998) 

reported lifetime and current rates of cigarette use among public school students in grades 9 through 12 as 67.8 percent and 30.2 percent, respectively‡

. 

Differences between current prevalence rates reported in the MYRBS and 

MPS for the same calendar year (e.g., 1993) might be a function of sampling 

error or of the timing for data collection. Specifically, the MYRBS is administered in April, May, and early June, whereas the MPS is conducted in 

November, December, and early January. 

‡ Data not shown. 

104

Chapter 6 

Table 6-2 

Lifetime and Current Smoking Prevalence of Adolescents by Sex, Grade, Race/Ethnicity*, 

Educational Performance, Friends who Smoke, Friends who Disapprove of Smoking, and Plans 

after High School—Massachusetts, 1993, 1996 

Lifetime Use 

1993 1996 

% (n) 95% CI % (n) 95% CI 

Sex 

Female 

Male 

Grade Level 

7th 

8th 

9th 

10th 

11th 

12th 

Race/Ethnicity* 

White 

Hispanic 

African American 

Asian/P.I. 

Native American 

62.0 (1,713) ± 1.8 63.1 (1,837) ± 1.8 

66.6 (1,679) ± 1.9 ** 62.2 (1,799) ± 1.8 

45.9 (439) ± 3.2 41.1 (412) ± 3.1 

60.1 (608) ± 3.0 58.5 (546) ± 3.2 

67.6 (617) ± 3.1 62.0 (635) ± 3.0 

67.8 (563) ± 3.2 70.6 (751) ± 2.7 

71.8 (548) ± 3.2 70.3 (633) ± 3.0 

75.1 (632) ± 2.9 74.9 (659) ± 2.9 

64.4 (1,694) ± 1.8 62.4 (1,719) ± 1.8 

64.2 (652) ± 3.0 61.6 (754) ± 2.7 

68.1 (856) ± 2.6 66.8 (887) ± 2.6 

44.3 (132) ± 5.7 ** 58.2 (174) ± 5.6 

70.6 (48) ±11.1 64.6 (53) ±10.6 

Educational Performance† 

Above average 53.5 (1,527) ± 1.8 50.1 (1,574) ± 1.8 

Average 75.2 (1,469) ± 1.9 75.9 (1,594) ± 1.8 

Below average 82.1 (389) ± 3.5 84.1 (455) ± 3.1 

Friends Who Smoke 

None 32.3 (352) ± 2.8 ** 25.4 (301) ± 2.5 

Few 60.2 (1,258) ± 2.1 57.9 (1,300) ± 2.0 

Many 79.6 (1,055) ± 2.2 82.5 (1,127) ± 2.0 

All 92.7 (719) ± 1.8 93.8 (877) ± 1.6 

Friends Who Disapprove 

None 77.5 (478) ± 3.3 76.1 (472) ± 3.4 

Few 76.7 (1,961) ± 1.6 78.9 (2,137) ± 1.5 

Many 56.4 (610) ± 3.0 53.2 (709) ± 2.7 

All 32.4 (329) ± 2.9 ** 26.6 (285) ± 2.7 

Plans after High School 

Go to work 

Armed Forces 

College 

Other/Unsure 

Totals 

79.1 (276) ± 4.3 80.2 (364) ± 3.7 

80.2 (162) ± 5.6 72.4 (268) ± 4.6 

61.1 (2,634) ± 1.5 59.3 (2,618) ± 1.5 

73.7 (323) ± 4.2 68.0 (376) ± 3.9 

64.0 (3,408) ± 1.3 62.5 (3,636) ± 1.3 

105

Smoking and Tobacco Control Monograph No. 14 

Table 6-2 (continued) 

Current Use 

1993 1996 

% (n) 95% CI % (n) 95% CI 

Sex 

Female 

Male 

Grade Level 

7th 

8th 

9th 

10th 

11th 

12th 

30.1 (830) ± 1.7 32.3 (936) ± 1.7 

28.9 (727) ± 1.8 29.1 (836) ± 1.7 

18.5 (177) ± 2.5 16.2 (162) ± 2.3 

26.5 (267) ± 2.7 26.0 (240) ± 2.8 

34.5 (314) ± 3.1 30.4 (309) ± 2.8 

28.9 (240) ± 3.1 33.7 (356) ± 2.9 

33.0 (252) ± 3.3 38.9 (348) ± 3.2 

37.7 (317) ± 3.3 40.7 (357) ± 3.3 

Race/Ethnicity* 

White 31.5 (828) ± 1.8 32.7 (897) ± 1.8 

Hispanic 26.1 (264) ± 2.7 26.5 (323) ± 2.5 

African American 22.2 (276) ± 2.3 ** 17.7 (230) ± 2.1 

Asian/P.I. 13.1 (39) ± 3.9 20.1 (60) ± 4.6 

Native American 34.3 (23) ±11.6 48.1 (39) ±11.1 

Educational Performance† 

Above average 20.3 (578) ± 1.5 20.0 (626) ± 1.4 

Average 37.2 (726) ± 2.2 41.0 (857) ± 2.1 

Below average 54.4 (254) ± 4.5 53.5 (284) ± 4.3 

Friends Who Smoke 

None 2.3 (25) ± 0.9 1.4 (16) ± 0.7 

Few 18.7 (391) ± 1.7 17.1 (382) ± 1.6 

Many 44.6 (589) ± 2.7 ** 50.5 (690) ± 2.7 

All 71.3 (552) ± 3.2 73.2 (679) ± 2.9 

Friends Who Disapprove 

None 52.2 (322) ± 4.0 51.4 (314) ± 4.0 

Few 39.7 (1,012) ± 1.9 ** 45.7 (1,233) ± 1.9 

Many 15.4 (166) ± 2.2 14.3 (190) ± 1.9 

All 5.2 (53) ± 1.4 ** 2.2 (24) ± 0.9 

Plans after High School 

Go to work 

Armed Forces 

College 

Other/Unsure 

Total 

46.8 (162) ± 5.3 ** 58.4 (261) ± 4.6 

47.5 (96) ± 7.0 40.2 (147) ± 5.0 

25.8 (1,110) ± 1.3 26.1 (1,149) ± 1.3 

43.9 (191) ± 4.7 38.3 (210) ± 4.1 

29.5 (1,568) ± 1.2 30.5 (1,772) ± 1.2 

* Analyses involving race/ethnicity were weighted to control for area as a possible confounding variable, due to the fact that a large 

proportion of minority students in Massachusetts live in urban areas. Area weights (based on population and student response 

per area stratum) were applied to all other analyses, so that the sample would be representative of the state population and 

inferences could be drawn for students on a statewide level. 

** Indicates significant difference from 1993 to 1996 for the variable of interest at p < 0.05. 

† Students reporting usual grades of As, As and Bs, or Bs were categorized as above average; Bs and Cs or Cs were categorized 

as average; Cs and Ds, Ds, or Ds and Fs were categorized as below average. 

106

Chapter 6 

Table 6-3 

Lifetime and Current Smoking Prevalence of Female Adolescents by Grade, Race/Ethnicity,* 

Educational Performance, Friends who Smoke, Friends who Disapprove of Smoking, and Plans 

after High School—Massachusetts, 1993, 1996 

Lifetime Use 

1993 1996 

% (n) 95% CI % (n) 95% CI 

Grade Level 

7th 

8th 

9th 

10th 

11th 

12th 

Race/Ethnicity* 

White 

Hispanic 

39.3 (194) ± 4.3 38.4 (186) ± 4.4 

54.2 (280) ± 4.3 55.9 (243) ± 4.7 

65.4 (315) ± 4.3 61.4 (341) ± 4.1 

69.7 (295) ± 4.4 74.7 (375) ± 3.8 

71.6 (293) ± 4.4 71.4 (339) ± 4.1 

76.6 (334) ± 4.0 76.6 (353) ± 3.9 

60.8 (833) ± 2.6 62.6 (869) ± 2.6 

67.9 (368) ± 4.0 64.3 (405) ± 3.8 

African American 74.3 (485) ± 3.4 70.5 (435) ± 3.7 

Asian/P.I. 38.2 (63) ± 7.5 49.0 (77) ± 7.9 

Native American 85.7 (18) ±15.7 81.8 (27) ±14.2 

Educational Performance† 

Above average 50.8 (841) ± 2.4 50.8 (885) ± 2.4 

Average 78.0 (712) ± 2.7 79.4 (742) ± 2.6 

Below average 87.6 (149) ± 5.0 90.3 (205) ± 4.0 

Friends Who Smoke 

None 30.1 (179) ± 3.7 23.5 (136) ± 3.5 

Few 58.1 (609) ± 3.0 57.0 (617) ± 3.0 

Many 76.4 (511) ± 3.2 ** 83.0 (571) ± 2.8 

All 92.4 (400) ± 2.5 93.9 (504) ± 2.1 

Friends Who Disapprove 

None 76.4 (197) ± 5.2 81.7 (214) ± 4.8 

Few 75.1 (1,036) ± 2.3 ** 79.8 (1,103) ± 2.1 

Many 57.5 (310) ± 4.2 54.8 (381) ± 3.7 

All 27.4 (154) ± 3.7 23.3 (127) ± 3.6 

Plans after High School 

Go to work 

Armed Forces 

College 

Other/Unsure 

Total 

78.1 (100) ± 7.3 86.0 (172) ± 4.9 

79.1 (34) ±12.7 78.0 (92) ± 7.6 

59.1 (1,403) ± 2.0 59.2 (1,404) ± 2.0 

80.2 (170) ± 5.4 74.8 (163) ± 5.8 

62.0 (1713) ± 1.8 63.1 (1837) ± 1.8 

107

Smoking and Tobacco Control Monograph No. 14 

Table 6-3 (continued) 

Current Use 

1993 1996 

% (n) 95% CI % (n) 95% CI 

Grade Level 

7th 

8th 

9th 

10th 

11th 

12th 

Race/Ethnicity* 

White 

Hispanic 

14.2 (70) ± 3.1 19.0 (91) ± 3.5 

25.5 (132) ± 3.8 27.5 (120) ± 4.2 

34.8 (167) ± 4.3 33.0 (182) ± 4.0 

32.2 (136) ± 4.5 35.2 (176) ± 4.2 

35.9 (147) ± 4.7 42.0 (198) ± 4.5 

40.9 (178) ± 4.6 36.5 (168) ± 4.4 

32.3 (442) ± 2.5 34.2 (474) ± 2.5 

27.5 (148) ± 3.8 29.0 (181) ± 3.6 

African American 22.3 (144) ± 3.2 18.4 (110) ± 3.1 

Asian/P.I. 10.8 (18) ± 4.8 17.1 (27) ± 6.0 

Native American 28.6 (6) ±21.3 54.5 (18) ±17.9 

Educational Performance† 

Above average 20.8 (344) ± 2.0 20.8 (362) ± 1.9 

Average 41.9 (382) ± 3.2 46.5 (434) ± 3.2 

Below average 59.8 (101) ± 7.5 62.9 (139) ± 6.5 

Friends Who Smoke 

None 1.3 (8) ± 1.0 1.4 (8) ± 1.0 

Few 19.9 (208) ± 2.4 16.8 (181) ± 2.2 

Many 43.9 (294) ± 3.8 51.1 (354) ± 3.8 

All 72.5 (313) ± 4.2 73.4 (390) ± 3.8 

Friends Who Disapprove 

None 54.3 (140) ± 6.1 58.8 (151) ± 6.1 

Few 42.0 (579) ± 2.6 ** 48.0 (662) ± 2.6 

Many 15.5 (83) ± 3.1 14.2 (99) ± 2.6 

All 3.4 (19) ± 1.5 2.8 (15) ± 1.4 

Plans after High School 

Go to work 

Armed Forces 

College 

Other/Unsure 

Total 

38.3 (49) ± 8.6 ** 63.9 (124) ± 6.8 

39.5 (17) ±15.3 44.4 (52) ± 9.1 

27.3 (647) ± 1.8 27.8 (657) ± 1.8 

54.0 (114) ± 6.8 45.4 (99) ± 6.7 

30.1 (830) ± 1.7 32.3 (936) ± 1.7 

* Analyses involving race/ethnicity were weighted to control for area as a possible confounding variable, due to the fact that a large 

proportion of minority students in Massachusetts live in urban areas. Area weights (based on population and student response 

per area stratum) were applied to all other analyses, so that the sample would be representative of the state population and 

inferences could be drawn for students on a statewide level. 

** Indicates significant difference from 1993 to 1996 for the variable of interest at p < 0.05. 

† Students reporting usual grades of As, As and Bs, or Bs were categorized as above average; Bs and Cs or Cs were categorized 

as average; Cs and Ds, Ds, or Ds and Fs were categorized as below average. 

108

Chapter 6 

Table 6-4 

Lifetime and Current Smoking Prevalence of Male Adolescents by Grade, Race/Ethnicity, 

Educational Performance, Friends who Smoke, Friends who Disapprove of Smoking, and 

Plans after High School—Massachusetts, 1993, 1996 

Lifetime Use 

1993 1996 

% (n) 95% CI % (n) 95% CI 

Grade Level 

7th 

8th 

9th 

10th 

11th 

12th 

Race/Ethnicity* 

White 

Hispanic 

52.9 (241) ± 4.3 ** 43.5 (226) ± 4.3 

66.5 (327) ± 4.2 60.8 (303) ± 4.4 

69.6 (295) ± 4.4 62.7 (294) ± 4.4 

67.1 (267) ± 4.6 67.0 (376) ± 3.9 

71.9 (253) ± 4.7 69.1 (293) ± 4.4 

74.1 (295) ± 4.3 73.0 (306) ± 4.3 

68.6 (857) ± 2.6 ** 62.2 (850) ± 2.6 

59.2 (273) ± 4.5 58.8 (349) ± 4.0 

African American 61.6 (361) ± 4.0 63.6 (452) ± 3.6 

Asian/P.I. 52.3 (69) ± 8.7 68.5 (98) ± 7.8 

Native American 63.0 (29) ±14.4 53.1 (26) ±14.5 

Educational Performance† 

Above average 57.9 (683) ± 2.8 ** 49.2 (689) ± 2.6 

Average 72.9 (754) ± 2.7 73.2 (852) ± 2.6 

Below average 78.9 (232) ± 4.8 79.6 (250) ± 4.4 

Friends Who Smoke 

None 35.5 (172) ± 4.3 ** 27.3 (165) ± 3.6 

Few 62.9 (647) ± 3.0 58.7 (683) ± 2.8 

Many 82.9 (539) ± 2.9 82.0 (556) ± 2.9 

All 93.1 (311) ± 2.7 93.7 (373) ± 2.4 

Friends Who Disapprove 

None 79.3 (279) ± 4.3 72.1 (258) ± 4.7 

Few 78.6 (912) ± 2.4 77.9 (1,034) ± 2.2 

Many 55.7 (299) ± 4.2 51.4 (328) ± 3.9 

All 39.3 (175) ± 4.6 ** 30.2 (159) ± 4.0 

Plans after High School 

Go to work 

Armed Forces 

College 

Other/Unsure 

Total 

80.1 (173) ± 5.4 75.6 (192) ± 5.3 

80.6 (129) ± 6.2 70.0 (177) ± 5.7 

63.8 (1,220) ± 2.2 ** 59.5 (1,214) ± 2.1 

67.7 (151) ± 6.2 63.6 (213) ± 5.2 

66.6 (1,679) ± 1.9 ** 62.2 (1,799) ± 1.8 

109

Smoking and Tobacco Control Monograph No. 14 

Table 6-4 (continued) 

Current Use 

1993 1996 

% (n) 95% CI % (n) 95% CI 

Grade Level 

7th 

8th 

9th 

10th 

11th 

12th 

Race/Ethnicity* 

White 

Hispanic 

22.7 (103) ± 3.9 ** 13.7 (71) ± 3.0 

27.7 (135) ± 4.0 24.7 (121) ± 3.8 

34.0 (144) ± 4.5 27.2 (127) ± 4.1 

26.1 (104) ± 4.3 32.1 (179) ± 3.9 

29.3 (103) ± 4.8 35.4 (150) ± 4.6 

34.5 (137) ± 4.7 ** 45.1 (188) ± 4.8 

30.7 (383) ± 2.6 31.1 (423) ± 2.5 

24.6 (113) ± 4.0 24.0 (142) ± 3.5 

African American 21.6 (125) ± 3.4 17.1 (120) ± 2.8 

Asian/P.I. 16.2 (21) ± 6.4 23.4 (33) ± 7.1 

Native American 36.2 (17) ±14.4 43.8 (21) ±14.4 

Educational Performance† 

Above average 19.5 (230) ± 2.3 19.0 (265) ± 2.1 

Average 33.3 (344) ± 2.9 36.6 (423) ± 2.8 

Below average 50.7 (146) ± 5.8 46.8 (145) ± 5.6 

Friends Who Smoke 

None 3.3 (16) ± 1.6 1.3 (8) ± 0.9 

Few 17.6 (181) ± 2.3 17.4 (201) ± 2.2 

Many 44.9 (290) ± 3.9 49.9 (337) ± 3.8 

All 70.1 (234) ± 4.9 72.9 (288) ± 4.4 

Friends Who Disapprove 

None 51.4 (181) ± 5.3 45.9 (163) ± 5.2 

Few 36.5 (422) ± 2.8 ** 43.3 (571) ± 2.7 

Many 15.3 (82) ± 3.1 14.3 (91) ± 2.7 

All 7.7 (34) ± 2.5 ** 1.7 (9) ± 1.1 

Plans after High School 

Go to work 

Armed Forces 

College 

Other/Unsure 

Total 

51.6 (110) ± 6.8 54.4 (137) ± 6.2 

49.4 (79) ± 7.9 38.2 (95) ± 6.1 

24.0 (457) ± 1.9 24.2 (493) ± 1.9 

33.9 (75) ± 6.3 33.5 (111) ± 5.1 

28.9 (727) ± 1.8 29.1 (836) ± 1.7 

* Analyses involving race/ethnicity were weighted to control for area as a possible confounding variable, due to the fact that a large 

proportion of minority students in Massachusetts live in urban areas. Area weights (based on population and student response 

per area stratum) were applied to all other analyses, so that the sample would be representative of the state population and 

inferences could be drawn for students on a statewide level. 

** Indicates significant difference from 1993 to 1996 for the variable of interest at p < 0.05. 

† Students reporting usual grades of As, As and Bs, or Bs were categorized as above average; Bs and Cs or Cs were categorized 

as average; Cs and Ds, Ds, or Ds and Fs were categorized as below average. 

110

Chapter 6 

From 1993 to 1995, MYRBS (Massachusetts Department of Education, 

1998) rates for lifetime cigarette use among high school students increased 

from 67.8 percent to 71.5 percent, while current use increased from 30.2 

percent to 35.7 percent. Daily smoking rates increased from 11.9 percent to 

14.6 percent. Current smokeless tobacco use in Massachusetts decreased by 

over 10 percent, from 9.4 percent to 8.4 percent. However, from 1995 to 

1997, daily smoking among high school students remained flat at 14.5 percent, while current-month smoking decreased somewhat to 34.4 percent 

and current smokeless tobacco use continued to decline sharply to 6.0 percent. Lifetime smoking remained flat at 69.1 percent‡

. 

The national YRBS (CDC, 1998), administered biannually, has reported 

flat rates for lifetime smoking since 1991 (70.1 percent, 69.5 percent, 71.3 

percent, 70.2 percent)(CDC, 1992), while current smoking rates continue to 

rise (27.5 percent, 30.5 percent, 34.8 percent, 36.4 percent). Nationally, current smokeless rates (10.5 percent, 11.5 percent, 11.4 percent, 9.3 percent) 

have declined at about half the rate experienced in Massachusetts from 

1995 to 1997‡

. 

During the period between 1995 and 1997, declines in smoking were 

evidenced in high school students overall, but the greatest declines were 

among the 9th graders—the first high school class to have had the benefit 

of sustained MTCP activity prior to their initiation of tobacco use. The 

increases observed among 9th graders from 1993 to 1995 in lifetime (64.4 

percent to 68.9 percent), past month (28.9 percent to 32.3 percent), and 

daily (8.1 percent to 11.8 percent) smoking were reversed in 1997, with lifetime and past-month cigarette use declining to pre-1993 levels (62.3 percent and 27.8 percent, respectively) and daily use easing slightly to 10.4 

percent. Smokeless tobacco use continued to decline in 9th graders from 

1993 to 1997 (10.3 percent to 5.7 percent)‡ (MYRBS, Massachusetts 

Department of Education, 1998). 

To summarize, prior to MTCP inception in 1993, overall trends for 

Massachusetts paralleled that of the nation, although Massachusetts’ cigarette rates were higher, and smokeless rates were lower, than the rest of the 

country5. Since 1993, however, there has been some divergence in these 

trends. Specifically, there have been significant declines in cigarette rates 

among junior high school students. Similarly, smokeless tobacco rates have 

declined among junior high and high school students in all grades—9th 

(current and lifetime), 10th (current), and 11th (lifetime) (MPS, Briton et al., 

1997). High school rates have remained level since 1995, yet declines in 

5. The 1993 MYRBS (administered prior to MTCP) indicated that 12th-grade students’ reported 

rate of current cigarette use was 20 percent higher than those reported for the country as a 

whole by MTF, a national survey of over 50,000 students (35.9 percent and 29.9 percent, 

respectively). MTF reported a national current smokeless tobacco rate of 10.4 percent for 

10th graders and 11.1 percent for 12th graders. In Massachusetts, 10th and 12th graders 

reported current smokeless tobacco use of 8.1 percent and 8.8 percent, respectively. ‡ Data not shown. 

111

Smoking and Tobacco Control Monograph No. 14 

smoking among 9th graders from 1995 to 1997, although nonsignificant, 

have returned the rates to pre-1993 levels (MYRBS—Massachusetts 

Department of Education, 1998). In contrast, the nation as a whole experienced increases in high school (CDC, 1995 & 1998; Kann, 1996) and 8th 

grade (Johnston et al., 1999) use during this same period. 

CHANGES IN The MPS in 1993 and 1996 contained items that have been 

CORRELATES OF associated with smoking prevalence—friends who smoke, 

SMOKING: 1993–1996 friends who disapprove of smoking, educational performance, and plans after high school. It is plausible that friends’ disapproval 

and the proportion of friends who smoke would be impacted by a program 

that seeks to de-normalize tobacco use. We would not expect educational 

performance or post-high-school plans to be affected by program exposure, 

although they are correlated with tobacco use and could alter program 

effectiveness. Findings revealed significant differences from 1993 to 1996 in 

overall proportions of those responding on friends who disapprove and 

plans after high school; in females on friends who smoke, friends who disapprove, educational performance, and plans after high school; and in 

males on plans after high school (Table 6-5). Within-grade analyses reveal 

significant differences for 8th, 9th, 11th,and 12th grades on friends who 

smoke, for 8th and 9th grades (marginally suggestive of change for 7th 

grade, p = 0.057) on friends who disapprove, for 9th grade on educational 

performance, and for all but 10th grade on plans after high school 

(Table 6-6). 

Changes Associated In 1996, girls were less likely to say that none, a few, or many 

with Gender of their friends smoke and more likely to say that all of their 

friends smoke than in 1993. Increases were observed overall and for girls 

reporting that many of their friends disapprove, with slight declines for 

those reporting that none, few, or all friends disapprove. Also, there were 

increases in the proportion of girls reporting below-average grades. Finally, 

increases were observed for both boys and girls across the same time period 

on plans to go to work and join the armed forces after high school, as were 

decreases in plans to attend college. For boys, there were also increases in 

the percentage that were unsure of post-high-school plans, or had other 

plans (Table 6-5). 

Changes Associated Patterns were consistent for all grades that showed signifiwith Grade Level cant changes on plans after high school: those expecting to 

go to college decreased, those going into the armed forces increased, and 

(with the exception of the 7th and 12th graders) those going to work 

increased. These changes should be associated with increased smoking from 

1993 to 1996. For educational performance, the proportion of 9th grade 

students reporting above-average grades increased, while those reporting 

average grades decreased. No changes were observed for those reporting 

below-average grades. It is unclear how these changes in educational performance may affect smoking behavior, although doing poorly in school 

has generally been associated with increased smoking behavior (Table 6-6). 

112

Chapter 6 

Table 6-5 

Friends who Smoke, Friends who Disapprove of Smoking, Educational Performance and Plans 

after High School, Overall and by Gender for 1993–1996 

Overall Females Males 

% (n) % (n) % (n) 

Friends who 

Smoke 

1993 

None 

Few 

Many 

All 

Total 

1996 

None 

Few 

Many 

All 

Total 

Friends who 

Disapprove 

of Smoking 

1993 

None 

Few 

Many 

All 

Total 

1996 

None 

Few 

Many 

All 

Total 

Educational 

Performance† 

1993 

Below Average 

Average 

Above Average 

Total 

1996 

Below Average 

Average 

Above Average 

Total 

* 

21 1,091 22 595 19 485 

40 2,088 38 1,049 41 1,029 

25 1,327 24 670 26 650 

15 776 16 434 13 334 

100 5,282 100 2,748 100 2,498 

21 1,188 20 581 21 607 

39 2,246 37 1,083 41 1,163 

24 1,371 24 693 24 678 

16 935 19 537 14 398 

100 5,740 100 2,894 100 2,846 

** ** 

12 617 9 259 14 352 

49 2,559 50 1,380 47 1,161 

21 1,081 20 539 22 537 

19 1,014 21 563 18 445 

100 5,271 100 2,741 100 2,495 

11 622 9 263 13 358 

47 2,714 48 1,386 47 1,328 

23 1,333 24 696 22 638 

19 1,073 19 547 19 526 

100 5,742 100 2,892 100 2,850 

* 

9 474 6 170 12 293 

37 1,955 33 913 41 1,034 

54 2,853 61 1,656 47 1,179 

100 5,282 100 2,739 100 2,506 

9 544 8 229 11 315 

36 2,105 32 940 40 1,165 

54 3,148 60 1,746 49 1,401 

100 5,797 100 2,915 100 2,881 

113

Smoking and Tobacco Control Monograph No. 14 

Table 6-5 (continued) 

Overall Females Males 

% (n) % (n) % (n) 

Plans after 

High School 

1993 

Go to work 

Armed forces 

College 

Other/unsure 

Total 

1996 

Go to work 

Armed forces 

College 

Other/unsure 

Total 

*** *** *** 

7 350 5 128 9 216 

4 203 2 43 6 160 

81 4,313 86 2,374 76 1,911 

8 438 8 211 9 224 

100 5,304 100 2,756 100 2,511 

8 454 7 199 9 255 

6 371 4 118 9 252 

76 4,424 82 2,379 71 2,045 

10 553 8 219 12 334 

100 5,802 100 2,915 100 2,886 

* Indicates significance for 1993 to 1996 at p < 0.05. 

** Indicates significance for 1993 to 1996 at p < 0.01. 

*** Indicated significance for 1993 to 1996 at p < 0.001. † Students reporting usual grades of As, As and Bs, or Bs were categorized as above average; Bs and Cs or Cs were 

categorized as average; Cs and Ds, Ds, or Ds and Fs were categorized as below average. 

114

Table 6-6 

Friends who Smoke, Friends who Disapprove of Smoking, Educational Performance and Plans after High School by Grad

1993–1996 

Grade Level 

7th 8th 9th 10th 11th 12th 

% (n) % (n) % (n) % (n) % (n) % (n) 

Friends who Smoke ** * ** *** 

1993 

None 43.3 (413) 19.9 (200) 14.1 (127) 15.7 (130) 14.2 (107) 13.6 (114) Few 37.6 (358) 41.6 (419) 38.2 (344) 39.1 (323) 36.4 (275) 43.9 (369) Many 11.6 (111) 26.7 (269) 28.2 (254) 25.0 (207) 32.2 (243) 28.9 (243) All 7.5 (71) 11.8 (119) 19.4 (175) 20.2 (167) 17.2 (130) 13.6 (114) 

Total 100.0 (953) 100.0 (1,007) 100.0 (900) 100.0 (827) 100.0 (755) 100.0 (840) 

1996 

None 43.0 (419) 25.1 (231) 18.1 (185) 15.0 (158) 14.2 (127) 7.8 (68) Few 36.3 (354) 42.3 (390) 40.6 (414) 40.9 (431) 33.1 (297) 41.2 (360) Many 14.2 (138) 19.8 (183) 24.8 (253) 25.1 (264) 28.0 (251) 32.2 (281) All 6.5 (63) 12.8 (118) 16.5 (168) 19.0 (200) 24.7 (222) 18.8 (164) Total 100.0 (974) 100.0 (922) 100.0 (1,020) 100.0 (1,053) 100.0 (897) 100.0 (873) 

Friends who Disapprove of Smoking   

1993 

None 13.9 (132) 11.8 (118) 11.3 (102) 11.0 (91) 11.5 (87) 10.4 (87) Few 27.1 (257) 47.4 (475) 55.9 (504) 54.1 (447) 53.4 (404) 56.5 (472) Many 19.8 (188) 22.0 (221) 18.5 (167) 20.4 (169) 20.5 (155) 21.8 (182) All 39.2 (372) 18.8 (189) 14.3 (129) 14.5 (120) 14.6 (110) 11.3 (94) 

Total 100.0 (949) 100.0 (1,003) 100.0 (902) 100.0 (827) 100.0 (756) 100.0 (835) 

1996 

None 10.0 (98) 12.1 (112) 11.2 (114) 11.5 (121) 10.2 (91) 9.7 (84) Few 28.9 (283) 39.7 (367) 49.0 (498) 53.3 (563) 56.4 (505) 57.3 (498) Many 21.6 (212) 25.6 (237) 24.0 (244) 22.4 (237) 22.1 (198) 23.7 (206) All 39.5 (387) 22.5 (208) 15.8 (161) 12.8 (135) 11.4 (102) 9.3 (81) Total 100.0 (980) 100.0 (924) 100.0 (1,017) 100.0 (1,056) 100.0 (896) 100.0 (869) 

115 
116 Table 6-6 (continued) 

Grade Level 

7th 8th 9th 10th 11th 12th 

% (n) % (n) % (n) % (n) % (n) % (n) 

Educational
Performance† ** *


1993 

Below Average 6.3 (59) 9.8 (99) 11.3 (103) 10.3 (85) 10.6 (80) 5.7 (48) Average 25.9 (244) 27.3 (275) 46.0 (419) 38.2 (317) 42.9 (324) 44.8 (375) Above Average 67.8 (638) 62.9 (634) 42.6 (388) 51.5 (427) 46.5 (351) 49.5 (414) 

Total 100.0 (941) 100.0 (1,008) 100.0 (910) 100.0 (829) 100.0 (755) 100.0 (837) 

1996 

Below Average 7.1 (71) 10.3 (96) 11.2 (115) 11.1 (118) 8.3 (74) 7.8 (69) Average 26.6 (266) 30.2 (282) 33.2 (340) 42.1 (447) 41.3 (370) 45.6 (401) Above Average 66.3 (664) 59.5 (556) 55.6 (570) 46.8 (498) 50.4 (451) 46.5 (409) Total 100.0 (1,001) 100.0 (934) 100.0 (1,025) 100.0 (1,063) 100.0 (895) 100.0 (879) 

Plans after High School *** *** * *** * *** 

1993 

Go to work 8.1 (77) 5.7 (58) 7.6 (69) 5.7 (47) 5.4 (41) 7.0 (59) Armed forces 2.9 (28) 5.0 (51) 3.5 (32) 4.9 (41) 2.4 (18) 4.0 (34) College 82.3 (784) 80.7 (817) 79.5 (725) 80.5 (668) 81.7 (618) 83.2 (701) Other/unsure 6.7 (64) 8.6 (87) 9.4 (86) 8.9 (74) 10.4 (79) 5.8 (49) 

Total 100.0 (953) 100.0 (1,013) 100.0 (912) 100.0 (830) 100.0 (756) 100.0 (843) 

1996 

Go to work 6.5 (65) 7.8 (73) 10.7 (110) 6.3 (67) 9.4 (84) 6.4 (56) Armed forces 8.2 (82) 9.2 (86) 5.0 (51) 6.5 (69) 4.6 (41) 4.8 (42) College 75.6 (758) 73.9 (691) 73.8 (757) 76.1 (809) 79.1 (710) 79.6 (698) Other/unsure 9.8 (98) 9.1 (85) 10.5 (108) 11.1 (118) 7.0 (63) 9.2 (81) Total 100.0 (1,003) 100.0 (935) 100.0 (1,026) 100.0 (1,063) 100.0 (898) 100.0 (877) 

* Indicates significance for 1993 to 1996 at p < 0.05 

** Indicates significance for 1993 to 1996 at p < 0.01 

*** Indicated significance for 1993 to 1996 at p < 0.001 

† Students reporting usual grades of As, As and Bs, or Bs were categorized as above average; Bs and Cs or Cs were categorized as average; Cs and Ds, Ds, or Ds a

categorized as below average. 
Chapter 6 

While there was no change in overall proportion with friends who 

smoke, 8th and 9th graders were more likely to increase in the frequency of 

reporting that none of their friends smoked. Similarly, for lower grades, the 

proportion reporting that all of their friends disapproved increased over 

time. While nonsignificant, the direction was reversed for 11th and 12th 

grades. These changes should produce declines in smoking from 1993 to 

1996 among lower grades (Table 6-6). 

CHANGES IN LIFETIME Results of analyses conducted to detect changes in lifeAND CURRENT SMOKING time and current smoking (overall, females, males) by 

ASSOCIATED WITH friends who smoke, friends who disapprove, educaCORRELATES tional performance, and post high school plans can be 

examined in Tables 6-2 through 6-4. Changes from 1993 to 1996 for both 

lifetime and current smoking are associated with differing levels of these 

variables. 

Correlates Associated Those who reported that none of their friends smoked were 

with Decreases in significantly less likely to have ever smoked in 1996 than 

Smoking in 1993, with similar patterns for males and females, but 

only the difference for males reached significance. Those who responded 

that all of their friends disapproved of smoking were significantly less likely 

to smoke (either current or lifetime) in 1996 than in 1993. Again, the direction of change was similar for females and males, but only the changes for 

males reached significance. Males whose grades were above average or who 

planned to go to college were significantly less likely to report lifetime 

smoking in 1996 than in 1993. 

Correlates Associated Those who reported that many of their friends smoked 

with Increases in were significantly more likely to have smoked in the past 

Smoking month in 1996 than in 1993. A similar result was obtained 

for those who planned to go to work after high school. Girls with many 

friends who smoked exhibited increases in lifetime smoking, while boys 

remained flat on this measure. Girls who planned to go to work increased 

significantly in current cigarette smoking from 1993 to 1996 (38.3 percent 

to 63.9 percent), while boys did not (51.6 percent to 54.4 percent). This is 

of concern in that the number of girls planning to go to work increased by 

50 percent during this time. When a few friends disapproved of smoking, 

significant increases were observed from 1993 to 1996 on current smoking 

(overall, for females, and for males). While girls who reported that a few of 

their friends disapproved were also significantly more likely to report 

increases in lifetime smoking in 1996 than in 1993, corresponding lifetime 

use among boys remained flat. 

To summarize, current smoking rates were virtually unchanged for 7th 

through 12th graders in Massachusetts from 1993 to 1996 (i.e., 29.5 percent 

to 30.5 percent; Table 6-2) and were compatible with changes in the overall 

percentage answering that many or all of their friends smoke (i.e, 39.8 percent to 40.2 percent; Table 6-5). 

117

Smoking and Tobacco Control Monograph No. 14 

Changes in current smoking within each of these grades, though not 

significant, are consistent with and directionally supportive of program 

impact. As mentioned earlier, the reductions in smoking for the combined 

sample of 7th, 8th, and 9th grade students were significant overall, for 

boys, and for Hispanic students on lifetime use, and for boys and African 

American students on current use. 

While both boys and girls increased in the percentage of those planning 

to go to work, the overall increase in this category was driven almost entirely by girls, and this increase was associated with significant increases in current smoking overall and among those girls planning to go to work. 

Those reporting that few of their friends disapproved of smoking were 

more likely to show increases in current and lifetime smoking. This was 

also true for girls. This effect was mitigated somewhat by the decline in 

those reporting that few of their friends disapproved. 

IMPACT OF PERCEIVED The price of cigarettes has been shown to impact 

INCREASING CIGARETTE smoking in both youths and adults (Chaloupka and 

PRICES Wechsler, 1997; Harris and Chan, 1999), with 

increases in premium brands more predictive of declines in youth smoking 

than price changes in generic or discount brands (Harris and Chan, 1999). 

In the 1993 and 1996 MPS, youths were asked if “price increases have 

affected your buying cigarettes.”6 Responses included the following: No, I 

don’t smoke; No, I don’t buy my own cigarettes; No, I buy the same number of packs as usual; No, the price of my brand did not increase; No, I 

switched to a cheaper brand; Yes, I buy fewer packs; Yes, I tried to quit 

smoking; Yes, I quit smoking. Results on this item were similar for both 

years. In 1996, 81.8 percent of youths either didn’t smoke or didn’t buy 

their own cigarettes and another 1.1 percent did not think their brand 

increased in price. Of the 17 percent remaining, close to one-third of those 

buying their own cigarettes and perceiving a price increase either tried to 

quit or actually quit. No behavior change was reported by 10.2 percent of 

respondents. Of the 6.8 percent who reported a change, quitting (3.2 percent) and attempting to quit (1.9 percent) were reported most often, while 

buying fewer packs (1.2 percent) was the next most frequent response. Very 

few reported switching to a cheaper brand (0.5 percent). 

6. During this interval, actual cigarette prices did not increase in Massachusetts. 

118

Chapter 6 

CONCLUSIONS The effect of a large cohort of junior high school smokers advancing into high school could overwhelm a prevention program that is based 

on de-normalization of smoking. What is promising is that the tremendous 

pressure that this smoking cohort might have exerted on younger students 

appears to have been mitigated by the tobacco control work in 

Massachusetts. 

Data are consistent with MTCP effectiveness in changing social norms 

and are supportive of behavior change in younger grades, among males, 

among African Americans, and possibly among girls. While current smoking rates for youths have increased nationally, rates in Massachusetts have 

remained flat. From 1993 to 1996, all grades showed increases in the proportion of youths reporting that many of their friends disapprove of smoking. This is consistent with success in changing social norms, yet is mitigated somewhat by a reduction in those reporting that all friends disapprove 

(occurring mostly in upper grades, which also report the highest rates of 

current smoking). In contrast, current smoking decreased in lower grades 

and among males, where decreases in all friends disapproving did not 

occur. Furthermore, the 9th graders in the 1997 MYRBS high school survey 

showed some non-significant declines which, if continued into 11th grade, 

will be documented by the recently administered 1999 MYRBS. Girls appear 

to be at higher risk from environmental pressures (i.e., below average 

grades, going to work after high school) and, more importantly, from the 

impact of these pressures on smoking rates (approximately 6 percent of the 

population of girls are responsible for 12 percent of the current smoking 

rate). Future programming may need to be more responsive to girls in this 

particular subset. While overall smoking rates for girls have not shown the 

same decline as for boys, it is notable that rates for girls have not increased. 

This fact suggests that the existing program may provide some protective 

effects for girls. 

The effectiveness of the first few years of MTCP programming may not 

become detectable until the students who were in 4th and 5th grades in 

1994 reach 9th and 10th grades in 1999. We can then determine any difference in their uptake process. The results of a successful program to de-normalize tobacco use may not be evident in the high school population until 

the present cohort of high school smokers—who began as most addicted 

smokers in junior high school—are out of high school and in their mid-20s. 

Older youths and young adults who smoke can continue to benefit from 

MTCP efforts as they become exposed to increased smoking restrictions in 

work and social settings. We are cautiously optimistic that the MPS conducted in November and December of 1999 and January of 2000 will continue to document significant progress in the area of youth smoking. 

119

Smoking and Tobacco Control Monograph No. 14 

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Tobacco Survey, 1993. Boston, MA: Center for 

Survey Research at University of Massachusetts, 

Boston, 1994. 

Briton, N.J., Clark, T.W., Baker, A.K., Posner, J., Soldz, 

S., Krakow, M. Adolescent Substance Use in 

Massachusetts: Trends among Public School Students 

1984–1996. Boston, MA: Massachusetts 

Department of Public Health. Report prepared by 

Health and Addictions Research, Inc., 1997. 

Burns, D., Lee, L., Shen, L.Z. Cigarette Smoking 

Behavior in the United States. In: Changes in 

Cigarette-Related Disease Risks and Their 

Implications for Prevention and Control. Smoking 

and Tobacco Control Monograph No. 8. Burns, 

D., Garfield, L., Samet, J.M. (Editors). Bethesda, 

MD: U.S. Department of Health and Human 

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of Health, National Cancer Institute. NIH 

Publication No. 97-4213, 1997. 

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41(24):417-421, 1992. 

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47(12):229-233, 1998. 

Center for Survey Research, University of 

Massachusetts. Clearing the Air in Massachusetts: 

Controlling Environmental Tobacco Smoke. Boston, 

MA: Center for Survey Research at University of 

Massachusetts, Boston, 1995. 

Chaloupka, F., Wechsler, H. Price, tobacco control 

policies and smoking among young adults. 

Journal of Health Economics 16(3):359-373, 1997. 

DiFranza, J., Richards, J., Paulman, P., Wolf-Gillespie, 

N., Fletcher, C., Jaffe, R., Murray, D. RJR 

Nabisco’s Cartoon Camel Promotes Camel 

Cigarettes to Children. Journal of the American 

Medical Association 266(22):3149-3153, 1991. 

Evans, N., Farkas, A., Gilpin, E., Berry, C., Pierce, J. 

Influence of tobacco marketing and exposure to 

smokers on adolescent susceptibility to smoking. 

Journal of the National Cancer Institute 

87(20):1538-1545, 1995. 

Hamilton, W. Independent Evaluation of the 

Massachusetts Tobacco Control Program: Fourth 

Annual Report. Cambridge, MA: Abt Associates, 

Inc., 1998. 

Harris, J.E., Chan, S.W. The continuum-of-addiction: 

cigarette smoking in relation to price among 

Americans aged 15–29. Health Economics 8(1):81-

86, 1999. 

Harris, J., Connolly, G., Brooks, D., Davis, B. 

Cigarette smoking before and after an excise tax 

increase and an anti-smoking campaign: 

Massachusetts—1990–1996. Mortality and 

Morbidity Weekly Report. 45:966-970, 1997. 

Johnston, L.D., O’Malley, P.M., Bachman, J.G. 

National Survey Results on Drug Use from the 

Monitoring the Future Study, 1975–1997, Vol. 1: 

Secondary School Students. Rockville, MD: U.S. 

Department of Health and Human Services, 

Public Health Service, National Institutes of 

Health, National Institute on Drug Abuse, 1999. 

Kann, L., Warren C., Harris, W., Collins, J., Williams, 

B., Ross, J., Kolbe, L. Youth Risk Behavior 

Surveillance—United States, 1995. Mortality and 

Morbidity Weekly Report 45(SS-4):1-83, 1996. 

King, C., 3rd, Siegel, M., Celebucki, C., Connolly, G. 

Adolescent exposure to cigarette advertising in 

magazines: An evaluation of brand-specific 

advertising in relation to youth readership. 

Journal of the American Medical Association 

279(7):516-520, 1998. 

Massachusetts Department of Education. Tobacco Use 

Among Massachusetts High School Students: 1997 

Massachusetts Youth Risk Behavior Survey Results. 

Malden: MA, Massachusetts Department of 

Education, 1998. 

Pierce, J.P., Choi, W.S., Gilpin, E.A., Farkas, A.J., 

Berry, C.C. Tobacco Industry Promotion of 

Cigarettes and Adolescent Smoking. Journal of the 

American Medical Association 279(7):511-515, 

1998. 

Pucci, L., Siegel, M. Features of sales promotion in 

cigarette magazine advertisements, 1980–1993: 

an analysis of youth exposure in the United 

States. Tobacco Control 8(1):29-36, 1999. 

SPSS. SPSS Version 8.0 for Windows. Chicago: IL., 

1998. 

U.S. Department of Health and Human Services. 

Preventing Tobacco Use Among Young People: A 

Report of the Surgeon General. Atlanta, GA: U.S. 

Department of Health and Human Services, 

Public Health Service, Centers for Disease 

Control and Prevention, National Center for 

Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 1994. 

Worden, J.K., Flynn, B.S., Secker-Walker, R.H. 

Antismoking advertising campaigns for youth. 

Journal of the American Medical Association 

280(4):323, 1998. 

120

Predictors of Tobacco Use among 

Adolescents in Florida, 1998–1999 

Ursula E. Bauer, Tammie M. Johnson 

INTRODUCTION Tobacco use is the single leading preventable cause of death in 

the United States (McGinnis and Foege, 1993) and is estimated to cost the 

state of Florida over $2 billion annually in direct health care expenditures 

(CDC, 1996). In August of 1997, the state of Florida settled its lawsuit 

against the tobacco industry for claims regarding tobacco-related health 

care costs. As part of the $11.3 billion settlement, the state appropriated 

$23 million in fiscal year (FY) 1997/1998 and $70 million in FY 1998/1999. 

Settlement monies were used to fund the Florida Pilot Program on Tobacco 

Control, designed to prevent and reduce tobacco use among Florida youths. 

To determine prevalence rates of cigarette, cigar, and smokeless tobacco 

(chewing tobacco or snuff) use for Florida public middle- and high-school 

students, the Florida Department of Health conducted the Florida Youth 

Tobacco Survey (FYTS) in February, 1998 and again in February, 1999. The 

purpose of these surveys was to establish baseline parameters for, and to 

monitor the progress of, the Pilot Program, which initiated prevention 

activities in April 1998. The Florida Pilot Program on Tobacco Control targets youths under age 18 and has four program components, each of which 

implements a variety of activities designed to combat youth tobacco use 

and lower tobacco’s attractiveness to youths. The program’s centerpiece is a 

youth-oriented, counter-marketing media campaign developed to reduce 

the allure of smoking. Community partnerships in all 67 Florida counties, 

an education and training initiative, and an enforcement arm comprise the 

other program components. The Florida Youth Tobacco Survey is a key 

measure of the program’s effectiveness. 

This chapter describes tobacco use patterns among Florida adolescents 

and also discusses factors associated with tobacco use; it summarizes 

changes in tobacco use over the 1-year time period between 1998 and 1999 

by sex, race/ethnicity, grade level, and geographic region (Bauer et al., 

1999). 

METHODS The 1998 Florida Youth Tobacco Survey (FYTS) used a two-stage cluster 

sample design within each of seven geographic regions (selecting schools 

within regions and classrooms within schools). It sampled middle (grades 6-

8) and high (grades 9-12) schools separately to obtain a representative sample of 11,865 public middle school and 10,675 public high school students 

in grades 6 through 12. The 1999 survey was conducted in 242 of the 255 

schools that participated in the 1998 survey sample, among a representative 

sample of 11,724 middle and 9,254 high school students. The middle 

school response rates for 1998 and 1999 were 97 percent and 93 percent, 

respectively; the student response rates were 82 percent and 88 percent, 

121 
Smoking and Tobacco Control Monograph No. 14 

respectively; and the overall response rates were 80 percent and 82 percent, 

respectively. For the high school surveys, school response rates for 1998 and 

1999 were 95 percent and 89 percent, respectively; the student response 

rates were 76 percent and 79 percent, respectively; and the overall response 

rates were 72 percent and 70 percent, respectively. Data were weighted to 

provide estimates generalizable to all public school students in grades 6-12 

in the seven regions and the state. Survey data were analyzed, and point 

estimates and odds ratios were generated using the Statistical Analysis 

System (SAS). Variance estimates and 95 percent confidence limits were calculated using the Software for Statistical Analysis of Correlated Data 

(SUDAAN). 

Students completed a self-administered questionnaire that included 

questions about prevalence of tobacco use (cigarette, cigar, and smokeless 

tobacco), exposure to environmental tobacco smoke, minors’ access to 

tobacco products, enforcement of tobacco purchasing and possession laws, 

knowledge and attitudes about tobacco use, media and advertising, tobacco 

use prevention school curricula, and student demographic and other information. Eight reports on the 1998 survey results are available from the 

Florida Department of Health (see the Florida Department of Health web 

site at http://www.state.fl.us/tobacco and click on “research”). Current cigarette, cigar, and smokeless tobacco users were students who reported product use on 1 or more of the 30 days preceding the survey. 

RESULTS	 One of the goals of the Florida Tobacco Pilot Program is 

to change attitudes about and de-glamorize tobacco use. 

Changes in Receptivity Adolescents’ attitudes toward tobacco and their percepto Tobacco Company tions of the glamour associated with tobacco products are 

Promotions measured by two questions about whether a student has 

bought or received anything in the past 12 months with a tobacco company name or picture on it, and whether the student would use or wear such 

a product. The “receptivity” scale, calculated from these questions, quantifies students’ receptivity to tobacco company promotions and has a range 

of 1 to 3, with 1 being less receptive and 3 being more receptive. Among 

middle school students, mean scale scores on the receptivity to tobacco 

company promotions index declined by 10 percent, from 2.0 in 1998 to 1.8 

in 1999. Among high school students, mean scores declined by 20 percent, 

from 2.0 in 1998 to 1.6 in 1999. Declines in receptivity were evident (and 

of similar magnitude) across all racial/ethnic groups (p < 0.05 for all comparisons). 

Changes in Prevalence of current cigarette use among middle school students 

Prevalence declined from 18.5 percent in 1998 to 15.0 percent in 1999 (p < 

of Current 0.0001) (Table 7-1). Among high school students, prevalence of curTobacco Use rent cigarette use declined from 27.4 percent in 1998 to 25.2 percent in 1999 (p < 0.02) (Table 7-2). Among middle school students, declines 

in current cigarette use were substantial and significant for both males and 

females; however, among high school students, the decline was statistically 

significant only among females. Among both middle and high school students, the declines were most pronounced among non-Hispanic White students. Current cigarette use declined from 22.0 percent in 1998 to 16.1 per122

Table 7-1


Percentage of Florida Public Middle School Students who Used Cigarettes, Cigars, or SmokTobacco by Sex, Race/Ethnicity, and Grade: Florida Youth Tobacco Survey, 1998 and 199

Current Cigarette Use* Current Cigar Use** Current Smokeless 

1998 1999 1998 1999 1998 199

Sample Size (N): (11,031) (10,268) (11,535) (10,890) (11,633) (10,

Category % CI % CI p % CI % CI p % CI % Sex 

Female 18.1 (±1.5) 14.9 (±1.8) 0.0040 10.3 (±1.0) 9.4 (±1.4) 0.2600 4.4 (±0.6) 2.8 (Male 18.9 (±1.7) 15.0 (±1.4) 0.0001 17.6 (±1.3) 14.2 (±1.3) 0.0002 9.3 (±1.1) 6.8 (

Race / Ethnicity† 

White, non-Hisp. 22.0 (±1.8) 16.1 (±1.7) 0.0000 14.5 (±1.2) 11.1 (±1.4) 0.0001 7.6 (±1.1) 4.8 (Black, non-Hisp. 9.5 (±1.4) 8.5 (±1.5) 0.3400 13.0 (±1.6) 12.3 (±1.9) 0.5500 5.3 (±1.1) 4.4 (Hispanic 16.8 (±2.1) 16.1 (±2.6) 0.5100 13.6 (±1.7) 12.9 (±2.3) 0.5300 5.5 (±1.3) 3.6 (

Grade Level 

6th 10.5 (±1.4) 8.0 (±1.3) 0.0100 7.8 (±0.9) 6.7 (±1.2) 0.1600 6.0 (±1.0) 3.9 (7th 19.3 (±2.1) 16.6 (±2.5) 0.0700 14.2 (±1.7) 11.4 (±1.8) 0.0200 7.0 (±1.2) 5.2 (8th 25.0 (±2.3) 19.5 (±2.5) 0.0005 19.5 (±1.7) 16.8 (±2.2) 0.0600 7.1 (±1.1) 4.8 (

Total 18.5 (±1.4) 15.0 (±1.3) 0.0000 14.1 (±1.0) 11.9 (±1.1) 0.0020 6.9 (±0.7) 4.9 (Note: CI = 95% confidence interval. 

* Smoked cigarettes on ≥1 of the 30 days preceding the survey. 

** Smoked cigars on ≥1 of the 30 days preceding the survey. 

*** Used smokeless tobacco on ≥1 of the 30 days preceding the survey. 

† Numbers of other racial/ethnic groups were too small for meaningful analysis. 

123 
124 

Table 7-2
Percentage of Florida Public High School Students who Used Cigarettes, Cigars, or SmokelTobacco by Sex, Race/Ethnicity, and Grade: Florida Youth Tobacco Survey, 1998 and 199

Current Cigarette Use* Current Cigar Use** Current Smokeless 

1998 1999 1998 1999 1998 199

Sample Size (N): (9,991) (9,991) (10,473) (9,099) (10,202) (9,0

Category % CI % CI p % CI % CI p % CI % Sex 

Female 28.3 (±1.9) 25.9 (±2.0) 0.0400 14.1 (±1.2) 14.1 (±1.6) 0.9600 2.1 (±0.5) 2.4 (Male 26.5 (±1.9) 24.6 (±2.4) 0.1600 27.0 (±1.8) 24.7 (±1.9) 0.0800 11.2 (±1.6) 10.3 (

Race / Ethnicity† 

White, non-Hisp. 34.8 (±1.8) 31.3 (±2.0) 0.0200 22.7 (±1.6) 21.4 (±2.2) 0.2400 8.7 (±1.5) 8.0 (Black, non-Hisp. 9.8 (±1.5) 9.4 (±1.9) 0.6100 17.1 (±2.1) 14.8 (±1.9) 0.0900 3.5 (±1.1) 2.8 (Hispanic 24.8 (±2.6) 24.2 (±2.8) 0.7000 17.9 (±2.0) 18.5 (±2.4) 0.8200 2.9 (±0.8) 4.4 (

Grade Level 

9th 25.9 (±2.6) 23.3 (±2.8) 0.1700 19.3 (±2.3) 18.8 (±2.7) 0.7800 6.5 (±1.4) 6.8 (10th 25.5 (±2.8) 24.4 (±2.8) 0.5000 19.5 (±2.2) 19.1 (±2.2) 0.7600 7.0 (±1.7) 5.9 (11th 29.8 (±2.5) 27.0 (±2.4) 0.0800 23.2 (±2.5) 19.2 (±2.2) 0.0100 7.3 (±1.4) 5.3 (12th 29.8 (±2.9) 27.8 (±4.0) 0.3200 21.5 (±2.7) 21.2 (±2.8) 0.8600 6.4 (±1.3) 7.1 (

Total 27.4 (±1.6) 25.2 (±1.8) 0.0200 20.7 (±1.2) 19.5 (±1.5) 0.1400 6.7 (±1.0) 6.4 (Note: CI = 95% confidence interval. 

* Smoked cigarettes on ≥1 of the 30 days preceding the survey. 

** Smoked cigars on ≥1 of the 30 days preceding the survey. 

*** Used smokeless tobacco on ≥1 of the 30 days preceding the survey. 

† Numbers of other racial/ethnic groups were too small for meaningful analysis. 
Chapter 7 

cent in 1999 (p < 0.0001) among non-Hispanic White middle school students, and from 34.8 percent in 1998 to 31.1 percent in 1999 among nonHispanic White high school students (p < 0.02). There was no statistically 

significant change in the prevalence of current cigarette use among nonHispanic Black or Hispanic students at the middle or high school level. 

Prevalence of cigarette use in these groups was lower than among nonHispanic Whites in both 1998 and 1999. 

Current cigar use declined significantly only among middle school students. Among this group, current cigar use declined from 14.1 percent in 

1998 to 11.9 percent in 1999 (p < 0.0002). This overall decline was almost 

entirely accounted for by the decline among males, from 17.6 percent in 

1998 to 14.2 percent in 1999. Among racial/ethnic groups at the middle 

school level, the decline in current use of cigars was statistically significant 

only for non-Hispanic White students. 

Current smokeless tobacco use declined among middle school students, 

among whom 6.9 percent were current users in 1998 and 4.9 percent were 

current users in 1999. The decline was evident in both male and female 

middle school students and among non-Hispanic White and Hispanic middle school students. Students at each grade level in middle school were significantly less likely to use smokeless tobacco products in 1999 than in 

1998. Current use of smokeless tobacco products remained unchanged 

among high school students from 1998 to 1999. 

Figures 7-1 and 7-2 show the change in current cigarette use from 1998 

to 1999 for middle and high school students, respectively, by racial/ethnic 

group. Among both middle and high school students, statistically significant declines in current cigarette use were evident among non-Hispanic 

White students. No significant change in current cigarette use was observed 

among African American or Hispanic students. Among middle school students, statistically significant declines in cigar use were evident only among 

non-Hispanic White students, and declines for smokeless tobacco use were 

evident among both non-Hispanic White students and Hispanic students. 

Among high school students, no change in current cigar or smokeless 

tobacco use was observed over the 1-year time period. 

Figures 7-3 through 7-5 show prevalence of current cigarette, cigar, and 

smokeless tobacco use, respectively, by grade, for 1998 and 1999. Although 

the 1998 and 1999 surveys were cross-sectional, the same schools (but not 

necessarily the same classrooms) were surveyed in each year. Thus, for 

example, the 7th grade students in 1999 were in the 6th grade in 1998. 

When viewed from this perspective, an estimate of initiation rates over the 

1-year time period can be calculated. In 1998, 10.5 percent of 6th grade students had used cigarettes in the past 30 days. By 1999, 16.6 percent of 7th 

grade students had used cigarettes in the past 30 days. This interval from 

6th to 7th grade is the only interval where an increase in cigarette use in 

the past 30 days was observed. Comparing grade “n” in 1999 to grade 

“n–1” in 1998 shows no similar increase (except marginally in the transition from 10th to 11th grade). Viewing current cigar and smokeless tobacco 

use in the same manner, increases across grade levels from 1998 to 1999 in 

125 
Smoking and Tobacco Control Monograph No. 14 

Figure 7-1 

Percentage of Current Cigarette Users: Public Middle School Students who Smoked 

on 1 or More of the Previous 30 Days—Florida Youth Tobacco Survey 

25 

20 

15 

10 

5 

0 

Female Male NH-White NH-Black Hispanic Other 

1998 1999 

18.1 

14.9 

18.9 

15 

22 

16.1 

9.5 

8.5 

16.8 16.1 

18.4 

19.6 

(0.004) (0.0001) (<0.0001) (0.34) (0.51) (<0.70) 

Difference (p) 

Figure 7-2 

Percentage of Current Cigarette Users: Public High School Students who Smoked on 

1 or More of the Previous 30 Days—Florida Youth Tobacco Survey 

35 

30 

25 

20 

15 

10 

5 

1998 1999 

28.3 

25.9 26.5 

24.6 

34.8 

31.3 

9.8 9.4 

24.8 24.2 

27.4 

24.6 

0 

Female Male NH-White NH-Black Hispanic Other 

(0.04) (0.16) (0.02) (0.61) (0.70) (<0.33) 

Difference (p) 

Percentage Percentage 

Source for both figures: Florida Department


126

Chapter 7 

Figure 7-3 

Current Cigarette Use by Grade: Public School Students who Used Cigarettes on 

1 or More of the Past 30 Days—Florida Youth Tobacco Survey 

30 

25 

20 

15 

10 

1998 1999 

10.5 

8 

19.3 

16.6 

25 

19.5 

25.9 

23.2 

25.524.4

29.8 

27 

29.8 

27.8 

5 

0 

6th 7th 8th 9th 10th 11th 12th 

(0.01) (0.07) (0.0005) (0.17) (0.51) (0.08) (0.32) 

Difference (p) 

Figure 7-4 

Current Cigar Use by Grade: Public School Students who Used Cigars on 

1 or More of the Past 30 Days—Florida Youth Tobacco Survey 

25 

20 

15 

10 

5 

1998 1999 

7.8 

6.7 

14.2 

11.4 

19.5 

16.8 

19.3 18.8 19.5 19.1 

23.2 

19.2 

21.5 21.2 

0 

6th 7th 8th 9th 10th 11th 12th 

(0.16) (0.02) (0.06) (0.78) (0.76) (0.01) (0.86) 

Difference (p) 

Percentage Percentage 

Source for both figures: Florida Department


127

Smoking and Tobacco Control Monograph No. 14 

Figure 7-5 

Current Smokeless Tobacco Use by Grade: Public School Students who Used 

Smokeless Tobacco on 1 or More of the Past 30 Days—Florida Youth Tobacco Survey 

1998 1999 

8 

7 

6 

5 

4 

3 

2 

1 

6 

3.9 

7 

5.2 

7.1 

4.8 

6.5 

6.8 7 

5.9 

7.3 

5.3 

6.4 

7.1 

0 

6th 7th 8th 9th 10th 11th 12th 

(0.0004) (0.01) (0.002) (0.74) (0.38) (0.02) (0.47) 

Difference (p) 

Source: Florida Department of Health. 

cigar use were only evident in the transition from grades 6 to 7 and from 

grades 7 to 8. For smokeless tobacco use, no increases were observed, suggesting limited initiation from over the 1-year interval. 

Figures 7-6 and 7-7 show the change in tobacco use (all products combined) for middle and high school students, respectively, by region of the 

state. Among both middle and high school students, current use of any 

tobacco product (all three forms combined) was highest in the Tampa Bay 

and South Central regions of Florida in both 1998 and 1999. Among middle school students, the largest decrements in prevalence of current tobacco 

use were observed in the Tampa Bay region and the northern regions of the 

state (the Panhandle, Northeast, and North Central regions). Among high 

school students, statistically significant declines in current tobacco use were 

evident only in the state as a whole and in the Northeast region. 

Percentage 

128

Chapter 7 

Figure 7-6 

Current Tobacco Use by Region: Public Middle School Students who Used Any 

Tobacco on 1 or More of the Past 30 Days—Florida Youth Tobacco Survey 

30


25


1998 1999

26.6 

19.7 

26.7 

17.9 

24.5 

17.6 

28.6 

19.4 

27.8 27.1 

20.2 

17.0 

18.7 

16.3 

24.4 

19.2 

Percentage Percentage 20


15


10


5


0


Panhandle North 

East 

North 

Central 

Tampa 

Bay 

South 

Central 

Palm 

Beach/ 

Broward 

Dade/ 

Monroe 

Total 

Florida 

(0.01) (0.0001) (0.01) (<0.0001) (0.81) (0.13) (0.16) (<0.0001)


Difference (p) 

Figure 7-7 

Current Tobacco Use by Region: Public High School Students who Used Any 

Tobacco on 1 or More of the Past 30 Days—Florida Youth Tobacco Survey 

50


40


30


20


1998 1999

37 36 

38 

32.8 

35.5 

29.4 

44.3 

41.3 40.3 

37.1 

33.4 

29.8 

22.3 

20.2 

35.3 

32.3 

10


0


Panhandle North 

East 

North 

Central 

Tampa 

Bay 

South 

Central 

Palm 

Beach/ 

Broward 

Dade/ 

Monroe 

Total 

Florida 

(0.62) (0.03) (0.08) (0.22) (0.26) (0.34) (0.27) (0.005)


Difference (p) Source for both figures: Florida Department
 129 
Smoking and Tobacco Control Monograph No. 14 

Susceptibility to Survey respondents were grouped into one of six mutually 

Cigarette Use exclusive categories representing the continuum of susceptibility to cigarette use from confirmed non-smokers to former users. The six 

categories are: 

• Confirmed non-smokers—those who have never tried cigarettes and 

who indicate on three separate questions that they will “definitely not” 

smoke in the future; 

• Considerers—those who have never tried cigarettes and who indicate 

that they will or are ambivalent about whether they will smoke in the 

future; 

• Experimenters—those who have tried cigarettes, have never smoked regularly, and have not smoked in the past 30 days; 

• Occasional users—those who have smoked cigarettes on 1 to 19 of the 

past 30 days; 

• Frequent users—those who have smoked cigarettes on 20 or more of the 

past 30 days; and 

• Former users—those who smoked daily at some point, but have not 

smoked in the past 30 days. 

Built into the susceptibility variable is a measure of attitude and behavior. The first two categories reflect the students’ past behavior and their predictions of future behavior based (presumably) on the attitudes they currently hold toward cigarette use. Overall, the percentage of students who 

are confirmed non-smokers increased from 38.5 percent in 1998 to 42.8 

percent in 1999 among middle school students and from 24.1 percent in 

1998 to 30.5 percent in 1999 among high school students (p-values for the 

difference: 0.0003 and 0.0001, respectively) (Figure 7-8). Among middle and 

high school students, the proportion of considerers remained constant over 

the 1-year period and, in middle school, the proportion of experimenters 

actually increased (from 21.8 percent to 23.6 percent, p = 0.02) (Figures 7-9 

and 7-10). Statistically significant declines were seen in every other susceptibility category, including “former”1 smoker. The lack of increase in the 

percentage of former smokers suggests that changes in susceptibility (particularly occasional and frequent users) are due to fewer initiations rather than 

more quitters. 

1. The increase in experimenters and the decline in former smokers likely reflects the way 

these categories are defined. With fewer adolescents smoking, fewer are, or have been, regular (daily) smokers. Those who have smoked, but never smoked daily, and who have not 

smoked in the past 30 days are experimenters, not former smokers. 

130

Chapter 7 

Figure 7-8


Percentage “Confirmed” Non-Smokers: Public School Students who Never Tried a


Cigarette and Are Not Considering Trying a Cigarette—Florida Youth Tobacco Survey


50 

40 

30 

20 

10 

0 Middle School High School Combined 

1998 1999 

38.7 

42.8 

24.1 

30.5 31.1 

36 

(0.0003) (<0.0001) (<0.0001) 

Difference (p) 

Figure 7-9


The “Susceptibility” Continuum: Public Middle School Students—Florida Youth


Tobacco Survey


50 

40 

30 

20 

10 

0 Confirmed Considerer Experimenter Occasional Frequent Former 

Nonsmoker User User User 

1998 1999 

38.7 

42.8 

19.1 18.6 

21.8 23.6 

13.1 

10.1 

5.4 3.8 2 1 

(<0.0003) (0.45) (0.02) (<0.0001) (0.001) (<0.0001) 

Difference (p) Source for both figures: Florida Department
 Percentage 

Percentage 

131

Smoking and Tobacco Control Monograph No. 14 

Figure 7-10


The “Susceptibility” Continuum: Public High School Students—Florida Youth


Tobacco Survey


35 

30 

25 

20 

15 

10 

5 

0	

1998 1999 

24.1 

30.5 

8.8 9.7 

33.5 

31.1 

14.6 

12.7 

14.2 

12.5 

4.7 3.5 

Confirmed Considerer Experimenter Occasional Frequent Former 

Nonsmoker User User User 

(<0.0001) (0.15) (0.008) (0.0006) (0.03) (0.03) 

Difference (p) 

Source: Florida Department of Health. 

Although no substantial change in current use of cigarettes was 

observed among African American students (Tables 7-1 and 7-2), this group 

experienced the largest increase in the proportion of students who are “confirmed” non-smokers. Among middle and high school students combined, 

the proportion of students who are confirmed non-smokers increased from 

28.7 percent to 33.1 percent among non-Hispanic White students (p < 

0.0001), from 36.9 percent to 45.2 percent among African American students (p < 0.0001), and from 31.6 percent to 34.6 percent among Hispanic 

students (p = 0.05). In addition, the percentage of “considerers” declined 

among African American students, from 17.3 percent to 15.4 percent (p = 

0.06), and the percentage of experimenters in the same group declined from 

33.5 percent to 29.9 percent (p= 0.008) over the 1-year period. There were 

no changes in the percentage of students who were considerers or experimenters in any other racial/ethnic group (Table 7-3). 

Percentage 

132

Chapter 7 

Table 7-3


Susceptibility to Cigarette Use, by Race/Ethnicity: Florida Youth


Tobacco Survey, 


1998 and 1999


Non-Hispanic White Non-Hispanic Black Hispanic (Any Race) 

Categories 1998 1999 1998 1999 1998 1999 

Never User 28.7 33.1* 36.9 45.2* 31.6 34.6* 

Considerer 12.1 12.7 17.3 15.4 15.4 14.6 

Experimenter 26.1 27.1 33.5 29.9* 28.2 29.0 

Occasional User 15.7 13.0* 8.0 6.1* 15.3 13.7 

Frequent User 13.4 11.0* 2.2 2.5 6.8 6.5 

Former User 4.1 3.2* 2.2 1.0 2.7 1.7 

Predictors of Logistic regression modeling was used to identify predictors of 

Tobacco Use and current use of cigarettes, cigars, and smokeless tobacco products 

Consideration of (separately) in each of the two survey years. Models were comCigarette Use pared to identify differences in the factors associated with 

tobacco use and differences in the magnitude of the association across the 

two survey years. In addition, among those students who have never tried 

cigarettes (even one or two puffs), logistic regression was used to identify 

predictors of considering cigarette use in the future. Models for 1998 and 

1999 were compared across the two time points for differences in the factors associated with considering smoking and in the magnitude of the association. The following variables were included in the models: 

• Sex: girls as the referent; 

• Race/ethnicity: Black, non-Hispanic as the referent; 

• Age: in 1-year increments; 

• Smokers at home: anyone who lives in the student’s household smokes 

(yes/no); 

• Number of friends who smoke cigarettes: continuous variable (0, 1, 2, 3, 

4); 

• Number of friends who use smokeless tobacco: continuous variable (0, 

1, 2, 3, 4); 

• Grade point average: continuous variable, A = 1, B = 2, C = 3, D = 4, F = 

5, Missing = 6; 

• Age inappropriate for grade: age-appropriate as the referent; 

• Current use of cigarettes: non-use as the referent; 

• Current use of cigars: non-use as the referent; 

• Current use of smokeless tobacco: non-use as the referent. 

133

Smoking and Tobacco Control Monograph No. 14 

Tables 7-4 and 7-5 show the odds ratios and 95 percent confidence limits for these variables for each of the three outcome variables (current use of 

cigarettes, cigars, and smokeless tobacco products), for 1998 and 1999, 

respectively, for middle and high school students combined. For the most 

part, the logistic regression models confirmed the findings from the descriptive analyses. Non-Hispanic White and Hispanic students were substantially 

more likely to use cigarettes relative to African American students; the odds 

of using cigarettes increased with increasing age and with the number of 

friends who use cigarettes or smokeless tobacco products; and the odds of 

using cigarettes were greater among those with a household member who 

smokes. Current use of cigars and smokeless tobacco were strongly associated with current cigarette use. 

The only difference across the two survey years in the models predicting cigarette use was a small, but statistically significant, decrement in the 

magnitude of the odds ratio for number of friends who smoke cigarettes in 

1999 compared to 1998. 

The model predicting cigar use changed more substantially across the 

two survey years. The observed decline in cigar use by middle school boys 

resulted in a substantial decline in the odds ratio for males relative to 

females across the two survey years. Likewise, the observed significant 

reduction in cigar use among 11th grade students contributed to a decline 

in the magnitude of the odds ratio for age in the cigar use model. The magnitude of the odds ratio for current use of smokeless tobacco as a predictor 

for current cigar use increased substantially across the two survey years, suggesting a concentration of tobacco use among those who use multiple 

forms of tobacco.2 

Not surprisingly, in the model predicting current use of smokeless 

tobacco products, the magnitude of the odds ratio for current cigar use also 

increased significantly. The magnitude of the odds ratios for number of 

friends who use smokeless tobacco and for current use of cigars significantly 

increased across the two survey years in the model predicting smokeless 

tobacco use. 

A logistic regression model was also developed to identify predictors of 

considering cigarette use in the future among middle and high school students who have never tried cigarettes (Table 7-6). Overall, the percentage of 

middle and high school students who have never tried cigarettes, but who 

are considering smoking, remained unchanged across the two survey years 

at 13.7 percent of the total population. However, among those who have 

never tried cigarettes, the percentage who are considering trying cigarettes 

2. Of the students who used any tobacco product in the previous 30 days (in 1998), 34.4 percent used cigarettes only, 28.1 percent used cigarettes and cigars, 15.8 percent used cigars 

only, 9.9 percent used all three types of tobacco, 5.3 percent used smokeless tobacco only, 

3.4 percent used smokeless and cigars, and 3.1 percent used cigarettes and smokeless tobacco. 

134

Chapter 7 

Table 7-4


Logistic Regression Model Predicting Odds of Tobacco Use, by Type of


Product:


Florida Youth Tobacco Survey, 1998


Cigarette Cigar Smokeless 

Use Use Tobacco Use 

Sample Size (N): (19,869) (19,869) (19,869) 

OR CI OR CI OR CI 

Sex 

Female 1.00 — 1.00 — 1.00 — 

Male 0.59 0.54–0.64 2.40 2.16–2.66 2.99 2.52–3.54 

Race/Ethnicity 

White, non-Hispanic 3.44 2.93–4.03 0.62 0.51–0.74 1.70 1.32–2.17 

Black, non-Hispanic 1.00 — 1.00 — 1.00 — 

Hispanic 2.63 2.19–3.16 0.63 0.51–0.77 0.81 0.60–1.11 

Asian/Pacific Islander 1.96 1.32–2.91 0.76 0.50–1.14 1.37 0.75–2.49 

Amer. Indian/AK Native 3.69 2.11–6.45 0.57 0.34–0.97 3.03 1.49–6.16 

Other 2.68 2.10–3.41 0.65 0.50–0.84 1.74 1.16–2.60 

Age 1.20 1.16–1.25 1.21 1.15–1.26 0.94 0.87–1.01 

Smokers at Home 

Yes 1.77 1.60–1.96 1.11 1.00–1.22 1.08 0.91–1.27 

No 1.00 — 1.00 — 1.00 — 

GPA 1.14 1.10–1.18 1.07 1.03–1.11 1.04 0.99–1.09 

No. of Friends—Smoke 2.21 2.12–2.30 1.26 1.20–1.32 0.93 0.87–0.99 

No. of Friends—Smokeless 0.94 0.88–1.02 1.08 1.01–1.15 2.21 2.06–2.36 

Current Tobacco Use 

Cigarette 

Yes 

No 

Cigar 

Yes 

No 

Smokeless 

Yes 

No 

Inappropriate Age 

Yes 

No 

NA NA 10.59 9.27–12.10 3.21 2.61–3.94 

NA NA 1.00 — 1.00 — 

10.72 9.38–12.25 NA NA 3.67 3.06–4.41 

1.00 — NA NA 1.00 — 

3.23 2.65–3.95 3.59 2.98–4.32 NA NA 

1.00 — 1.00 — NA NA 

0.96 0.86–1.07 1.03 0.93–1.15 1.48 1.22–1.79 

1.00 — 1.00 — 1.00 — 

12th Grader 0.92 0.79–1.06 0.72 0.59–0.88 1.05 0.80–1.37 

Note: CI= 95% confidence interval. 

135

Smoking and Tobacco Control Monograph No. 14 

Table 7-5


Logistic Regression Model Predicting Odds of Tobacco Use, by Type of


Product: 


Florida Youth Tobacco Survey, 1999


Cigarette Cigar Smokeless 

Use Use Tobacco Use 

Sample Size (N): (18,193) (18,193) (18,193) 

OR CI OR CI OR CI 

Sex 

Female 1.00 — 1.00 — 1.00 — 

Male 0.61 0.52–0.73 2.05 1.75–2.40 3.25 2.40–4.41 

Race/Ethnicity 

White, non-Hispanic 3.19 2.60–3.91 0.55 0.45–0.67 1.32 0.94–1.85 

Black, non-Hispanic 1.00 — 1.00 — 1.00 — 

Hispanic 2.60 2.08–3.24 0.67 0.54–0.83 0.83 0.58–1.17 

Asian/Pacific Islander 2.69 1.74–4.13 0.43 0.28–0.65 0.90 0.48–1.67 

Amer. Indian/AK Native 3.16 2.03–4.92 0.77 0.52–1.13 2.18 1.07–4.44 

Other NA NA NA NA NA NA 

Age 1.19 1.14–1.23 1.12 1.08–1.15 0.96 0.91–1.02 

Smokers at Home 

Yes 1.64 1.45–1.86 1.19 1.04–1.37 1.22 1.00–1.50 

No 1.00 — 1.00 — 1.00 — 

GPA 1.13 1.08–1.18 1.11 1.05–1.17 1.04 0.96–1.12 

No. of Friends—Smoke 2.11 2.03–2.19 1.30 1.23–1.38 0.90 0.83–0.96 

No. of Friends—Smokeless 0.87 0.80–0.93 1.13 1.03–1.23 2.81 2.60–3.05 

Current Tobacco Use 

Cigarette 

Yes 

No 

Cigar 

Yes 

No 

Smokeless 

Yes 

No 

Inappropriate Age 

Yes 

No 

NA NA 11.15 9.58–12.97 2.77 2.07–3.71 

NA NA 1.00 — 1.00 — 

11.19 9.60–13.04 NA NA 4.85 3.88–6.04 

1.00 — NA NA 1.00 — 

2.88 2.14–3.88 4.66 3.74–5.82 NA NA 

1.00 — 1.00 — NA NA 

1.13 0.91–1.41 0.94 0.76–1.15 1.09 0.77–1.54 

1.00 — 1.00 — 1.00 — 

Unknown 2.32 0.58–9.28 2.70 1.02–7.15 7.70 3.36–17.66 

Note: CI= 95% confidence interval. 

136

Chapter 7 

Table 7-6


Logistic Regression Model Predicting Odds of “Considering” Cigarette


Use: 


Never-Smokers, Florida Youth Tobacco Survey, 1998 and 1999


1998 Considerer 1999 Considerer 

Sample Size (N): (8,730) (9,058) 

OR CI OR CI 

Sex 

Female 1.00 — 1.00 — 

Male 0.87 0.79–0.96 0.83 0.72–0.96 

Race/Ethnicity 

White, non-Hispanic 0.86 0.74–1.00 1.20 1.02–1.42 

Black, non-Hispanic 1.00 — 1.00 — 

Hispanic 0.97 0.82–1.15 1.26 1.07–1.49 

Asian/Pacific Islander 1.24 0.97–1.59 1.55 1.12–2.14 

American Indian/AK Native 0.68 0.33–1.39 1.29 0.84–1.97 

Other 0.69 0.54–0.87 NA NA 

Age 0.92 0.88–0.95 0.90 0.85–0.96 

Smokers at Home 

Yes 0.86 0.77–0.95 0.89 0.76–1.05 

No 1.00 — 1.00 — 

GPA 1.08 1.03–1.13 1.08 1.04–1.12 

No. of Friends—Smoke 1.44 1.35–1.54 1.34 1.25–1.43 

No. of Friends—Smokeless 1.02 0.92–1.12 1.08 0.95–1.22 

Current Tobacco Use 

Cigarette 

Yes 

No 

Cigar 

Yes 

No 

Smokeless 

Yes 

No 

Inappropriate Age 

Yes 

No 

12th Grader/Unknown 

NA NA 1.00 — 

1.78 1.25–2.54 1.99 1.33–3.00 

1.00 — 1.00 — 

2.65 1.84–3.81 2.38 1.34–4.21 

1.00 — 1.00 — 

1.23 1.12–1.35 1.35 1.03–1.77 

1.00 — 1.00 — 

0.76 0.55–1.05 0.27 0.05–1.00 

Receptivity 1.90 1.76–2.06 2.04 1.87–2.23 

Note: CI= 95% confidence interval. 

137

Smoking and Tobacco Control Monograph No. 14 

in the future declined from 30.7 percent in 1998 to 27.6 percent in 1999 (p 

= 0.0005). In the logistic regression model in 1998, the strongest predictors 

of considering trying cigarettes in the future were current use of another 

tobacco product (cigars or smokeless tobacco), the child’s receptivity to 

tobacco company promotions3, the number of friends who smoke, and 

being age-inappropriate for grade. Protective factors (against considering 

using cigarettes in the future) were living in a household with a smoker, 

being of non-Hispanic White race/ethnicity, and older age (possibly because 

students who fall into these three categories are significantly less likely to 

be never-smokers). In 1999, the model changed somewhat. Non-Hispanic 

White students were more likely than their African American counterparts 

to consider using cigarettes in the future (likely due to the decrease in considering among African American students) and the magnitude of the odds 

ratio for number of friends who smoke declined significantly. 

SUMMARY In Florida, attitudes and behaviors related to tobacco use changed 

among public school-enrolled youths in the 1-year time interval between 

the 1998 and 1999 Youth Tobacco Surveys, an interval that included the 10 

months immediately following the initiation of the Florida Pilot Program 

youth tobacco use prevention activities. Overall, current cigarette use 

declined 19 percent among middle school students and 8 percent among 

high school students. The percentage of students who are confirmed nonsmokers increased in all racial/ethnic groups and at all grade levels. 

Predictors of tobacco use remained relatively unchanged over the 1-year 

time period; however, the magnitude of the predictors had changed. Peer 

influence, defined by the number of friends who use cigarettes, declined in 

importance as a predictor of cigarette use. The observed trend of increasing 

cigar use with increasing age was reduced. 

Nationwide, the prevalence of cigarette smoking among adolescents 

increased during the 1990’s (CDC, 1998; Johnston et al., 1998b); however, 

smoking prevalence rates may have peaked in 1996 or 1997 and could be 

starting to decline (Johnston et al., 1998a). Currently, national data for 

1998 and 1999 are unavailable for comparison with the Florida data. 

However, the decline in cigarette use between 1998 and 1999 among 

Florida adolescents reported here is larger than any annual decline observed 

in this nation among youths since 1980 (Johnston et al., 1998a & 1998b). 

Ongoing evaluation efforts are underway to determine whether the 

observed declines in youth tobacco use are related primarily to the program 

activities implemented by the Florida Pilot Program on Tobacco Control. If 

this is the case, similar programs or program components should be implemented nationwide to reverse the increase in youth smoking observed during the 1990’s (CDC, 1998; Johnston et al., 1998b). 

3. Whether the student has bought or received anything with a tobacco company name or picture on it in the past 12 months and whether the student would use or wear something with 

a tobacco company name or picture on it. 

138

Chapter 7 

REFERENCES


Bauer, U., Johnson, T., Pallentino, J., et al. Tobacco 

use among middle and high school students— 

Florida, 1998 and 1999. Morbidity and Mortality 

Weekly Reports 48:248-253, 1999. 

Centers for Disease Control and Prevention. State 

Tobacco Control Highlights 1996. Atlanta, GA: U.S. 

Department of Health and Human Services, 

Public Health Service, Centers for Disease 

Control and Prevention, National Center for 

Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health. CDC 

Publication No. 099-4895, 1996. 

Centers for Disease Control and Prevention. Tobacco 

use among high school students—United States, 

1997. Morbidity Mortality Weekly Reports 

47(12):229-233, 1998. 

Florida Department of Health. Florida Youth Tobacco 

Survey Reports. Florida Tobacco Education 

Resources website: www.state.fl.us/tobacco (click 

on "research"), June, 2000. 

Johnston, L.D., O’Malley, P.M., Bachman, J.G. 

National Press Release. Smoking Among American 

Teens Declines Some. Ann Arbor, Michigan: 

University of Michigan News and Information 

Services, December 18, 1998a. 

Johnston, L.D., O’Malley, P.M., Bachman, J.G. 

National Survey Results on Drug Use from the 

Monitoring the Future Study, 1975–1997. Volume I: 

Secondary School Students. NIH Publication No. 

98–4345. Rockville, MD: U.S. Department of 

Health and Human Services, Public Health 

Service, National Institutes of Health, National 

Institute on Drug Abuse, 1998b. 

McGinnis, J.M., Foege, W.H. Actual causes of death 

in the United States. Journal of the American 

Medical Association 270(18):2207-2212, 1993. 

139

Changes in Adolescent Smoking 

Behaviors in Sequential Birth Cohorts 

Christy M. Anderson, David M. Burns, Jacqueline M. Major, 

Jerry W. Vaughn, Thomas G. Shanks 

INTRODUCTION Never starting to smoke is the best way to avoid the disease consequences of smoking, and preventing initiation of smoking among adolescents is a goal of almost all tobacco control campaigns. Success in reducing 

adolescent initiation is described in several other chapters in this monograph, using changes in adolescent prevalence derived from multiple crosssectional surveys over time. One of these chapters discusses the longest 

series of survey data collection, the Monitoring the Future study (see 

Chapter 2). 

The focus of this chapter is to examine past changes in past smoking 

initiation rates at various ages. Recent cross-sectional survey data on adults 

were used to reconstruct the adults’ rates of initiation in the past. This technique is subject to recall and other biases, but allows examination of smoking initiation that occurred prior to the availability of cross-sectional data. 

Initiation of cigarette smoking varies dramatically by year of age and 

has varied substantially across calendar year as well (see Chapter 2). The 

changes in adolescent initiation over time may have occurred uniformly 

across all ages, may be larger at some ages than at others, or may change in 

different directions at different ages. In order to examine initiation trends 

by both age and calendar year, age-specific initiation rates were estimated 

for successive birth cohorts of the U.S. population. A birth cohort is a group 

of individuals born during specific calendar years; in these analyses, a birth 

cohort consisted of 5-calendar-year groups. Five-year birth cohorts from 

1926–30 through 1981–85 were examined, which allowed examination of 

changes in age-specific initiation rates over a span of approximately 60 

years. By examining initiation rates at specific ages (i.e., initiation at age 15) 

across sequential cohorts born during different calendar years, it is possible 

to examine changes over time in smoking initiation rates at each year of 

age. In addition, these age-specific initiation rates by birth cohort can be 

examined by gender, and for different race and ethnic groups, in order to 

define differences among these groups in smoking initiation. 

METHODS The principal data source used for these analyses was the Tobacco 

Supplement to the Current Population Surveys of September, 1992; January 

and May, 1993; September, 1995; and January and May, 1996. Data from 

417,116 self-respondents between 15 and 84 years of age were available for 

analysis. Ever-smokers were defined as those who had smoked at least 100 

cigarettes in their lifetime. Among ever-smokers, age and year of initiation 

were obtained from the year of the survey, age at the time of the survey, 

and the answer to the question, "When did you first start smoking fairly 

141 
Smoking and Tobacco Control Monograph No. 14 

regularly?" Each person’s ever-smoking status for each calendar year prior to 

the date of the survey was reconstructed based upon the respondent’s recollection of starting smoking. 

All respondents were grouped into sequential 5-year birth cohorts, 

beginning with those born between the calendar years 1926 and 1930 and 

extending to those born between 1981 and 1985. Age-specific initiation 

rates were constructed within each birth cohort by defining those who 

began the year of age as never-smokers as the population at risk for initiation (denominator for the initiation rate). Those who initiated during that 

year of age formed the numerator of the rate. Details of the CPS methodology are published elsewhere (see Chapter 9; Bureau of the Census, 1978). 

Determination of the smoking status of respondents in any given year 

was based on the survey administration date, the reported initiation age, 

and the age given in the survey. The age of initiation was subtracted from 

the age at the time of the survey, and the result was subtracted from the 

survey year to define the calendar year in which the respondent began to 

smoke. The respondent was considered a smoker from that year forward. 

The survey administration date was represented as a partial year, using both 

the year and month of the survey in this calculation (e.g., September 1992 

became 1992.75). Additionally, 6 months were added to all age responses to 

account for the distribution of birthdays occurring over the entire calendar 

year. 

The distribution of ages reflected in the original sample was preserved 

while calculating the initiation rates for each calendar year. Since the distribution of 12- to 17-year-olds varied between calendar years, each initiation 

rate for each calendar year was standardized to the birth-year distribution of 

all respondents who would have been between the ages of 12 and 17 in 

that calendar year. Likewise, in order to make similar comparisons between 

ethnically diverse samples, the rates for each calendar year were standardized by ethnicity to the ethnic distribution of the United States represented 

by the 1995/1996 CPS. 

HAVE AGE-SPECIFIC Figure 8-1 presents initiation rates at single years of age 

ADOLESCENT INITIA- for sequential 5-year birth cohorts of males born 

TION RATES CHANGED between 1926 and 1980. The age-specific initiation rate 

OVER TIME? for each 5-year birth cohort was constructed by using 

the number of individuals born during the 5 calendar years of a birth 

cohort who began smoking during a specified age as the numerator. The 

denominator consisted of the number of individuals who began the same 

specified age as never-smokers. For example, the initiation rate at age 12 for 

the 1926–1930 birth cohort between the years 1926 and 1930 used the 

number of those who began smoking during their 12th year of age (which 

would have occurred between 1938 and 1942 for this birth cohort) as the 

numerator and the number of individuals who began their 12th year of age 

as never-smokers as the denominator. This measure averaged initiation rates 

at age 12 years for those born during the 5 calendar years that defined the 

birth cohort. The average age-specific initiation rate for each sequential 

cohort represented a calendar year period 5 years later than the initiation 

142

Chapter 8 

Figure 8-1 

Age-Specific Cigarette Smoking Initiation Rates with 95% Confidence Intervals by 5-

Year Birth Cohorts, United States—Males 

3.5 

3.0 

2.5 

2.0 

1.5 

1.0 

0.5 

0 

’26-’30 ’31-’35 ’36-’40 ’41-’45 ’46-’50 ’51-’55 ’56-’60 ’61-’65 ’66-’70 ’71-’75 ’76-’80 

Age 14 

Age 13 

Age 12 

Birth Cohort 

7 

6 

5 

4 

3 

2 

1 

0 

Age 17 

Age 16 

Age 15 

’26-’30 ’31-’35 ’36-’40 ’41-’45 ’46-’50 ’51-’55 ’56-’60 ’61-’65 ’66-’70 ’71-’75 ’76-’80 

Birth Cohort 

Initiation Rate (%) Initiation Rate (%) 

143

Smoking and Tobacco Control Monograph No. 14 

Figure 8-1 (continued) 

12 

10 

8 

6 

4 

2 

0 

’26-’30 ’31-’35 ’36-’40 ’41-’45 ’46-’50 ’51-’55 ’56-’60 ’61-’65 ’66-’70 ’71-’75 ’76-’80 

Age 20 

Age 19 

Age 18 

Birth Cohort 

5.0 

4.5 

4.0 

3.5 

3.0 

2.5 

2.0 

1.5 

1.0 

0.5 

0 ’26-’30 ’31-’35 ’36-’40 ’41-’45 ’46-’50 ’51-’55 ’56-’60 ’61-’65 ’66-’70 ’71-’75 ’76-’80 

Age 25 

Age 24 

Age 23 

Age 22 

Age 21 

Birth Cohort 

Initiation Rate (%) Initiation Rate (%) 

144

Chapter 8 

rate for the cohort that preceded it. Thus, by examining initiation rates for 

these sequential birth cohorts, a measure of the change (or lack of change) 

in rates of initiation at specific ages is obtained over a range of calendar 

years from about 1940 onward. 

Figure 8-1 contains initiation rates for males at each single year of age 

from age 12 through age 25 for 5-year birth cohorts beginning with the 

1926–1930 birth cohort and including the 1976–1980 birth cohort. The 

data are limited to the 1971–1975 birth cohort for those age 20 years and 

older, since individuals born during the years 1976–1980 would not have 

reached age 20 by the time of the most recent survey (1995/1996). In general, rates of smoking initiation have declined over time at every age, but the 

proportionate rate of decline is somewhat greater at older ages than it is at 

younger ages for males. 

Initiation rates for females at each single year of age from age 12 

through age 25 are presented in Figure 8-2. Rates of initiation among earlier 

birth cohorts of females are generally lower than for age- and cohortmatched males, but this difference disappears among more recent cohorts. 

The pattern of initiation over time appears to be quite different for females. 

Initiation rates at ages 12–14 appear to increase steadily from earlier birth 

cohorts to more recent ones, in contrast to the decline over time observed 

for male initiation rates at these ages. There is a suggestion that this trend 

of increasing female initiation at ages 12–14 is moderating or disappearing 

among the more recent cohorts. Initiation rates at ages 15 and 16 among 

females increase prior to the 1956–60 birth cohort, and then level off or 

decline slightly in more recent birth cohorts. Female initiation rates at ages 

17–20 years show a pattern of increasing rates among earlier birth cohorts, 

but show a marked decline beginning with those born after 1955. The pattern of initiation rates over time at older ages among females born after 

1945 are similar to the pattern over time among males, with a steep decline 

evident for most cohorts. 

Tables 8-1 and 8-2 present the initiation rates estimated for each birth 

cohort by single year of age of initiation. The results of a linear regression 

of the rates over time are also presented for both the absolute value of the 

rate and for the proportional change in rates over time. Among males, there 

is a statistically significant decline in rates of initiation across sequential 

cohorts for all ages from age 8 through age 25, with the exception of age 

11. The absolute and proportional differences are greatest at ages 18 and 19. 

Among females, however, there is not a statistically significant decline in 

initiation for most of the ages under age 16, with the exception of a statistically significant decline for the 11-year-old age group. There are statistically 

significant declines among females over the age of 16 years (except age 23). 

When median values for slopes of the proportional change across cohorts 

are compared for ages 12–17 and ages 18–25, there is a statistically significantly greater set of slopes among the older group compared to the younger 

group for both males (P = 0.0005) and females (P = 0.0017). This confirms 

the impression derived from the differences in absolute rates of initiation 

that older adolescents have had a greater decline in initiation over time 

compared to younger adolescents. 

145 
Smoking and Tobacco Control Monograph No. 14 

Figure 8-2 

Age-Specific Cigarette Smoking Initiation Rates with 95% Confidence Intervals by 5-

Year Birth Cohorts, United States—Females Initiation Rate (%) Initiation Rate (%) 

2.5 

2.0 

1.5 

1.0 

0.5 

0 

5.0 

4.5 

4.0 

3.5 

3.0 

2.5 

2.0 

1.5 

1.0 

0.5 

0 

Age 14 

Age 13 

Age 12 

’26-’30 ’31-’35 ’36-’40 ’41-’45 ’46-’50 ’51-’55 ’56-’60 ’61-’65 ’66-’70 ’71-’75 ’76-’80 

Birth Cohort 

Age 17 

Age 16 

Age 15 

’26-’30 ’31-’35 ’36-’40 ’41-’45 ’46-’50 ’51-’55 ’56-’60 ’61-’65 ’66-’70 ’71-’75 ’76-’80 

Birth Cohort 

146

Chapter 8 

Figure 8-2 (continued) 

6 

5 

4 

3 

2 

1 

0 ’26-’30 ’31-’35 ’36-’40 ’41-’45 ’46-’50 ’51-’55 ’56-’60 ’61-’65 ’66-’70 ’71-’75 ’76-’80 

Birth Cohort 

Age 20 

Age 19 

Age 18 

3.0 

2.5 

2.0 

1.5 

1.0 

0.5 

0 ’26-’30 ’31-’35 ’36-’40 ’41-’45 ’46-’50 ’51-’55 ’56-’60 ’61-’65 ’66-’70 ’71-’75 ’76-’80 

Birth Cohort 

Age 25 

Age 24 

Age 23 

Age 22 

Age 21 

Initiation Rate (%) Initiation Rate (%) 

147

148 Table 8-1 Cigarette Smoking Initiation Rates with 95% Confidence Intervals, by 5-Year Birth Cohorts and Age, for CPS 1992/1993 

CPS 1995/1996: United States—Males 

Initiation Rate (%) by Age 

Birth Age 8 Age 9 Age 10 Age 11 Age 12 Age 13 Age 14 Age 15 Cohort Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) 

‘26-‘30 0.67 0.16 0.25 0.10 0.51 0.14 0.28 0.10 1.50 0.24 1.34 0.23 2.66 0.33 4.25 0.42 

‘31-‘35 0.59 0.15 0.29 0.11 0.53 0.14 0.41 0.13 1.37 0.23 1.10 0.21 2.59 0.33 4.18 0.43 

‘36-‘40 0.66 0.15 0.27 0.10 0.49 0.13 0.27 0.10 1.36 0.22 1.61 0.25 2.47 0.31 3.90 0.40 

‘41-‘45 0.48 0.12 0.22 0.08 0.39 0.11 0.28 0.09 1.34 0.20 1.49 0.21 2.60 0.28 3.87 0.35 

‘46-‘50 0.36 0.09 0.19 0.06 0.31 0.08 0.23 0.07 1.03 0.15 1.31 0.17 1.90 0.21 3.14 0.27 

‘51-‘55 0.25 0.07 0.16 0.06 0.23 0.07 0.17 0.06 0.75 0.12 0.94 0.14 1.74 0.19 3.03 0.25 

‘56-‘60 0.20 0.06 0.12 0.05 0.21 0.06 0.21 0.06 0.83 0.12 1.09 0.14 1.67 0.18 2.95 0.24 

‘61-‘65 0.21 0.06 0.11 0.05 0.24 0.07 0.25 0.07 0.80 0.13 1.10 0.15 1.50 0.18 2.53 0.23 

‘66-‘70 0.19 0.07 0.08 0.04 0.18 0.07 0.15 0.06 0.52 0.11 0.89 0.15 1.38 0.19 2.10 0.23 

‘71-‘75 0.28 0.10 0.09 0.05 0.22 0.09 0.25 0.09 0.64 0.15 0.97 0.18 1.51 0.23 2.40 0.29 

‘76-‘80 0.15 0.08 0.06 0.05 0.16 0.09 0.22 0.10 0.64 0.17 1.14 0.23 1.62 0.27 1.89 0.30 

Slope -0.05* -0.02* -0.04* -0.01 -0.10* -0.05* -0.15* -0.25* Scaled 

Slope -0.08* -0.08* -0.07* -0.04 -0.07* -0.03* -0.05* -0.05* 

Initiation Rate (%) by Age 

Birth Age 17 Age 18 Age 19 Age 20 Age 21 Age 22 Age 23 Age 24 Cohort Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) 

‘26-‘30 4.95 0.52 8.95 0.72 3.32 0.50 5.05 0.64 3.50 0.57 2.45 0.50 1.01 0.33 0.92 0.32 

‘31-‘35 4.15 0.47 8.20 0.68 3.71 0.52 5.68 0.66 3.82 0.59 2.61 0.51 0.86 0.31 0.54 0.24 

‘36-‘40 4.56 0.48 7.81 0.64 3.84 0.51 5.36 0.62 3.28 0.52 2.22 0.45 1.02 0.31 0.73 0.27 

‘41-‘45 4.22 0.41 7.67 0.57 3.62 0.44 4.82 0.52 3.70 0.49 2.04 0.38 0.88 0.26 0.57 0.21 

‘46-‘50 3.36 0.31 7.20 0.46 4.04 0.38 4.19 0.41 2.59 0.34 1.60 0.28 0.78 0.20 0.49 0.16 

‘51-‘55 3.63 0.30 6.25 0.40 2.92 0.30 3.59 0.34 1.85 0.26 1.20 0.21 0.61 0.15 0.38 0.12 

‘56-‘60 3.80 0.29 4.92 0.35 2.12 0.24 2.49 0.27 1.32 0.20 0.99 0.18 0.47 0.12 0.37 0.11 

‘61-‘65 2.62 0.25 3.75 0.31 1.83 0.23 1.85 0.23 1.18 0.19 0.96 0.17 0.55 0.13 0.38 0.11 

‘66-‘70 2.64 0.27 3.54 0.33 1.83 0.25 1.59 0.23 1.01 0.19 0.63 0.15 0.32 0.12 0.27 0.11 

‘71-‘75 2.77 0.33 3.28 0.40 1.57 0.31 1.20 0.30 0.66 0.26 0.57 0.31 0.00 0.00 0.00 0.00 

‘76-‘80 2.02 0.56 1.85 0.72 0.63 0.62 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 

Slope -0.25* -0.72* -0.31* -0.57* -0.40* -0.25* -0.09* -0.06* Scaled 

Slope -0.05* -0.07* -0.07* -0.08 -0.09* -0.09* -0.08* -0.08* 

*Indicate significance at 0.05 level. 
Table 8-2 

Cigarette Smoking Initiation Rates with 95% Confidence Intervals, by 5-Year Birth Cohorts and Age, for CPS 1992/1993 

CPS 1995/1996: United States—Females 

Initiation Rate (%) by Age 

Birth Age 8 Age 9 Age 10 Age 11 Age 12 Age 13 Age 14 Age 15 

Cohort Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) 

‘26-‘30 0.08 0.05 0.02 0.02 0.03 0.03 0.07 0.04 0.22 0.08 0.36 0.10 0.57 0.13 1.23 0.19 

‘31-‘35 0.11 0.06 0.08 0.05 0.11 0.06 0.10 0.05 0.30 0.09 0.38 0.11 0.61 0.14 1.34 0.20 

‘36-‘40 0.14 0.06 0.06 0.04 0.07 0.04 0.07 0.04 0.39 0.10 0.55 0.12 0.90 0.16 1.78 0.22 

‘41-‘45 0.07 0.04 0.06 0.04 0.09 0.04 0.11 0.05 0.42 0.10 0.77 0.13 1.03 0.15 2.02 0.21 

‘46-‘50 0.07 0.03 0.04 0.03 0.07 0.04 0.13 0.05 0.45 0.09 0.67 0.11 0.91 0.13 1.66 0.17 

‘51-‘55 0.08 0.03 0.04 0.03 0.09 0.04 0.10 0.04 0.38 0.08 0.69 0.10 1.02 0.13 2.08 0.18 

‘56-‘60 0.11 0.04 0.05 0.03 0.10 0.04 0.15 0.05 0.64 0.09 1.20 0.13 1.53 0.15 2.68 0.20 

‘61-‘65 0.09 0.04 0.09 0.04 0.12 0.04 0.19 0.05 0.79 0.11 1.21 0.13 1.71 0.16 2.81 0.21 

‘66-‘70 0.12 0.05 0.12 0.05 0.10 0.04 0.23 0.06 0.70 0.11 1.23 0.15 1.43 0.16 2.59 0.22 

‘71-‘75 0.11 0.05 0.11 0.05 0.12 0.06 0.23 0.08 0.80 0.14 1.17 0.17 1.85 0.22 2.68 0.27 

‘76-‘80 0.12 0.07 0.06 0.05 0.13 0.07 0.27 0.10 0.78 0.18 1.04 0.21 1.61 0.26 2.04 0.30 

Slope 0.01 0.01 0.01 0.03* 0.03 -0.03 0.03 -0.11 

Scaled 

Slope -0.06 0.15 0.06 0.22* 0.05 -0.02 0.02 -0.04 

Initiation Rate (%) by Age 

Birth Age 17 Age 18 Age 19 Age 20 Age 21 Age 22 Age 23 Age 24 Cohort Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) Rate ± CI (%) 

‘26-‘30 1.91 0.24 4.11 0.36 1.82 0.25 2.97 0.33 2.12 0.29 1.30 0.23 0.69 0.17 0.59 0.16 

‘31-‘35 2.38 0.28 4.48 0.39 2.18 0.29 3.81 0.38 2.09 0.30 1.23 0.23 0.71 0.18 0.62 0.17 

‘36-‘40 2.28 0.27 4.99 0.40 2.50 0.30 3.97 0.38 2.31 0.31 1.46 0.25 0.82 0.19 0.55 0.16 

‘41-‘45 2.50 0.25 4.96 0.36 2.71 0.28 3.93 0.35 2.26 0.28 1.51 0.23 0.78 0.17 0.51 0.14 

‘46-‘50 2.22 0.21 4.96 0.31 2.71 0.24 3.55 0.29 2.10 0.23 1.30 0.19 0.69 0.14 0.52 0.12 

‘51-‘55 2.62 0.21 5.07 0.30 2.34 0.22 3.18 0.26 1.84 0.21 0.97 0.15 0.67 0.13 0.41 0.10 

‘56-‘60 3.35 0.24 4.93 0.30 2.09 0.21 2.40 0.22 1.35 0.17 0.82 0.14 0.48 0.11 0.42 0.10 

‘61-‘65 3.24 0.24 4.19 0.28 1.88 0.20 1.84 0.20 1.10 0.16 0.73 0.13 0.46 0.11 0.36 0.09 

‘66-‘70 3.00 0.25 3.59 0.29 1.69 0.21 1.43 0.19 0.84 0.15 0.49 0.12 0.34 0.10 0.25 0.09 

‘71-‘75 2.95 0.30 2.95 0.33 1.32 0.24 1.00 0.23 0.63 0.21 0.37 0.21 0.11 0.14 0.16 0.23 

‘76-‘80 2.14 0.52 1.77 0.62 0.79 0.60 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 

Slope -0.20* -0.37* -0.25* -0.47* -0.23* -0.16* -0.09 -0.08* 

Scaled 

Slope -0.05* -0.12* -0.11* -0.16* -0.16* -0.16* -0.15 -0.16* 

149 

*Indicate significance at 0.05 level. 
Smoking and Tobacco Control Monograph No. 14 

Have Race/Ethnic-Specific Initiation rates for the different race/ethnic groups 

Initiation Rates Changed in are presented in Chapter 2 and show that initiation 

Recent Cohorts? is markedly different over time for adolescents from 

different racial/ethnic backgrounds. In this section, age-specific initiation 

rates by race/ethnicity for the three most recent birth cohorts are examined. 

Age- and race-specific initiation rates are presented for these birth cohorts 

in Figure 8-3 (males) and Figure 8-4 (females). In general, age-specific initiation rates were lower for Hispanic and African American adolescents of 

both genders compared to those of non-Hispanic White adolescents. There 

were no clear differences between age-specific initiation rates for Hispanic 

and African American adolescents, but there was a suggestion that Hispanic 

females were somewhat more likely to initiate smoking at ages greater than 

15 years than were African American females. 

These lower age-specific initiation rates among African American adolescents are in apparent contrast with the higher adult smoking prevalences 

among African Americans compared to non-Hispanic White adults. An 

explanation of this anomaly is presented in Figures 8-5 and 8-6. These two 

figures present the prevalence of ever-smoking by attained age for nonHispanic White and African American males (Figure 8-5) and females 

Figure 8-3 

Age-Specific Initiation Rates for Recent Birth Cohorts of White, African American, and 

Hispanic Males 

10 

8 

6 

4 

2 

0 

African American: ’76-’80 

African American: ’71-’75 

African American: ’66-’70 

Hispanic: ’76-’80 

Hispanic: ’71-’75 

Hispanic: ’66-’70 

White: ’76-’80 

White: ’71-’75 

White: ’66-’70 

Initiation Rate (%) 

11 12 13 14 15 16 17 18 

Age 

150

Chapter 8 

Figure 8-4 

Age-Specific Initiation Rates for Recent Birth Cohorts of White, African American, and 

Hispanic Females 

10 

8 

6 

4 

2 

0 

African American: ’76-’80 

African American: ’71-’75 

African American: ’66-’70 

Hispanic: ’76-’80 

Hispanic: ’71-’75 

Hispanic: ’66-’70 

White: ’76-’80 

White: ’71-’75 

White: ’66-’70 

Initiation Rate (%) 

11 12 13 14 15 16 17 18 

Age 

(Figure 8-6). African American ever-smoking prevalence lags behind that of 

non-Hispanic White males during adolescence, but increases much more 

rapidly during young adulthood. By age 25 years, the more rapid increase 

in ever-smoking prevalence among African American young adults results 

in the rates of ever-smoking prevalence that exceed those of non-Hispanic 

Whites. 

A similar pattern is evident when African American female ever-smoking prevalence rates are compared to those of non-Hispanic White females. 

There is an even more pronounced lag in the rise of ever-smoking prevalence rates among African American females during adolescence, and the 

rates of rise in prevalence are also higher during young adulthood compared to non-Hispanic White females. However, among females, the more 

rapid rise in smoking prevalence during young adulthood does not result in 

smoking prevalences that exceed those of non-Hispanic White females. 

What these analyses suggest is that the period of vulnerability to smoking initiation is longer for African American populations; it extends beyond 

adolescence and well into young adulthood. These data also suggest that 

the recent gains in lowering African-American smoking prevalence among 

151

Smoking and Tobacco Control Monograph No. 14 

Figure 8-5 

Delayed Onset Only among the Most Recent Cohort of Black Males 

60 

50 

40 

30 

20 

10 

0 

8 9 10 12 13 14 15 16 18 19 20 21 23 24 25 26 27 29 30 

White Males 1965-69 

White Males 1960-64 

White Males 1955-59 

African American Males 1965-69 

African American Males 1960-64 

African American Males 1955-59 

Age 

adolescents should be observed well into the early adult years before they 

can be counted as successful reductions in the fraction of African Americans 

who become cigarette smokers. 

Are Age-Specific Initiation Age-specific initiation rates by birth cohort are preRates Different by Level of sented for those with less than 12 years of educaEducational Attainment? tion compared to those with at least 12 years of 

education. Among males with more than 12 years of education (Figure 8-7), 

initiation rates are higher for each birth cohort at each age compared to 

those who completed less than 12 years of education. The pattern among 

females is more complicated (Figure 8-8). For ages 16 and below, the pattern 

is similar to that for males, with those with 12 or more years of education 

showing a marked difference in rates of initiation for each birth cohort at 

each age compared to those who completed less than 12 years of education. 

However, initiation rates at ages 17 and 18 show no clear relationship to 

level of educational attainment. These analyses suggest that level of educational attainment may remain an important determinant of adolescent 

male initiation throughout adolescence, but that it is only an important 

determinant of adolescent initiation for females during early and mid-adolescence (age 16 and younger). 

Ever Smoking Prevalence 

152

Chapter 8 

Figure 8-6 

Delay Onset of Initiation among Black Females 

60 

50 

40 

30 

20 

10 

0 

8 9 10 12 13 14 15 16 18 19 20 21 23 24 25 26 27 29 30 

White Females 1965-69 

White Females 1960-64 

White Females 1955-59 

African American Females 1965-69 

African American Females 1960-64 

African American Females 1955-59 

Age 

DISCUSSION The data presented in this chapter are derived from surveys of adults 

using the adult definition of smoking and, therefore, are measures of initiation and prevalence among those who have actually become cigarette 

smokers as defined for most tobacco control programs. The questions raised 

by the use of a very sensitive adolescent definition of smoking (any smoking in the last month), and by the wide differences in prevalence estimates 

from school-based and telephone surveys, do not influence these measures. 

These estimates of initiation over time can, therefore, be used to compliment the cross-sectional survey data derived from individuals during adolescence. Issues of differential recall over time, differential mortality for 

smokers and never-smokers, and demographic changes in the population 

over time can bias these reconstructed estimates; therefore, the estimates 

that result may not match those that would be generated from a cross-sectional sample of the population taken in the year of the estimate. 

In general, the estimates presented in this chapter mirror the cross-sectional data presented in other chapters in this volume, supporting the legitimacy of adolescent definitions of smoking as predictors of adult smoking 

behavior. 

Ever Smoking Prevalence 

153

Smoking and Tobacco Control Monograph No. 14 

Figure 8-7 

Age-Specific Initiation Rates for Males by Education Level and Birth Cohort 

16 

14 

12 

10 

8 

6 

4 

2 

0 

11 12 13 14 15 16 17 18 

‡12 Yrs. Ed.:1976-1980 

‡12 Yrs. Ed.:1971-1975 

‡12 Yrs. Ed.:1966-1970 

‡12 Yrs. Ed.:1961-1965 ‡12 Yrs. Ed.:1956-1960 

<12 Yrs. Ed.: 1976-1980 

<12 Yrs. Ed.: 1971-1975 

<12 Yrs. Ed.: 1966-1970 

<12 Yrs. Ed.: 1961-1965 

<12 Yrs. Ed.: 1956-1960 

Age 

SUMMARY Age-specific rates of smoking initiation during adolescence derived from 

sequential birth cohorts of adults show that initiation rates have declined 

over time at all ages for males, with a steeper rate of decline across cohorts 

for initiation rates at ages over 16 years. Initiation rates among females rose 

across sequential cohorts with little evidence for a decline in initiation over 

time for ages and 16 years and under. At ages 16 and older, there is a trend 

of increasing rates of initiation for cohorts that were born prior to the early 

1960s with a decline for subsequent cohorts. 

Initiation rates during adolescence are lower for African American and 

Hispanic adolescents at all ages. However, initiation continues much later 

into young adulthood among African American adolescents with the result 

that they ultimately reach—and exceed, for African American males—the 

ever-smoking prevalence rates of non-Hispanic White populations. 

Initiation rates among those with 12 or more years of education, compared to those with less educational attainment, are lower at all ages for 

males. The same trend is evident for females aged 16 years and younger. 

However, for initiation at ages 17 and 18 among females, there is little difference in rates of initiation evident for the two categories of educational 

attainment. 

Initiation Rate (%) 

154

Chapter 8 

Figure 8-8 

Age-Specific Initiation Rates for Females by Education Level and Birth Cohort 

14 

12 

10 

8 

6 

4 

2 

0 

‡12 Yrs. Ed.: 1976-1980 

‡12 Yrs. Ed.: 1971-1975 

‡12 Yrs. Ed.: 1966-1970 

‡12 Yrs. Ed.: 1961-1965 ‡12 Yrs. Ed.: 1956-1960 

<12 Yrs. Ed.: 1976-1980 

<12 Yrs. Ed.: 1971-1975 

<12 Yrs. Ed.: 1966-1970 

<12 Yrs. Ed.: 1961-1965 

<12 Yrs. Ed.: 1956-1960 

11 12 13 14 15 16 17 18 

Age 

REFERENCES 

Bureau of the Census. The Current Population 

Survey: Design and methodology. Technical Paper 

40. Washington, D.C.: U.S. Department of 

Commerce, Bureau of the Census, 1978. 

Initiation Rate (%) 

155

Pattern of Adolescent Initiation Rates 

over Time: National and California 

Data 

Christy M. Anderson, David M. Burns 

INTRODUCTION This chapter presents data on trends in adolescent smoking initiation nationally and in California. Historical trends in adolescent initiation 

are presented for the nation and contrasted with those occurring in 

California. In 1988, Californian voters passed Proposition 99, which raised 

the tax on a pack of cigarettes by 25 cents and allotted 20 percent of the 

revenues to anti-tobacco education and prevention programs. Shortly after 

Proposition 99 was implemented, cigarette consumption and smoking 

prevalence in California declined (Bal et al., 1990; Breslow and Johnson, 

1993; Burns et al., 1992; Burns, 1994; Elder et al., 1996; Hu et al., 1994; 

Pierce et al., 1991). In this chapter, the impact of this proposition, and of 

the programs funded by it, on the initiation of cigarette smoking by 

Californian adolescents is examined. 

Definitions used to define adolescent and adult smokers differ. 

Adolescent-based surveys define smokers as respondents who have smoked 

at least one cigarette in the last 30 days; the definitions are intended to be 

sensitive enough to capture respondents who are experimenting with cigarettes and are in the early stages of beginning smoking. Adult-based surveys 

define smokers as respondents who have smoked at least 100 cigarettes and 

currently smoke every day or some days. Adult-based surveys are intended 

to identify those respondents who are regular cigarette smokers—either 

occasionally or daily—and exclude those who are experimenting or in early 

initiation. Since not all those who first use cigarettes as adolescents become 

adult cigarette smokers, adolescent-based surveys may include as smokers 

those individuals who will be defined as never-smokers in adult surveys. To 

define initiation rates during adolescence among those who become adult 

smokers, cross-sectional surveys of adults are used to reconstruct past rates 

of initiation (Burns et al., 1995; Cummings and Shah, 1995; Gilpin and 

Pierce, 1997; Pierce et al., 1994). These cross-sectional surveys use the adult 

definition of ever-smoking and reconstruct adolescent initiation rates using 

questions that ask for the age at which respondents started smoking regularly, the current age of the respondent, and the survey year. 

For this chapter, adolescent initiation rates for each calendar year were 

reconstructed retrospectively from subjects’ responses on the Current 

Population Survey (CPS) of adults. All ever-smokers were asked the age at 

which they remembered beginning to smoke regularly. From their current 

age and the year of the survey, the year at which they initiated could be cal157 
Smoking and Tobacco Control Monograph No. 14 

culated. Prevalence rates also could be reconstructed using the age at which 

respondents recalled beginning to smoke and the time they reported quitting. The pattern of U.S. initiation rates from 1940 to 1992 were examined 

and compared for males and females and for older and younger adolescents. The initiation rates of male and female adolescents in California were 

also compared with those of the rest of the nation. The rates were computed for males and females by three age groups: 12- to 17-year-olds, 12- to 14-

year-olds, and 15- to 17-year-olds. 

METHODS	 To generate retrospective initiation and prevalence rates, two sets of 

cross-sectional surveys were used from the Tobacco Use Surveys that 

Data periodically supplement the Census Bureau’s Current Population 

Surveys (CPS). One set was administered in September, 1992; January, 1993; 

and May, 1993. The other was administered in September, 1995; January, 

1996; and May, 1996. For the CPS, the Census Bureau collects labor force 

and demographic information monthly from about 50,000 households 

from the civilian, non-institutional population, surveying household members who are 15 years of age or older; the details of the survey methodology 

are described elsewhere (Bureau of the Census, 1978). All respondents are 

weighted to reflect the actual civilian, non-institutional population of the 

United States and of each individual state. 

The 1992/1993 and 1995/1996 surveys interviewed a combined total of 

623,613 people who were 15 to 84 years old at the time of the survey. Of 

these respondents, 68.5 percent were self-respondents, and only the 

answers from these respondents were used for this analysis. Another 1.5 

percent were eliminated from the analysis due to unanswered questions, 

leaving 417,550 respondents available for analysis. 

Cigarette sales and advertising data were used to make comparisons 

with initiation rates over time. Cigarette sales data were drawn from the 

Maxwell consumer report, which reports annual cigarette sales for each 

major cigarette brand since 1925 (Maxwell, Jr., 1994). Additionally, quantitative estimates were collected of the number of cigarette advertisements 

appearing in 11 popular magazines available from the beginning of the century to 1996. For each advertisement, the cigarette brand name, the title of 

the magazine, and the date of the magazine issue were compiled, among 

other facts. These data were summarized to present the average number of 

advertisements per magazine issue for each calendar year for the Virginia 

Slims brand of cigarettes. 

Calculation of Each person’s smoking status for each calendar year prior 

Initiation and to the date of the survey was reconstructed based upon 

Prevalence Rates the respondent’s recollection of starting and stopping 

smoking. All respondents were asked, "Has [respondent] 

smoked at least 100 cigarettes in his/her entire life?" Those respondents 

who answered "no" were considered never-smokers. Those respondents who 

answered "yes" were asked, "How old was [respondent] when he/she started 

smoking cigarettes fairly regularly?" This question was used to determine 

the age at initiation of smoking. Respondents who had smoked at least 100 

cigarettes were also asked, "Does [respondent] now smoke cigarettes every 

158

Chapter 9 

day, some days, or not at all?" Those respondents who answered "every day" 

or "some days" were considered current smokers; those who responded "not 

at all" were former smokers. 

All calculations to determine the year in which respondents were smoking were based upon responses given in the survey regarding the survey 

administration date, the initiation age, and the age. The survey administration date was represented as a partial year, using both the year and month 

of the survey in this calculation (e.g., September 1992 became 1992.75). 

Additionally, 6 months were added to all age responses to account for the 

distribution of birthdays occurring over the entire calendar year. These age 

and calendar-year calculations were then used, together with the questions 

on age of initiation, to reconstruct, for each calendar year, which adolescents were not smoking and which ones had begun smoking during that 

same year. For each calendar year, the number of adolescents who began 

that year as non-smokers represented the denominator of the initiation 

rate. The numerator of the rate was the number of adolescents who initiated during that calendar year. 

The survey subjects were 15 to 84 years old at the time of the survey, 

the last of which was administered in 1996. Since the rates for each calendar year measured smoking initiation and prevalence of 12- to 17-year-olds, 

the last year all ages were present was 1993. The only survey available for 

the 1993 analysis was the May 1996 survey, providing a sample size of only 

about 200 for each gender (compared to 500 in 1992, and 950 in 1990). 

The small sample size for 1993 offered unstable estimates of the initiation 

and prevalence rates, so the last year from which the analysis was performed was 1992. 

While calculating the initiation rates for each calendar year, the distribution of ages reflected in the original sample was preserved. Since the distribution of 12- to 17-year-olds varied between calendar years, each initiation rate for each calendar year was standardized to the birth-year distribution of all respondents who would have been between the ages of 12 and 

17 in that calendar year. Likewise, to make similar comparisons between 

ethnically diverse samples, the rates for each calendar year were standardized by ethnicity to the ethnic distribution of the United States represented 

by the 1995/1996 CPS. When comparing the initiation rates across the different ethnic groups, the rates were smoothed using the loess procedure in 

S-Plus (MathSoft, Inc., 1999; Cleveland, 1979). Twenty percent of the rates 

were used to quadratically fit each rate, and each rate was weighted to the 

sample size used to calculate that rate. 

The CPS weights were used to calculate the initiation rates, and those 

rates and their corresponding sample sizes were used to calculate exact 95-

percent binomial confidence intervals (Snedecor and Cochran, 1989). 

RESULTS	 Initiation rates of U.S. adolescents, aged 12 to 17, were 

compared between males and females. Male adolescents 

National Male and initiated smoking at a higher rate than did female adolesFemale Initiation Rates cents prior to the mid-1970s (Figure 9-1). Specifically, 

from 1940 to 1973, boys initiated cigarette smoking at a significantly 

159

Smoking and Tobacco Control Monograph No. 14 

Figure 9-1 

Incidence of Smoking among 12- to 17-Year-Old Adolescents in the United States, 

1940-1993 

8


7


6


Females 

Males 

Initiation (%) 5


4


3


2


1


0


1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990


Year 

greater rate than did girls. From 1974 to 1980, boys and girls initiated at 

rates not significantly different from one another. Between 1981 and 1984, 

initiation rates for boys were significantly lower than for girls. Initiation 

rates have been similar for boys and girls since 1985. These observations are 

consistent with those reported elsewhere in this volume and in previous literature (Fiore et al., 1989; see Chapter 2). 

Smoking initiation rates among male adolescents have generally 

decreased since 1940 (Figure 9-1). This decline in the initiation rate reached 

its lowest level in 1983. Since that time, initiation rates among adolescent 

males have increased. 

Unlike initiation rates among male adolescents, initiation rates among 

female adolescents have generally increased since 1940. Female adolescent 

initiation rates increased from 1940 to 1959, but declined during the early 

1960s. Female adolescent initiation rates increased sharply from the late 

1960s to the mid 1970s, then declined from the late 1970s to the early 

1980s. 

As previously reported (Burns, 1994; Pierce et al., 1994; Pierce and 

Gilpin, 1995), the dramatic increase in girls’ initiation rates in the late 

1960s coincided with Philip Morris’ introduction of Virginia Slims cigarettes 

(Figure 9-2). Sales of Virginia Slims rose from its inception in 1968 to a peak 

160 
Chapter 9 

in 1981. Contemporaneously, the number of Virginia Slims’ cigarette advertisements in popular magazines increased from 1968 to 1987. In fact, the 

introduction of Virginia Slims was so successful that this brand has commanded up to 3 percent of the market share of cigarette sales (Kluger, 

1997). 

Initiation rates of 12- to 17-year-old males and females have also been 

computed for non-Hispanic White, Hispanic, and African American adolescents. Annual initiation rates and the 95-percent confidence intervals 

appear at the end of the chapter. Figures 9-3 and 9-4 display the loesssmoothing trend lines for male and female adolescents by ethnicity. Since 

the overall population of the United States is comprised mostly of Whites, 

initiation rates among White male and female adolescents are similar to initiation rates for males and females overall. In 1940, initiation rates among 

all three ethnic groups of adolescents were not significantly different for 

males or females. However, by 1992, White male and female adolescents 

initiated smoking at a significantly higher rate than the corresponding 

African American and Hispanic males and females aged 12 to 17 years. 

From 1940 to 1992, White male adolescents generally initiated cigarette 

smoking at higher rates than did Hispanic or African American male adolescents. On the whole, initiation rates among male adolescents of all three 

ethnicities declined during this period. The overall patterns of initiation 

among Hispanic and African American male adolescents were similar until 

recent years. In the early 1980s, initiation rates among African American 

males declined steeply while White and Hispanic male adolescent initiation 

rates increased. By the late 1980s, these trends had changed with Hispanic 

male adolescent initiation rates decreasing and African American and White 

initiation rates increasing. 

Initiation rates among White and Hispanic female adolescents generally 

increased from 1940 to 1992, although there was less of an increase among 

Hispanic female adolescents. In contrast, adolescent female initiation rates 

among African Americans have been decreasing since the mid 1970s and do 

not show evidence of the recent increase noted among African American 

male adolescents. The recent increase in African American male initiation 

rates has returned their rates of initiation to a level similar to those for 

African American females. 

Comparison of Younger U.S. initiation rates were computed for two separate age 

and Older Adolescent groups of adolescents: 12- to 14-year-olds and 15- to 17-

Initiation Nationally year-olds. The initiation rates of both younger and older 

male adolescents declined from 1940 to 1992, but the decline was much 

greater among older boys than among younger boys (Figure 9-5). The calendar-year variability of initiation rates among male adolescents is largely 

explained by calendar-year variability among older boys, suggesting that 

temporal events have greater influence, both positively and negatively, on 

older male adolescents than on younger male adolescents. 

Female adolescent initiation rates (Figure 9-6) revealed a rise in initiation rates since 1940 for both younger and older adolescents, with a significant increase in initiation among both groups starting around the mid161

Smoking and Tobacco Control Monograph No. 14 

Figure 9-2 

Incidence of Smoking among 12- to 17-Year-Old Adolescent Females Compared to 

Virginia Slims’ Sales and Advertisement 

6


5


Female Smoking Initiation 

Virginia Slims’ Sales (x 5 bil) 

Virginia Slims’ Ads 

Introduction of Virginia Slims 

120


100


Number of Ads/Cigarettes 

Initiation (%) Initiation (%) 4


3


2


1


0


80


60


40


20


0


1950 1955 1960 1965 1970 1975 1980 1985 1990 1995


Year 

Figure 9-3 

Cigarette Smoking Initiation among Adolescent Males 12 to 17 Years Old by Ethnicity 

[Weighted by Sample Size—Trendlines Fitted with Loess Algorithm (Quadratic)] 

8


All Ethnicities 

African American 

Hispanic 

White 

7


6


5


4


3


2


1


0


1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 

162 

Year 
Chapter 9 

Figure 9-4 

Cigarette Smoking Initiation among Adolescent Females 12 to 17 Years Old by 

Ethnicity [Weighted by Sample Size—Trendlines with Loess Algorithm (Quadratic)] 

6 

5 

4 

3 

2 

1 

0 

1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 

All Ethnicities 

African American 

Hispanic 

White 

Year 

Figure 9-5 

Comparison of the Smoking Initiation among Older and Younger Male Adolescents in 

the United States 

14 

13 

12 

11 

10 

9 

8 

7 

6 

5 

4 

3 

2 

1 

0 

15-17 Years Old 

12-14 Years Old 

Initiation Rate (%) Initiation (%) 

1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990


Year 

163

Smoking and Tobacco Control Monograph No. 14 

1960s. The pattern of increases and decreases in initiation rates by calendar 

year was similar among older and younger female adolescents, but the fluctuations were more pronounced among the older girls. The pattern of initiation rates over time for female adolescents aged 12 to 17 can be attributed 

to the increases and decreases in initiation rates among both younger (12 to 

14 years of age) and older (15 to 17 years of age) girls. Furthermore, the 

increase in initiation rates that coincided with the Virginia Slims’ advertising campaign was present in both age groups of girls, but not in either age 

group of boys. 

Comparison of California Initiation rates from 1978 to 1992 were calculated 

and the Rest of the Nation for California and for the rest of the nation. These 

rates were evaluated for 12- to 14-year-old male and female adolescents and 

for 15- to 17-year-old male and female adolescents. They were also contrasted before and after 1988, the year in which Proposition 99 was passed. 

Among younger male adolescents, there was no significant difference in 

smoking initiation rates between California and the rest of the nation, 

either before or after 1988 (Figure 9-7). However, for older male adolescents, 

some differences were apparent (Figure 9-8). Before 1988, there was no significant difference in initiation rates between male adolescents in California 

and in the rest of the nation; however, after 1988, the initiation rates of 

older Californian boys declined significantly and were significantly lower 

than rates in the rest of the nation in 1991. This difference was no longer 

statistically significant in 1992. Smoking prevalence rates among this older 

group of adolescents (not shown) followed a pattern similar to the initiation rates, but differences were not statistically significant. 

Initiation rates among younger girls were not significantly different 

between those in California and the rest of the nation, and there did not 

appear to be a significant change in the initiation rates in California among 

younger female adolescents after 1988 (Figure 9-9). 

Before standardization by ethnicity, initiation rates among older 

Californian girls were lower than among girls in the rest of the nation, and 

most of these rates were significantly different. After standardization for 

ethnicity, the difference in initiation rates between older girls in California 

and the rest of the United States disappeared (Figure 9-10). The lower rates 

in California, before standardization, appeared to be attributable to the 

lower rates of smoking initiation among the different ethnic groups that 

comprised California’s population in contrast to the rest of the nation. 

With or without standardization, there did not appear to be a difference 

between initiation rates among older girls in California following the passage of Proposition 99 in 1988. 

SUMMARY The analysis had some limitations because rather than surveying the 

populations present in each year and calculating corresponding rates, 

respondents were surveyed in the 1990s and their rates were reconstructed 

retrospectively for each year from 1940 to 1992. Because the surveys were 

conducted in the recent past, the survey samples reflected the distribution 

of ethnic groups present today. Large proportions of the ethnic groups in 

today’s population have immigrated to the United States since 1940, so any 

164

Chapter 9 

Figure 9-6 

Comparison of Smoking Initiation among Older and Younger Female Adolescents in 

the United States 

8 

7 

6 

5 

4 

3 

2 

1 

0 

15-17 Years Old 

12-14 Years Old 

1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 

Year 

Figure 9-7 

Comparison of Smoking Initiation Rates of California to the Rest of the Nation among 

12- to 14-Year-Old Male Adolescents 

5 

4 

3 

2 

1 

0 

USA minus CA 

CA 

Initiation Rate (%) 

Initiation Rate (%) 

’78 ’79 ’80 ’81 ’82 ’83 ’84 ’85 ’86 ’87 ’88 ’89 ’90 ’91 ’92 ’93 ’94 ’95 

Year 165 
Smoking and Tobacco Control Monograph No. 14 

Figure 9-8 

Comparison of Smoking Initiation Rates of California to the Rest of the Nation among 

15- to 17-Year-Old Male Adolescents 

9 

8 

7 

6 

5 

4 

3 

2 

1 

0 

USA minus CA 

CA 

’78 ’79 ’80 ’81 ’82 ’83 ’84 ’85 ’86 ’87 ’88 ’89 ’90 ’91 ’92 ’93 ’94 ’95 

Year 

Figure 9-9 

Comparison of Smoking Initiation Rates of California to the Rest of the Nation among 

12- to 14-Year-Old Female Adolescents 

6 

5 

4 

3 

2 

1 

0 

USA minus CA 

CA 

Initiation Rate (%) Initiation Rate (%) 

’78 ’79 ’80 ’81 ’82 ’83 ’84 ’85 ’86 ’87 ’88 ’89 ’90 ’91 ’92 ’93 ’94 ’95 

Year 

166 
Chapter 9 

Figure 9-10 

Comparison of Smoking Initiation Rates of California to the Rest of the Nation among 

15- to 17-Year-Old Female Adolescents 

12 

10 

8 

6 

4 

2 

0 

’78 ’79 ’80 ’81 ’82 ’83 ’84 ’85 ’86 ’87 ’88 ’89 ’90 ’91 ’92 ’93 ’94 ’95 

USA minus CA 

CA 

Year 

fluctuations in initiation rates do not necessarily reflect events that happened in the United States. These initiation rates also reflected when the 

current population of the United States and California began smoking, not 

necessarily when the people present in the United States during each particular year began smoking. 

Adolescent males have significantly decreased their smoking initiation 

since 1940 and most of the decreases and increases in initiation rates can be 

attributed to the changes among older 15- to 17-year-old adolescents. After 

the passage of Proposition 99 in California, older Californian boys’ initiation rates decreased significantly. In 1991, these rates were significantly 

lower than the initiation rates among similarly aged boys in the rest of the 

nation. This suggests that tobacco control efforts in California may have 

differentially impacted this age group during the early years of the campaign. 

Female adolescents increased their smoking initiation rates after 1940; 

in particular, initiation rates among female adolescents sharply increased at 

the time that Philip Morris introduced Virginia Slims. Both older and 

younger female adolescents experienced the increase in smoking initiation 

rates coincident with the introduction of the Virginia Slims brand. There 

did not appear to be a significant change in smoking initiation rates among 

either younger or older Californian girls after the passage of Proposition 99 

in 1988. 

Initiation Rate (%) 

167

Smoking and Tobacco Control Monograph No. 14 

FOLLOWING ARE FIGURES 9-1a THROUGH 9-1c, WHICH SHOW ANNUAL 

INITIATION RATES AND 95% CONFIDENCE INTERVALS 

Figure 9-1a 

Cigarette Smoking Initiation among 12- to 17-Year-Old White Adolescents 

8


7


6


5


4


3


2


1


0


Females Actual 

Males Actual 

Females Smoothed 

Males Smoothed 

’40 ’45 ’50 ’55 ’60 ’65 ’70 ’75 ’80 ’85 ’90 

Year 

Initiation (%) 

168

Chapter 9 

Figure 9-1b 

Cigarette Smoking Initiation among 12- to 17-Year-Old Hispanic Adolescents 

8 

7 

6 

5 

4 

3 

2 

1 

0

’40 ’45 ’50 ’55 ’60 ’65 ’70 ’75 ’80 ’85 ’90 

Females Actual 

Males Actual 

Females Smoothed 

Males Smoothed 

Year 

Figure 9-1c 

Cigarette Smoking Initiation among 12- to 17-Year-Old African American Adolescents 

8 

7 

6 

5 

4 

3 

2 

1 

0 

’40 ’45 ’50 ’55 ’60 ’65 ’70 ’75 ’80 ’85 ’90 

Females Actual 

Males Actual 

Females Smoothed 

Males Smoothed 

Initiation (%) Initiation (%) 

Year 

169

Smoking and Tobacco Control Monograph No. 14 

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Bal, D.G., Kizer, K.W., Felten, P.G., Mozar, H.N., 

Niemeyer, D. Reducing tobacco consumption in 

California. Development of a statewide antitobacco use campaign. Journal of the American 

Medical Association 264(12):1570-1574, 1990. 

Breslow, L., Johnson, M. California's Proposition 99 

on tobacco, and its impact. Annual Review of 

Public Health 14:585-604, 1993. 

Bureau of the Census. The Current Population 

Survey: Design and Methodology. Technical Paper 

40. Washington, D.C.: U.S. Department of 

Commerce, Bureau of the Census, 1978. 

Burns, D.M. Use of media in tobacco control programs. American Journal of Preventive Medicine 

10(3 Suppl):3-7, 1994. 

Burns, D.M., Lee, L., Vaughn, J.W., Chiu, Y.K., 

Shopland, D.R. Rates of smoking initiation 

among adolescents and young adults, 1907–81. 

Tobacco Control 4(Suppl 1):S4-S8, 1995. 

Burns, D.M., Pierce, J.P., et al. Tobacco Use in 

California 1990–1991. Sacramento, CA: 

California Department of Health Services, 1992. 

Cleveland, W.S. Robust locally-weighted regression 

and smoothing scatterplots. Journal of the 

American Statistical Association 74:829-836, 1979. 

Cummings, K.M., Shah, D. Trends in smoking initiation among adolescents and young adults— 

United States, 1980–1989. Morbidity and Mortality 

Weekly Report 44(28):521-525, 1995. 

Elder, J.P., Edwards, C.C., Conway, T.L., Kenney, E., 

Johnson, C.A., Bennett, E.D. Independent evaluation of the California Tobacco Education 

Program. Public Health Report 111(4):353-358, 

1996. 

Fiore, M.C., Novotny, T.E., Pierce, J.P., Hatziandreu, 

E.J., Patel, K.M., Davis, R.M. Trends in cigarette 

smoking in the United States. The changing 

influence of gender and race. Journal of the 

American Medical Association 261(1):49-55, 1989. 

Gilpin, E.A., Pierce, J.P. Trends in adolescent smoking initiation in the United States: Is tobacco 

marketing an influence? Tobacco Control 

6(2):122-127, 1997. 

Hu, T.W., Bai, J., Keeler, T.E., Barnett, P.G., Sung, H.Y. 

The impact of California Proposition 99, a major 

anti-smoking law, on cigarette consumption. 

Journal of Public Health Policy 15(1):26-36, 1994. 

Kluger, R. Ashes to Ashes: America's Hundred-Year 

Cigarette War, the Public Health, and the 

Unabashed Triumph of Philip Morris. New York: 

Alfred A. Knopf, 1997. 

MathSoft Inc. S-Plus 2000, Guide to Statistics. Seattle, 

WA: Data Analysis Division, 1999. 

Maxwell, J.C., Jr. Historical Sales Trends in the Cigarette 

Industry: A Statistical Summary Covering 69 Years 

(1925–93). Richmond, VA: Wheat, First 

Securities, Inc., 1994. 

Pierce, J.P., Burns, D.M., Berry, C., Rosbrook, B., 

Goodman, J., Gilpin, E., Winn, D., Bal, D. 

Reducing tobacco consumption in California: 

Proposition 99 seems to work [letter]. Journal of 

the American Medical Association 265(10):1257-

1258, 1991. 

Pierce, J.P., Gilpin, E.A. A historical analysis of tobacco marketing and the uptake of smoking by 

youth in the United States: 1890–1977. Health 

Psychology 14(6):500-508, 1995. 

Pierce, J.P., Lee, L., Gilpin, E.A. Smoking initiation by 

adolescent girls, 1944 through 1988. An association with targeted advertising [see comments]. 

Journal of the American Medical Association 

271(8):608-611, 1994. 

Snedecor, G.W., Cochran, W.G. Statistical Methods. 

(8th ed.). Ames, Iowa: Iowa State University 

Press, 1989. 

170

Changing Adolescent Smoking 

Prevalence: Impact of Advertising 

Interventions 

Cornelia Pechmann 

INTRODUCTION The U.S. federal and state governments are increasingly using 

paid mass-media advertising to communicate with the U.S. public. The U.S. 

Congress has allocated $1.2 billion—$200 million per year for 5 years—to 

fund an advertising campaign to keep youths from using illicit drugs 

(Fairclough, 1999). The U.S. Census Bureau has, for the first time, used 

advertising to increase mail-in response rates to the dicennial census; its 

advertising budget was roughly $100 million (U.S. Census Bureau, 1999). 

The American Legacy Foundation (http://www.americanlegacy.org), which 

is funded by the national U.S. tobacco settlement, is overseeing an antismoking advertising and promotional campaign amounting to $300 million 

in expenditures per year. U.S. states are currently trying to decide if they 

should run state-level antismoking campaigns (Brull, 1999). Several states, 

including Arizona, California, Florida, and Massachusetts, have already 

begun multi-year campaigns. California spends roughly $0.40 per capita 

($12 million) per year while Massachusetts spends considerably more, or 

roughly $2.33 per capita ($14 million), per year on campaigns (Pechmann, 

1997; Pechmann and Reibling, 2000a; Goldman and Glantz, 1998). Many 

other states are currently trying to decide if they should run state-level antismoking campaigns and are uncertain that antismoking advertising will pay 

off in terms of reduced smoking prevalence and lower health care costs 

(Brull, 1999). 

The goal of this chapter is to assist decision-makers in making informed 

decisions about using advertising for tobacco use prevention. The first part 

will address the question, “Should antismoking advertising be used? That is, 

will it work?” To answer this question, the chapter will review research on 

the impact of such advertising on adolescent smoking prevalences and on 

leading indicator beliefs and attitudes. The second part of the chapter will 

describe research on the most promising message types in order to address 

the issue of how antismoking advertising campaigns should be designed. 

SHOULD ANTISMOKING The question of whether antismoking advertising 

ADVERTISING BE USED should be used for tobacco use prevention depends on 

FOR TOBACCO USE both its effectiveness and its cost-effectiveness, but neiPREVENTION? ther issue has been resolved as yet. To date, there is little conclusive evidence of a direct link between advertising-only interventions and reduced adolescent smoking prevalences. However, one can point 

to a triangulation of indirect evidence for the effectiveness of antismoking 

advertising. That evidence is reviewed below. 

171

Smoking and Tobacco Control Monograph No. 14 

Research on Antismoking At least three studies have examined the efficacy of 

Advertising Plus School- combining school-based tobacco use prevention proBased Programs grams with antismoking advertising, and the results 

look promising. In one study (Flynn et al., 1992), students participated in a 

school-based program consisting of about four tobacco-specific classes per 

year for four years, spanning both middle school and high school. In addition, half of the students were exposed to a four-year antismoking advertising campaign. Each year, the advertising aired for five months and students 

saw roughly two antismoking spots per day; many students also assisted in 

the ad campaign design and evaluation (Worden et al., 1988). By 10th 

grade, 12.8% of the students in the school-plus-advertising intervention 

group had smoked in the past week versus 19.8% in the school-only intervention group (Flynn et al., 1992). This difference was significant and was 

sustained for at least 2 years after the program had ended (Flynn et al., 

1994).1 In summary, the advertising and school program worked synergistically to lower adolescent smoking prevalences. However, there is no way of 

knowing how effective the advertising would have been on its own (Figure 

10-1). 

The intervention by Perry et al. (1992) targeted students in grades 6-8 

with 6 to 10 tobacco-specific classes per year that were supplemented by 

antismoking advertising, health screenings, and community-based activities. By grade 8, the weekly smoking prevalences for the intervention group 

and the no-intervention control group began to diverge such that, by grade 

10, the prevalence for the intervention group was half that of the control 

group (11 percent and 22 percent, respectively; Figure 10-2). Finally, Murray 

et al. (1992) studied middle school (junior high) students who were exposed 

to a less intensive school- and advertising-based intervention. The effects 

were weaker but nonetheless statistically significant. At the end of the 

study, the weekly smoking prevalence was 12 percent for the intervention 

group versus 16 percent for the no-intervention control group. 

If states were to fund antismoking advertisements and school programs, 

however, they could not necessarily expect similar results. Both California 

and Massachusetts have used this dual-pronged approach, and neither state 

has produced sustained reductions in adolescent smoking prevalences 

(Goldman and Glantz, 1998; Pechmann, 1997; Pechmann and Reibling, 

2000a; Popham et al., 1994; Siegel and Biener, 1997). By splitting up limited 

funds between advertising and school programs, a state risks funding both 

programs inadequately (Pechmann and Reibling, 2000b). Indeed, California 

has been criticized for underfunding both its antismoking advertising campaign and its school-based initiatives (Pierce et al., 1998; California 

Department of Education, 1995). Funding for California’s antismoking 

school programming amounts to roughly $6 per student per year and 

experts say this amount should be at least doubled (California Department 

of Education, 1995). 

1. Any effect that is described as significant is based on p ≤ 0.05 unless otherwise specified. 

172

Chapter 10 

Figure 10-1


Results of Flynn and Worden et al.’s (1992) Longitudinal Field Experiment


19.8 

20 

Control 

15 

3.4 

9.3 

14.8 

1.6 

12.8* 

9.1* 

5.0* 

1.3 1.8 

5-Month Ad 

Campaigns 

Group 

Experimental 

10 Group 

* Difference 

5	 Significant 

at p < 0.05 

0 

Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 

(age 11) (age 12) (age 13) (age 14) (age 15) 

NOTES: 1. Each cohort group spanned 3 grades, so the grades listed are the medians (e.g., 

“Grade 6” represents the cohort group when in grades 5 - 7). Ages are 

approximate. 

2. A similar pattern was observed for “Smoked yesterday” and “Smoked recently.” 

3. Flynn and Worden et al. (1994) found the effects were sustained 2 years hence 

(median grade = 12). 

Further, it is often difficult to persuade schools to use the tobacco-specific programs that have been scientifically proven to work due to program 

length and intensity, teacher training requirements, and a general preference for locally produced, general drug programs (California Department of 

Education, 1995). Hence, while school-based programs combined with antismoking advertising could work, communities generally have been unable 

to implement this approach effectively. It would be easier to rely strictly on 

antismoking advertising, but more research is needed to determine whether 

advertising alone will work. 

Research on Antismoking Two recent evaluations of state-based antismoking 

Advertising and Adolescents campaigns used longitudinal surveys of adolescents 

to ascertain whether there was a link between self-reported ad exposure and 

reductions in smoking initiation (Sly et al., 2001) or progression to regular 

use (Siegel and Biener, 2000). The evaluations involved Massachusetts 

(Siegel and Biener, 2000) and Florida (Sly et al., 2001). It was concluded that 

these states’ antismoking television ads were effective in dissuading adolescents from taking up smoking (also see MMWR, 1999). Unfortunately, the 

contribution of this research is somewhat limited by the correlational 

nature of the data. The data clearly show that adolescents who reported seeing the antismoking ads later manifested a lower propensity to smoke, but 

% Smoking (Past 

Week) 

173

Smoking and Tobacco Control Monograph No. 14 

Figure 10-2


Results of Perry et al.’s (1992) Longitudinal Field Experiment


25 

20 

Interventions 

2 

8 

13 

19 

22 

1 2.5* 

5* 

11* 

12* 

Control 

Group 

15 

Experimental 

Group 

10 

* Difference 

5	 Significant 

at p < 0.05 

0 

Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 

(age 11) (age 12) (age 13) (age 14) (age 15) 

NOTES: 1. The intervention depicted was a 6 - 10 session/year school education program, but 

subjects in the experimental group were also exposed to a multi-year community 

health intervention involving mass media ads. 

2. Ages are approximate. 

these data could be interpreted in one of two ways. One possibility is that 

the antismoking ads reduced adolescent smoking. A rival explanation is 

that adolescents who had strong antismoking beliefs at the onset were more 

likely to pay attention to the antismoking ads and also were less likely to 

smoke in the future (Pechmann and Reibling, 2000b). 

It is a well-established fact that consumers selectively attend to ads that 

support their prevailing product-related attitudes and behaviors, in part to 

avoid cognitive dissonance and preserve self-esteem (Alba and Hutchinson, 

1987; Festinger, 1964; Frey, 1986). Hence, while there is generally a positive 

correlation between ad exposure and product beliefs and intentions, this 

seems to be due to reverse causality, to a large extent: beliefs and intentions 

drive exposure to advertising rather than exposure to advertising driving 

beliefs and intentions. Sly et al. (2001) and Siegel and Biener (2000) sought 

to control youths’ prior smoking beliefs by including covariates in the 

analyses, such as age, sex, prior smoking status, and the smoking status of 

friends and parents; Siegel and Biener (2000) also controlled for the extent 

of television viewing. However, adolescents’ preexisting smoking beliefs 

were not directly assessed and so it is difficult to draw any firm conclusions 

from the results. 

% Smoking (Weekly) 

174

Chapter 10 

Research on Antimarijuana Some encouraging evidence that antimarijuana ads 

Advertising and Adolescents can reduce adolescents’ propensity to use marijuana comes from a recent three-year, two-county study (Palmgreen et al., 

2001). One county received two waves of antimarijuana television advertising while a second county received just the second wave, and each wave 

lasted four months. When the advertising was airing, it is estimated that 

90+ percent of the adolescents saw three antimarijuana ads per week. 

To measure the impact of the advertising, monthly surveys were conducted of 100 randomly selected youths from each county. The youths sampled were in grades 7-10 initially and the group sampled advanced to grades 

10-13 (first year of college) at the end. Identical sampling and interview 

procedures were used throughout and the interviews were conducted at the 

youths’ homes with the drug-related survey items being self-administered 

via laptop computer to ensure confidentiality. The results indicate that the 

ad campaign was highly effective. In each county, the prevalence of marijuana use among high-risk youths declined concurrently with the first wave 

of advertising. In the county that received a second wave of advertising, the 

initial declines in marijuana use were perpetuated. Overall, this study indicates that marijuana advertising alone can work, but it remains to be seen 

whether the results are applicable to antismoking advertising. 

Research on Antismoking Pierce et al. (1998) assessed the efficacy of the 

Advertising and Adult California tobacco control program that commenced 

Smoking in 1989 and included antismoking advertising (18 

percent of total dollar expenditures), school-based programs (32 percent), 

and community-based antismoking efforts (40 percent). The advertising and 

community interventions targeted both adolescents and adults. In the preprogram years, per capita cigarette consumption was declining in both the 

United States and California, but more so in California. In the early program years (1989-1993), the rate of decline intensified significantly in 

California relative to both the previous trend in that state and the U.S. 

trend at that time. In the later program years (1994-1997), both California 

and the United States experienced a significant weakening in the rate of 

decline relative to the prior period (Figure 10-3). The researchers attribute 

the reduced efficacy of the California program to a 40-percent decrease in 

annual tobacco control expenditures from early to later program years. In 

conclusion, the Pierce et al. (1998) study suggests that well-funded tobacco 

control programs can be effective. It does not, however, partition out the 

effects of antismoking advertising relative to California’s other tobacco control activities, such as tax-induced increases in cigarette prices. Nor does it 

address the specific issues of adolescent-focused advertising or adolescent 

smoking prevalences. 

Research on Advertising’s More direct evidence of the causal effect of antismokImpact on Adolescents’ ing advertising on youth has been provided by ranBeliefs and Behavioral domized experimental trials that are typically called 

Intentions “copytests.” Typically, in such copytests, hundreds of 

adolescents who are representative of the U.S. population in terms of gender, ethnicity, and socioeconomic status are randomly assigned to view 

either antismoking advertising or control advertising (unrelated to smok175

Smoking and Tobacco Control Monograph No. 14 

Figure 10-3 

Trends in per-Capita Cigarette Consumption in California and the Rest of the United 

States (Pierce et al., 1998) 

Fitted Regression 

Lines (piecewise 

linear model) for: 

United States — 

California 

California 

1 Significant Difference 

CA versus USA 

2 Significant Difference 

versus Prior Period 

Per-Capita Packs Per Month 

Early Late 

Preprogram Program 16 

14 

12 

slope = -0.42 

slope = -0.04 

slope = -0.42 

slope = -0.36 

slope = -0.64 

slope = -0.17 

Program 

1,2 

1,2 

1 

2 

10 

8 

6 

4 

1982 1986 1990 1994 1998 

Year 

ing), after which they complete surveys. If the youths in the antismoking 

advertising (versus control) condition report significantly less favorable 

smoking-related beliefs or intentions, it is concluded that the advertising is 

efficacious. These measures have been shown to be leading indicators of 

adolescents’ later smoking behaviors (Aitken and Eadie, 1990; Aitken et al., 

1991; Pierce et al., 1995; Pierce et al., 1996). 

Pechmann and her colleagues have copytested a large number of youthoriented advertisements that seek to de-normalize smoking by portraying 

teenage smokers as uncool, unwise, and misguided. The results are encouraging (Table 10-1). Pechmann and Ratneshwar (1994) found that the antismoking advertising lowered 6th graders’ perceptions of a smoker’s common sense, personal appeal, maturity, and glamour. Pechmann and Knight 

(2000) showed that just one antismoking ad was able to offset the impact of 

three cigarette ads that would otherwise have enhanced 9th graders’ perceptions of a smoker’s social stature, popularity, and vitality. Pechmann and 

Shih (1999) assessed 9th graders’ reactions to a PG-rated feature film that 

depicted highly intelligent and attractive young movie stars smoking in 

one-third of the scenes. The findings suggest that the film enhanced 

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Chapter 10 

Table 10-1

Copytest Research Findings on Impact of Antismoking Ads on Adolescents’ Beliefs about

Teenagers who Smoke

Pechmann and Ratneshwar’s (1994) Study of 6th Graders 

Teenage smokers’ common sense, control ads antismoking ads 

personal appeal, maturity, and glamour 3.6 > 3.1 

Pechmann and Knight’s (2000) Study of 9th Graders 

cigarette cigarette + anti- control 

Teenage smokers’ social stature, ads smoking ads ads 

popularity, and vitality 4.1 > 3.2 = 2.9 

Pechmann and Shih’s (1999) Movie Study with 9th Graders 

smoking antismoking ad before control 

scenes smoking scenes scenes 

Teenage smokers’ social stature 3.9 > 3.3 = 3.1 

Note: Higher numbers indicate more favorable beliefs. The symbol “ >” indicates statistically significant mean difference (p ≤ 0.05). 

youths’ perceptions of a smoker’s social stature, but that showing a 30-second antismoking ad immediately before the film prevented youths from 

being as influenced by the film’s content. As a follow-up, “market test evaluation” studies should be conducted (Palmgreen et al., 2001) to show a 

direct link between antismoking advertising and reductions in adolescent 

smoking prevalence. 

HOW SHOULD When designing an advertising campaign, at least four imporADVERTISING tant issues must be addressed: the message content (what to 

CAMPAIGNS BE say), the executional style (how to say it), the target audience 

DESIGNED? (whom to say it to and, hence, which media to choose), and 

the budget. In the interests of brevity, this section will focus on research 

regarding message content. For information on the other topics, readers can 

refer to the following articles and resources: Best Practices for Comprehensive 

Tobacco Control Programs (CDC, 1999); Everett and Palmgreen, 1995; 

Donohew et al., 1991; Lorch et al., 1994; Palmgreen et al., 1991; Pechmann, 

1997; Pechmann and Reibling, 2000a & 2000b; Worden et al., 1988. 

Focus Group Studies Several small-scale studies have utilized the focus group 

on Antismoking method to assess adolescents’ reactions to different antiAdvertising Messages smoking messages. Focus groups are structured and monitored group discussions that typically involve from 6 to 12 people. Most of 

these studies were conducted informally by advertising agencies to assist 

them in selecting specific ads for state-level campaigns and, as such, the 

results have not been published or widely disseminated. One exception is a 

study that was spearheaded by the Centers for Disease Control and 

Prevention (CDC), in which groups of adolescents were asked to comment 

on ten representative antismoking ads from various states (Teenage 

Research Unlimited, 1999). One hundred and twenty adolescents participated in the research and they reportedly preferred ads that dramatized the 

serious physical consequences of smoking. Many of the youths were critical 

of the Philip Morris “Think. Don’t Smoke” ads, indicating that the ads did 

not give them any compelling reasons not to smoke. 

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Smoking and Tobacco Control Monograph No. 14 

Another published study, by Goldman and Glantz (1998), reviewed 

transcripts of focus groups that were conducted to develop antismoking 

advertisements for California, Massachusetts, and Michigan. The study concluded that the most compelling advertisements addressed second-hand 

smoke or tobacco industry manipulation. However, several researchers have 

disputed these conclusions (Worden et al., 1998; Balch and Rudman, 1998). 

Since focus group researchers typically obtain qualitative data from small 

numbers of people and do not statistically analyze these data, definitive 

conclusions are difficult to reach. 

Copytest Study on A large-scale, two-part copytest study has been recently 

Antismoking completed by Pechmann et al. (2000). The researchers 

Advertising Messages identified the seven most common types of antismoking 

advertising messages used in recent years and evaluated the efficacy of each 

message type. The ads were obtained from several different U.S. states and 

health groups, Canada, and Australia, and represented a variety of executional styles. Close to 3,000 7th and 10th graders participated in the 

research. Roughly half of the youths were used to classify nearly 200 antismoking television ads into 7 distinct message types. The remaining youths 

participated in a copytest that assessed the impact of each message type 

(versus control messages) on their smoking-related knowledge, beliefs, and 

intentions. The copytest used eight randomly selected ads to represent each 

of the seven message types, or, in other words, assessed advertising “flights” 

or mini campaigns. Youths were randomly assigned to view just one ad type 

in order to obtain uncontaminated measures of persuasiveness. If an ad 

type significantly lowered adolescents’ intention to smoke, it was considered to be efficacious; otherwise, it was not (Azar, 1999; Pierce et al., 1995 & 

1996). 

“Disease and Death” ads emphasized the long-term physical effects of 

smoking, such as cancer, lung and heart disease, and death. “Cosmetics” 

ads claimed that smokers risk social rejection due to their bad breath and 

smelly clothes and hair. “Endangers Family” ads stressed that smokers can 

hurt their families with their second-hand smoke and untimely deaths. 

“Smokers’ Negative Life Circumstances” ads associated smoking with negative loser imagery to imply an unattractive, undesirable, unhealthy lifestyle. 

“Refusal Skills Role Model” ads portrayed attractive, popular role models 

proudly and confidently resisting peer pressure to smoke. “Marketing 

Tactics” ads disclosed the tactics used to market cigarettes, such as image 

ads and the targeting of vulnerable groups. “Selling Disease and Death” ads 

stated that tobacco firms use manipulative and deceptive marketing tactics 

to sell a deadly product. All seven ad types apparently utilized principles 

from Protection Motivation Theory (Rogers, 1975 & 1983), which is a popular, well-substantiated theory of how people are persuaded to adopt riskreduction behaviors, such as not smoking (Sturges and Rogers, 1996). 

Pechmann et al. (2000) found that three of the seven message types 

were efficacious in terms of reducing adolescents’ intention to smoke: 

“Endangers Family”, “Smokers’ Negative Life Circumstances”, and “Refusal 

Skills Role Model”. These ads were effective for precisely the same reason: 

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Chapter 10 

they enhanced adolescents’ perceptions that smoking poses severe social 

risks, in that it could lead to social rejection and/or social sanctions, whereas nonsmoking could lead to social acceptance and respect. The “Disease 

and Death” and “Selling Disease and Death” messages made the physical 

risks of smoking seem more severe, but had no impact on intentions, presumably because youths perceived themselves to be invulnerable to the 

long-term physical risks. The “Selling Disease and Death” and “Marketing 

Tactics” messages increased youths’ knowledge of marking tactics, but, 

again, there was no impact on intentions. Finally, the “Cosmetics” messages 

were the least effective of all; they produced no statistically significant 

effects. 

CONCLUSION There is evidence that antismoking advertising can help to deter 

adolescents from smoking cigarettes. But, to date, all of the evidence is indirect. Also, research seems to suggest that certain types of advertising messages work better than others, but additional studies must be conducted 

before any definitive conclusions can be drawn. Since the funding that is 

available for tobacco use prevention is unprecedented, a portion of that 

money should be allocated to research on program development and evaluation, with a particular emphasis on advertising. Controlled experimental 

studies, including advertising copytests, should be an integral part of the 

research so that statistical analyses can be conducted and scientifically valid 

conclusions can be drawn. Proper research is essential for ensuring program 

success and for documenting that success. 

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Frey, D. Recent research on selective exposure to 

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Teenage Research Unlimited. Youth focus groups to Worden, J., Flynn, B., Geller, B., Chen, M., Shelton, 

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181

Has Youth Access to Tobacco Changed 

over the Past Decade? 

Joseph R. DiFranza 

In this chapter, the relationship between the availability of tobacco and 

the prevalence of adolescent tobacco use will be addressed. This chapter 

will discuss, in turn, how youths obtain tobacco, how the availability of 

tobacco is measured, the evidence concerning an impact of reduced availability on tobacco use rates, and national trends in the availability of tobacco. 

SOURCES OF TOBACCO Youths obtain tobacco from a variety of sources. 

Noncommercial sources of tobacco include friends, siblings, parents, relatives, and even baby sitters (DiFranza et al., 1994). Youths most commonly 

obtain their first cigarettes from friends or siblings, although it is not 

uncommon for youths to steal their first cigarettes from parents (DiFranza 

et al., 1994). After the first cigarette, those who continue to smoke will typically rely upon same-aged friends as their first steady source (Stanwick et al., 

1987). Sharing cigarettes among friends is very common. In one study, 99 

percent of young smokers reported having, at some time, obtained tobacco 

from friends (DiFranza et al., 1994). The youths who are most likely to supply tobacco to their friends are those who are getting it from a commercial 

source (Wolfson et al., 1997). In one survey, youths who obtained their 

most recent cigarettes from a commercial source were 73 percent more likely to provide tobacco to another adolescent (Wolfson et al., 1997). 

However, generosity does have its limits. With increasing levels of cigarette consumption, young smokers will be expected to pay for their own 

tobacco (DiFranza et al., 1994). A developing dependence on nicotine with 

the accompanying need for a reliable source is another factor that encourages youths to begin to purchase their own tobacco (DiFranza et al., 1994). 

Many youths begin to purchase tobacco soon after starting to smoke 

(DiFranza et al., 1994; Forster et al., 1997). Within ten weeks of the first cigarette, half of the young smokers in one survey had purchased their own 

tobacco (DiFranza et al., 1994). 

Youths may have several options for purchasing tobacco. They may do 

so directly from a commercial source, such as a store or vending machine, 

or they may give money to a peer or someone who is older to buy the 

tobacco for them (DiFranza et al., 1994; Forster et al., 1989). In one survey, 

66 percent of young smokers reported having asked someone older to buy 

them tobacco at least once (DiFranza et al., 1994). In communities where 

tobacco is easier to purchase, youths start to purchase their own tobacco 

sooner after starting to smoke (Forster et al., 1997). Youths who are older 

and those who smoke more regularly are also more likely to purchase their 

own tobacco (Stanwick et al., 1987; Forster et al., 1997; Wolfson et al., 1997; 

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Smoking and Tobacco Control Monograph No. 14 

Leopardi et al., 1989). These youths then become sources for their friends. 

In addition, shoplifting is a common practice and is relied upon most heavily by younger smokers and boys (Forster et al., 1997; Wildey et al., 1995; 

CDC, 1996). Self-service displays in stores greatly facilitate shoplifting and 

are a common promotional strategy used by tobacco companies (Wildey et 

al., 1995; Caldwell et al., 1996). 

The proportion of youths who buy their own tobacco probably varies 

from community to community, depending in part upon how difficult it is 

for underage youths to purchase tobacco. The 1995 Youth Risk Behavior 

Survey inquired of youths under age 18 as to their usual source of tobacco 

(CDC, 1996). For 40.9 percent of the youths, the usual source was a direct 

purchase from a commercial source, 32.9 percent borrowed from others, 

and 15.8 percent gave money to someone else to buy for them (CDC, 

1996). Illegal sales are a primary source of cigarettes for underage smokers, 

either through direct purchase or through borrowing from friends who 

bought them. These facts underlie the supply side approach to tobacco use 

prevention. In theory, if the illegal sale of tobacco from retailers to youths 

could be stopped, the availability of tobacco to youths might be seriously 

diminished and fewer youths would use tobacco. Skeptics argue that other 

sources would be developed to replace commercial sources, thus negating 

the impact of the intervention. Also, restricting the sale of tobacco to 

minors might increase the temptation to smoke by painting tobacco as a 

forbidden fruit. 

MEASURES In 1987, the compliance test was introduced as a research tool for 

OF TOBACCO measuring the availability of tobacco to minors from commercial 

AVAILABILITY sources (DiFranza et al., 1987). In the compliance test, an underage youth attempts to purchase tobacco from a commercial outlet in order 

to measure its compliance with tobacco sales laws. Since its introduction, 

the compliance test has been used extensively as an evaluation tool in studies concerning both tobacco and alcohol. It is also federally mandated as 

the official method by which state compliance with federal regulations is 

measured (DiFranza et al., 1992; Jason et al., 1991; Hinds, 1992; Forster et 

al., 1998; Rigotti et al., 1997; Center for Substance Abuse Prevention, 1996; 

Williams et al., 1994; U.S. DHHS, 1997). Compliance tests are now performed in every U.S. state and territory, Canada, Britain, and Australia (U.S. 

DHHS, 1998; Radecki and Zdunich, 1993; Andrews et al., 1994; Bagott et al., 

1997). However, despite its widespread adoption, the validity of the compliance test as a measure of retailer compliance or as a measure of the availability of tobacco has yet to be established. 

The author has concerns that the methods used to conduct compliance 

tests are too artificial to accurately represent the interaction between the 

store clerk and the underage customer. Compliance test protocols employed 

for enforcement and evaluation purposes have always placed constraints on 

the behavior of the underage shopper (Riggoti et al., 1997). Typical protocols prohibit the participation of youths who appear older than average; the 

use of measures, such as makeup or jewelry, to present a mature appearance; the misrepresentation of age; presentation of true or false proof of 

age; or the use of any story, plea, or conversation intended to persuade the 

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Chapter 11 

clerk. Some protocols prohibit the youth from completing the purchase 

(Cummings et al., 1996). When the compliance test was first introduced, 

merchants had no reasonable concern about being penalized for making 

illegal sales (DiFranza et al., 1987; Kirn, 1987). In areas where the law is 

enforced through the use of underage decoys, merchants may be more careful about who they will sell to. Compliance tests conducted with unfamiliar, inexperienced, non-smoking youths adhering to an artificial protocol 

may raise the suspicion of leery merchants. Compliance tests conducted 

under these circumstances may seriously overestimate actual merchant 

compliance. Unfortunately, the validity of the compliance test has never 

been assessed by comparing compliance rates obtained by underage smokers behaving naturally and those obtained by non-smokers following a protocol. 

In addition to the behavior of the youth used for compliance testing, 

several other factors can introduce bias into the measurement of compliance. For example, many studies have demonstrated that girls are more 

often sold tobacco than are boys and that older youths are more successful 

than younger youths (CDC, 1996; DiFranza et al., 1996; Forster and 

Wolfson, 1998). Tests conducted with young boys can be expected to yield 

much higher compliance rates compared to tests conducted with older girls 

(DiFranza et al., 1996). Since merchant behavior is related to the characteristics of the buyer, it is not consistent over time. In other words, many merchants will refuse some youths, but sell to others. This has important implications for the interpretation of community compliance rates (the proportion of merchants who obey the law during a compliance test). Community 

compliance rates are typically determined by performing a survey in which 

all merchants are tested once (a census) or in which a random sample of 

merchants is tested (Williams et al., 1994). In either case, individual merchants are tested only once. For example, in one survey, 33 percent of 

attempted purchases resulted in illegal sales (DiFranza et al., 1996). From 

this, it might be deduced that 33 percent of merchants break the law. In 

fact, the actual proportion of law breakers was twice as high—this survey 

included six attempts to purchase tobacco from each merchant and, over 

the course of six attempts, 72 percent of merchants broke the law (DiFranza 

et al., 1996). Community compliance rates based on single measurements of 

merchant compliance do not accurately reflect the proportion of merchants 

who are obeying the law. 

Perhaps the greatest concern over the interpretation of compliance tests 

is that they cannot mimic how youths select the outlets from which to 

make their purchase attempts. Although there are no relevant published 

studies, common sense would suggest that youths do not attempt to obtain 

tobacco by conducting either a census or a random sample of merchants. It 

is more likely that youths ask their friends where they buy their cigarettes. 

Common sense would also suggest that youths would continue to patronize 

outlets where they have already been successful rather than try a new store 

every time they want to make a purchase. From the merchants’ standpoint, 

it would be much safer to sell a pack of cigarettes to a particular youth if 

the first sale to that same youth did not result in legal action. Thus, youths 

185 
Smoking and Tobacco Control Monograph No. 14 

who live in the community—and are known to the merchants—may have a 

much higher success rate at purchasing tobacco than would be suggested by 

the community compliance rate. 

In theory, it takes only one merchant in a community to supply a high 

school with cigarettes. Law enforcement and merchant education interventions are intended to shut off the supply of tobacco to youths by convincing all merchants to obey the law. For the many reasons outlined above, 

compliance tests may underestimate how frequently young smokers are 

refused a sale. Thus, compliance tests may seriously overestimate the impact 

of interventions on merchant behavior. 

Another approach to assess the availability of tobacco is by surveying 

youths (DiFranza et al., 1994; Stanwick et al., 1987; Cummings et al., 1992; 

Cismoski and Sheridan, 1994). Approaches that have been employed 

include asking youths how hard it is to purchase tobacco, whether they 

have ever purchased tobacco, how often they try to buy, and how often 

they are turned down (Forster et al., 1998; Rigotti et al., 1997; Johnston et 

al., 1998). Two studies have obtained self-reports of tobacco availability and 

measured community compliance rates at the same time (Forster et al., 

1998; Rigotti et al., 1997). In both studies, youths reported much greater 

ease at purchasing tobacco than would be suggested by the community 

compliance rate. In the first study, compliance rates averaged 82 percent 

across three communities, but the vast majority of young smokers in those 

communities reported never, or hardly ever, being refused a sale (Rigotti et 

al., 1997). In the second study, with a measured community compliance 

rate of 97 percent, 77 percent of youths perceived a high availability of 

tobacco from commercial sources and 19.5 percent of male smokers still 

reported that their most recent cigarette came from a commercial source 

(Forster et al., 1998). Whether community compliance rates or self-reports 

are the more accurate measure of availability is unknown since self-reported 

availability has not been validated. However, these self-reports raise further 

concern that community compliance rates seriously overestimate how hard 

it is for youths to buy tobacco from stores. If this were true, it would be reasonable to hypothesize that actual and measured community compliance 

rates would have to be very high in order to reduce the availability of 

tobacco to minors. 

EVIDENCE THAT Given the extent of the effort to reduce youth access to tobacAVAILABILITY co, there have been relatively few studies of the impact of such 

AFFECTS USE efforts on tobacco use rates (DiFranza et al., 1992; Hinds, 1992; 

Forster et al., 1998; Rigotti et al., 1997; Jason et al., 1991, 1999a & 1999b). 

In the first study to assess the effects of an enforcement intervention, Jason 

was able to demonstrate a 69-percent reduction in youth tobacco use rates 

in Woodridge, IL (Jason et al., 1991). This effect has persisted for 8 years, 

despite a dramatic increase in the prevalence of smoking in the rest of the 

nation (Johnston et al., 1998). Although the initial study consisted of before 

and after assessments, there were no control communities included. The 

investigators were able to expand this study into a controlled experiment 

with the inclusion of another intervention community and control com186

Chapter 11 

munities (Jason et al., 1999b). The prevalence of tobacco use among youths 

was nearly 50 percent lower in communities that had instituted enforcement against the merchants (Jason et al., 1999b). Community compliance 

rates between 90 percent and 100 percent were documented in Woodridge 

(Jason et al., 1991). 

This report was followed by another single-community study conducted 

in Leominster, Massachusetts, in which compliance rates over 90 percent 

were also associated with a significant drop in underage smoking rates 

(DiFranza et al., 1992). This study also lacked a control condition. A third 

study reported a 22-percent drop in smoking prevalence in a community in 

the state of Washington after the enactment and enforcement of a ban on 

tobacco sales to minors (Hinds, 1992). Compliance rates were not measured 

in this study and a control group was not included. A well-controlled, 

multi-community trial in Minnesota reported a 28-percent reduction in 

tobacco use in communities with compliance rates of 97 percent compared 

to communities with compliance rates of 91 percent (Forster et al., 1998). 

Reductions in smoking among younger, but not older, adolescents were 

reported in a four-community controlled trial in rural California, where 

compliance rates reached 100 percent (Altman et al., 1999). 

A sixth study, also a well-controlled, multi-community trial, failed to 

demonstrate any impact of an enforcement program on tobacco use (Rigotti 

et al., 1997). This last study has been widely misinterpreted to show that 

vigorous enforcement has no impact. The investigators actually report that 

enforcement did not occur as planned. This study was designed to evaluate 

the impact of the 90-percent community compliance rates seen in the successful interventions (Rigotti et al., 1997). Political considerations resulted 

in a scaling back of enforcement efforts in all intervention communities 

and, as a result, community compliance rates peaked at 82 percent. With 82 

percent compliance rates, the vast majority of young smokers reported 

never, or hardly ever, being refused a sale (Rigotti et al., 1997). The proportion of young smokers who purchased their own tobacco decreased very little in the intervention communities. The authors conclude that, rather 

than demonstrating the futility of enforcement efforts, the study indicates 

that 82-percent compliance rates are inadequate to impact on the ability of 

youths to purchase tobacco (Rigotti et al., 1997). 

Existing literature is consistent with the conclusion that curtailing illegal tobacco sales to minors can reduce tobacco use rates, but very high 

compliance rates are probably necessary in order to see any effect since 

compliance rates seriously underestimate the commercial availability of 

tobacco to minors. In each of the successful intervention studies in which 

compliance rates were measured, the rates were all above 90 percent. It is 

important to note that no enforcement intervention has resulted in 

increased tobacco use either by inadvertently portraying tobacco use as a 

forbidden fruit or through any other mechanism. 

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Smoking and Tobacco Control Monograph No. 14 

TRENDS IN THE In 1987, it was demonstrated that illegal sales were made to 

AVAILABILITY OF an 11-year-old girl in 75 out of 100 attempts to purchase 

TOBACCO TO tobacco (DiFranza et al., 1987). At that time, only 38 states 

MINORS had laws concerning the sale of tobacco to children, but 

enforcement was almost unheard of (DiFranza et al., 1987; Kirn, 1987; U.S. 

DHHS, 1990). Several years later, not much had changed. In a survey of 93 

U.S. communities in 1991–1992, 77 percent of merchants made illegal 

tobacco sales (Radecki and Zdunich, 1993). 

To provide a picture of the magnitude of the problem, it was estimated 

that underage smokers consumed 924 million packs of cigarettes in 1998. 

These cigarettes were worth $1.86 billion at retail and generated $222 million of federal tax revenues and $293 million of state tax revenues (U.S. 

DHHS, 1990). Given the financial incentives of tobacco sales, it might not 

be too surprising that merchant education programs to discourage illegal 

sales have produced disappointing results (DiFranza and Brown, 1992; 

DiFranza and Librett, 1999; DiFranza et al., 1996). Sustained success in 

reducing the availability of tobacco to minors has been achieved only 

through tough enforcement, typically through the frequent inspection of 

all retail outlets with underage decoys followed by penalties and re-inspection (Jason et al., 1991; DiFranza et al., 1992, 1998). 

To encourage state level enforcement, Congress in 1992 enacted Public 

Health Service Act 398, which stipulates that states are entitled to block 

grants from the Substance Abuse and Mental Health Services 

Administration (SAMHSA). The grants are given contingent upon states 

enacting and enforcing a prohibition on the sale of tobacco to minors 

(State law regarding sale of tobacco products to individuals under age of 18. 

106 STAT. 394, Public Law 102-321, July 10, 1992, Sec 1926. 42 USC 300x26). States are required to conduct annual random surveys that measure 

statewide compliance to document the effectiveness of their enforcement 

efforts (U.S. DHHS, 1997). The limitations of this type of sampling have 

been discussed above. A recent review was conducted of the Federal Fiscal 

Year 1996 activities in 50 states, the District of Columbia, and 8 territories 

(DiFranza, 1999). Eighteen of these jurisdictions failed to provide a single 

example of a merchant being penalized for making an illegal sale during 

the previous fiscal year. Forty-seven states, eight territories, and the District 

of Columbia all reported compliance rates below the 82-percent rate that 

proved to be ineffective at significantly reducing the availability of tobacco 

or its use (Rigotti et al., 1997; U.S. DHHS, 1998). Only three states reported 

compliance rates above 82 percent, and only one state—Florida—reported a 

compliance rate above 90 percent (U.S. DHHS, 1998). Thus, even though 

there are isolated communities where compliance rates are above 90 percent, only one state as of 1996 had enforced its law at the state level with 

sufficient vigor to achieve a level of compliance that could potentially 

impact on tobacco use rates. 

Given the reported levels of compliance across all states and territories, 

it can be concluded that, with the possible exception of Florida, youth 

access to tobacco has not changed during the recent past. This conclusion is 

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Chapter 11 

supported by longitudinal tracking data from the Monitoring the Future 

study (Johnston et al., 1998). In annual surveys, high school students have 

been asked to judge how easy it would be to obtain tobacco. Although the 

validity of this measure has not been established, 89.1 percent of 10th 

graders in 1992 felt that tobacco would be “fairly easy” or “very easy” to 

obtain and 89.6 percent felt this way in 1997. 

It is interesting to note that, despite long-standing tobacco control programs in California and Massachusetts, these states had not achieved the 

82-percent compliance rate (U.S. DHHS, 1998). While California, 

Massachusetts, and Florida all had anti-tobacco media campaigns, only 

Florida had implemented effective enforcement of tobacco sales laws and 

only Florida has reported an actual reduction in teen smoking rates 

(Connolly and Robbins, 1998; Pierce et al., 1998; CDC, 1999). Surveys conducted by the Florida Department of Health in 1998 and 1999 demonstrated a decline in the proportion of underage smokers who obtained cigarettes 

from a store or friend or by giving someone money to purchase for them. 

This at least suggests that the decreased availability of tobacco to youths in 

Florida may have contributed to the observed decline in tobacco use (CDC, 

1999). Another possible explanation is that this very recent downturn in 

adolescent tobacco use in Florida is part of a national trend. 

CONCLUSION Except in the state of Florida and in scattered communities where 

laws are being vigorously enforced, there is no evidence that there has been 

any meaningful reduction in the availability of tobacco to youths and, 

hence, no impact on youth tobacco use would be expected. 

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191

The Impact of Price on Youth 

Tobacco Use 

Frank J. Chaloupka, Rosalie Liccardo Pacula 

INTRODUCTION Over the past three decades, numerous econometric studies have 

researched the impact of price and tobacco control policies on tobacco use. 

These studies have examined the applicability of a fundamental principle of 

economics—the law of the downward sloping demand curve—to tobacco 

use. This principle states that as the price of a product rises, the quantity 

demanded of that product falls. To economists, price includes not only the 

monetary cost of purchasing a product, but also the time and other costs 

associated with buying that product, as well as the health consequences 

and other costs from using the product. 

The demands for tobacco products, however, differ from those for most 

other products because of the addictive drug they contain—i.e., nicotine. 

For years, the conventional wisdom was that addictive consumption was an 

irrational behavior that did not follow the basic laws of economics, including that of the downward sloping demand curve. However, a variety of 

econometric studies conducted over the past several decades clearly indicate 

that cigarette smoking and other tobacco use are not exceptions to the 

principles of economics. Several of the most recent studies apply economic 

models of addiction that explicitly recognize the intertemporal links in the 

consumption of addictive substances (Becker and Murphy, 1988). That is, 

economic models of addiction incorporate the acquired tolerance, reinforcement, and withdrawal effects that distinguish the consumption of addictive 

goods, including tobacco products, from the consumption of nonaddictive 

substances. The key implication of these models is that changes in addictive 

behavior in response to changes in price will not occur quickly, as they 

would for nonaddictive goods, but that the effects of permanent price 

changes will grow gradually over time. 

PRICES AND ADULT Many studies have examined the effects of prices and 

TOBACCO USE tobacco control policies on overall cigarette demand and 

other tobacco use using diverse econometric and other statistical methods, 

employing data from the United States and many other countries. Several 

have used aggregate time-series data for a single geographical unit, while 

others have employed pooled cross-sectional time-series data; still others 

have used individual-level data taken from surveys. Most of these studies 

ignored the addictive aspects of tobacco use, although several recent studies 

have theoretically and empirically modeled addiction. Several clear conclusions emerge from this large, increasingly sophisticated, and rapidly 

expanding literature. 

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Smoking and Tobacco Control Monograph No. 14 

Permanent, inflation-adjusted increases in cigarette prices, which could 

be achieved by increasing cigarette taxes, will lead to significant reductions 

in cigarette smoking rates. Economists use the term “price elasticity of 

demand” to describe the impact of a change in price on consumption, 

defining it as the percentage change in consumption that results from a 1 

percent increase in price. Price elasticity estimates from recent studies of 

cigarette demand fall in a relatively wide range, but most are in the narrow 

range from –0.3 to –0.5. These estimates imply that a 10 percent increase in 

price reduces cigarette demand among adults by approximately 3 to 5 percent. Similar findings are obtained for other tobacco products, although 

there are fewer studies for these products (Chaloupka and Warner, 2000). 

The smoking reductions resulting from increased cigarette prices are not 

limited to reductions in the number of cigarettes smoked, but also include 

significant reductions in smoking prevalence. Several recent estimates based 

on individual level data from large, nationally representative surveys imply 

that a permanent, real 10-percent increase in price reduces smoking prevalence by 1 to 2 percent. For example, the Centers for Disease Control and 

Prevention (CDC, 1998) estimated that the price elasticity of smoking 

prevalence in the United States was –0.15, based on 13 of the National 

Health Interview Surveys (NHIS) conducted from 1976 through 1993. The 

changes in prevalence estimated using cross-sectional survey data are 

assumed to reflect reduced smoking initiation among youths and increased 

smoking cessation and reduced relapse among adults. Few studies have 

directly addressed these issues, however, given the lack of appropriate longitudinal data. However, by using retrospective data on smoking initiation 

from the NHIS, Douglas (1998) concluded that a 10-percent increase in 

price would reduce the duration of smoking by approximately 10 percent. 

In the context of the economic models of addiction, cigarette smoking 

is clearly an addictive behavior in that current cigarette demand depends 

on past smoking. The most important policy implication of this is that the 

long-run impact of a permanent price increase or change in tobacco control 

policy will grow over time. Estimates imply that the long-run effect of a 

permanent price increase is approximately double the short-run impact 

(Chaloupka, 1991; Becker et al., 1994). Thus, a 10-percent increase in cigarette price is expected to reduce cigarette smoking by approximately 8 percent in the long run. 

PRICES AND Economic theory suggests that the price sensitivity of cigarette 

YOUTH/YOUNG demand will be inversely related to age for several reasons. 

ADULT SMOKING First, the share of young smokers’ disposable incomes spent on 

cigarettes is likely to be larger than that of adult smokers. Economic theory 

implies that the price sensitivity of demand will be greater the greater the 

share of income spent on a good, assuming that there is a positive impact 

of income on demand. Recent studies of youth smoking with good measures of youths’ disposable income (Chaloupka and Grossman, 1996) provide clear evidence that youths with greater disposable income smoke more 

than those with fewer resources. 

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Chapter 12 

Second, peer influence is more important to youths than to adults. This 

has a positive multiplying effect for cigarette price increases—in addition to 

reducing a given youth’s smoking directly, his or her smoking is reduced 

indirectly as peers reduce their smoking. In addition, because they have 

been smoking for a shorter time, youths are likely to be less addicted than 

adults and, consequently, youths’ smoking decisions will be more immediately responsive to price. 

Finally, youths are generally assumed to behave more myopically than 

adults. This implies that many of the future consequences of smoking will 

be more heavily discounted by youths than by adults, while the more 

immediate costs, particularly the monetary price, will be relatively more 

important. 

The hypothesis that cigarette smoking by younger persons will be relatively more responsive to price than smoking among older persons is confirmed by several recent studies of cigarette demand based on cross-sectional surveys of youths and young adults. Recent estimates indicate that 

youths are up to three times more sensitive to price than adults, with a 10-

percent price increase estimated to reduce youth smoking prevalence by 5 

percent or more and also to reduce cigarette consumption among continuing young smokers (Chaloupka and Grossman, 1996; Evans and Huang, 

1998; Lewit et al., 1997). These empirical findings are consistent with the 

findings from recent qualitative research on youth smoking conducted by 

the CDC’s network of prevention research centers (Balch, personal communication) as well as with the sharp increases in youth smoking prevalence 

observed after the prices of branded cigarettes were sharply reduced in 

April, 1993. 

There appear to be important differences in price sensitivity among 

population subgroups. A recent study by Chaloupka and Pacula (1998a) 

concluded that young Blacks and young men are relatively more responsive 

to changes in price than are young Whites and young women, a finding 

consistent with the CDC’s (1998) evidence on price responsiveness among 

adult population subgroups. 

Similarly, several recent econometric studies based on cross-sectional 

data conclude that young adults are somewhat less responsive to price than 

youths, but more responsive than older adults. For example, the CDC 

found that persons ages 18 through 24 years were about 40 percent more 

responsive to price than those 25 through 39 years and almost six times 

more responsive than older adults (CDC, 1998). Similarly, Chaloupka and 

Wechsler (1997) found that college students were significantly more responsive to price than older persons. 

Tauras and Chaloupka (1999a), using longitudinal data on young adult 

smoking from the Monitoring the Future surveys, provide additional evidence that young adults are more responsive to price than adults, but less 

responsive than youths, estimating an average overall price elasticity of 

–0.79. Also, as expected, in the context of an economic model of addictive 

behavior, they find that the long-run impact of a sustained price increase is 

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Smoking and Tobacco Control Monograph No. 14 

larger than the short-run effect (Chaloupka et al., 1999b). Finally, they find 

strong evidence that increases in cigarette prices significantly raise the probability of smoking cessation among young adults, estimating that a sustained inflation-adjusted price increase of 10 percent increases the probability of cessation among young adult male and female smokers by 11 and 12 

percent, respectively (Tauras and Chaloupka, 1999b). 

Other tobacco control policies that raise the “costs” of smoking and 

other tobacco use lead to significant reductions in overall cigarette demand 

and smoking prevalence, particularly increased information on the health 

consequences of tobacco use, strong restrictions on cigarette smoking in 

public places and private workplaces, and counter-advertising campaigns 

(Chaloupka and Warner, 2000). Chaloupka and Grossman (1996), for example, concluded that strong restrictions on smoking reduced both the prevalence of youth smoking and cigarette consumption among young smokers. 

In contrast, they found little evidence that laws limiting youth access to 

tobacco reduced youth smoking, a finding they attributed to the relatively 

poor enforcement of these laws. Chaloupka and Pacula (1998b) examined 

the impact of enforcement directly, concluding that policies limiting youth 

access to tobacco that were comprehensive, aggressively enforced, and 

resulted in higher retailer compliance could produce relatively modest 

reductions in the prevalence of youth smoking. 

DISCUSSION While much is known from economic research about the impact of 

price on cigarette demand, there is much more to learn. Advances in econometric methods, more and better data, and increased interdisciplinary 

research can help to address many of these issues. 

The econometric evidence on the impact of price on cigarette smoking 

and other tobacco use is based on the relatively small changes in price that 

occur cross-sectionally and over time. Little is known, however, about the 

impact of relatively large price increases on cigarette demand, particularly 

among youths. The relatively new field of behavioral economics provides 

some evidence on this issue, suggesting that the price elasticity of demand 

rises as price rises (Bickel and Madden, 1998). This issue is currently being 

researched using more recent U.S. data that include several large state cigarette tax increases. 

In addition, relatively little is known about the impact of large price 

increases on the growth of a black market in tobacco products and its subsequent impact on demand, particularly among youths. To the extent that 

organized and casual smuggling of tobacco products would result from large 

tax and price increases, the effects of the increases on tobacco use might be 

smaller than otherwise expected. The limited research in this area, however, 

suggests that the presence of a black market in tobacco products may be 

just as, or more, related to other factors—including the presence of informal distribution networks, nonexistent or weak policies concerning black 

market sales, and their lack of enforcement—as it is to prices (Joossens and 

Raw, 1995). Clearly, this issue needs to be explored more carefully. 

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More information is needed about the compensating behavior of smokers in response to price and policy changes that may offset some of the 

health benefits expected to result from the changes. The one study in this 

area suggests that some smokers respond to price increases by switching to 

longer and/or higher tar and nicotine cigarettes (Evans and Farrelly, 1998), 

with the largest effects found among the youngest smokers, thus offsetting 

some of the potential health benefits resulting from the reductions in 

smoking prevalence produced by a tax increase. Cummings and his colleagues (1997a) provided some related evidence based on data from the 

National Cancer Institute’s Community Intervention Trial for Smoking 

Cessation that show that the use of generic cigarettes (typically higher in 

tar and nicotine) is higher in areas where average cigarette prices are higher, 

particularly among lower-income and heavier smokers. 

Similarly, little is known about the potential for substitution between 

tobacco products and other licit and illicit addictive substances in response 

to higher cigarette prices and stronger tobacco control policies. In the 

recent debate over proposed national tobacco legislation, for example, some 

opponents of large tax increases argued that these would lead more youths 

to take up marijuana use even if they succeeded in reducing youth smoking. The very limited evidence on this issue, however, suggests that increases in cigarette prices will reduce not only cigarette smoking, but can also 

reduce alcohol and marijuana use among youths and young adults (Pacula, 

1998; Chaloupka et al., 1999a). Much more research is needed, however, to 

clarify these relationships. 

Similarly, more research is needed to elucidate the impact of prices and 

tobacco control policies on the pathways and trajectories of smoking. This 

is particularly true with respect to the process from first use, through experimentation, and eventually to addiction, as well as with the processes 

around cessation and re-initiation. One recent study by a group of economists at Cornell University (DeCicca et al., 1998) attempted to directly 

address the issue of the impact of price on smoking initiation using data 

from the National Education Longitudinal Survey of 1988 (U.S. Department 

of Education, 1988). The survey results concluded that higher cigarette 

taxes had little impact on the initiation of daily smoking between 8th and 

12th grade. A similar analysis, using the same data but treating respondents 

with missing data differently, produced estimates of the price elasticity of 

smoking initiation comparable to the prevalence elasticities obtained from 

cross-sectional survey data described above (Dee and Evans, 1998). 

Comparable analyses examining this and other aspects of the uptake and 

cessation processes that employ better longitudinal data are needed to adequately address these issues. 

Information about the effects of the pricing, availability, and marketing 

of nicotine replacement products on both the demand for these products 

and on cigarette smoking and other tobacco use is needed. Until very 

recently, the tobacco industry held a virtual monopoly on the distribution 

of products containing nicotine. Economic theory suggests that the 

increased availability of nicotine replacement products should both reduce 

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Smoking and Tobacco Control Monograph No. 14 

the demand for tobacco products as well as increase the price sensitivity of 

demand, potentially making tax increases an even more effective tobacco 

control policy. Some have argued, however, that the increased availability 

of these products and the marketing that accompanies them may affect 

youths’ perceptions of the long-term consequences of tobacco use by creating the illusion that it is relatively easy to quit. If true, this reduction in the 

perceived “cost” of smoking may have contributed to the increases in youth 

smoking prevalence observed over the past decade as nicotine replacement 

products (NRP) became more widely available and heavily marketed. The 

very limited empirical information on the determinants of the use of nicotine replacement products suggests that economic influences, including 

income and price, may be particularly important (Cummings et al., 1997b). 

More information is needed on the determinants of the demand for these 

alternative products and the impact of their availability on the demand for 

tobacco products, particularly among youths. This is relevant both to the 

long-term use and to the potential for abuse of these products. Long-term 

use could be considered part of a broader market for nicotine delivery products that includes cigarettes. 

While much is known about the independent effects of price and tobacco control policies, more research is needed on the interaction between 

these interventions. There may be important, unrealized synergies between 

policies that could be used to enhance the effectiveness of tobacco control 

programs. For example, there is clear evidence that the earmarking of revenues from cigarette tax increases for anti-tobacco media campaigns and 

other efforts to reduce tobacco use have been very successful in California 

and Massachusetts (Hu et al., 1995; CDC, 1996). In contrast, less is known 

about the interaction of a variety of other macro-level approaches to tobacco control. 

CONCLUSIONS While there is still much to be learned, the existing research clearly 

indicates that macro-level interventions, including increased tobacco taxation and stronger tobacco control policies, can be very effective in reducing 

cigarette smoking and other tobacco use, particularly among youths and 

young adults. Moreover, because of its addictive nature, the long-run reductions in tobacco use resulting from sustained macro-level interventions will 

be even larger than those realized immediately. 

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Economic Review 84(3):396-418, 1994. 

Becker, G.S., Murphy, K.M. A theory of rational 

addiction. Journal of Political Economy 96(4):675-

700, 1988. 

Bickel, W.K., Madden, G.J. The Behavioral Economics 

of Smoking. National Bureau of Economic 

Research Working Paper No. W6444, 1998. 

Centers for Disease Control and Prevention. 

Cigarette smoking before and after an excise tax 

increase and an antismoking campaign— 

Massachusetts, 1990–1996. Morbidity and 

Mortality Weekly Report 45(44):966-970, 1996. 

Centers for Disease Control and Prevention. 

Response to increases in cigarette prices by 

race/ethnicity, income, and age groups—United 

States, 1976–1993. Morbidity and Mortality Weekly 

Report 47(29):605-609, 1998. 

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Chaloupka, F.J. Rational addictive behavior and cigarette smoking. Journal of Political Economy 

99(4):722-42, 1991. 

Chaloupka, F.J., Grossman, M. Price, Tobacco Control 

Policies and Youth Smoking. National Bureau of 

Economic Research Working Paper No. W5740, 

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Chaloupka, F.J., Pacula, R.L. An Examination of 

Gender and Race Differences in Youth Smoking 

Responsiveness to Price and Tobacco Control Policies. 

National Bureau of Economic Research Working 

Paper No. W6541, 1998a. 

Chaloupka, F.J., Pacula, R.L. Limiting Youth Access to 

Tobacco: The Early Impact of the Synar Amendment 

on Youth Smoking. Working Paper, Department of 

Economics, University of Illinois at Chicago, 

1998b. 

Chaloupka, F.J., Pacula, R.L., Farrelly, M.C., 

Johnston, L.D., O'Malley, P.M., Bray, J.W. Do 

Higher Cigarette Prices Encourage Youth to Use 

Marijuana? National Bureau of Economic 

Research Working Paper No. W6939, 1999a. 

Chaloupka, F.J., Tauras, J.A., Grossman, M. Cigarette 

Smoking and Addiction: Economic Models and New 

Empirical Evidence. Manuscript presented at the 

International Workshop on Nicotine 

Dependence, Lausanne, Switzerland, 1999b. 

Chaloupka, F., Wechsler, H. Price, tobacco control 

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Chaloupka, F.J., Warner, K.E. The economics of 

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The Handbook of Health Economics. New York: 

North-Holland, 1999/2000-forthcoming. 

Cummings, K., Hyland, A., Lewit, E., Shopland, D. 

Use of discount cigarettes by smokers in 20 communities in the United States, 1988–1993. 

Tobacco Control 6(S2):25-30, 1997a. 

Cummings, K., Hyland, A., Ockene, J., Hymowitz, 

N., Manley, M. Use of the nicotine skin patch by 

smokers in 20 communities in the United States, 

1992–1993. Tobacco Control 6(S2):63-70, 1997b. 

DeCicca, P., Kenkel, D., Mathios, A. Putting Out the 

Fires: Will Higher Cigarette Taxes Reduce Youth 

Smoking? Working Paper, Department of Policy 

Analysis & Management, Cornell University, 

1998. 

Dee, T.S., Evans, W.N. A Comment on DeCicca, Kenkel, 

and Mathios. Working Paper. School of 

Economics, Georgia Institute of Technology, 

1998. 

Douglas S. The duration of the smoking habit. 

Economic Inquiry 36(1):49-64, 1998. 

Evans, W.N., Farrelly, M.C. The compensating behavior of smokers: taxes, tar and nicotine. RAND 

Journal of Economics 29(3):578-595, 1998. 

Evans, W.N., Huang, L.X. Cigarette Taxes and Teen 

Smoking: New Evidence from Panels of Repeated 

Cross-Sections. Working Paper, Department of 

Economics, University of Maryland, 1998. 

Hu, T.W., Sung, H.Y., Keeler, T.E. Reducing cigarette 

consumption in California: tobacco taxes vs an 

anti-smoking media campaign. American Journal 

of Public Health 85(9):1218-22, 1995. 

Joossens, L., Raw, M. Smuggling and cross border 

shopping of tobacco in Europe. British Medical 

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Lewit, E., Hyland, A., Kerrebrock, N., Cummings, K. 

Price, public policy and smoking in young people. Tobacco Control 6(S2):17-24, 1997. 

Pacula, R.L. Adolescent Alcohol and Marijuana 

Consumption: Is There Really a Gateway Effect? 

National Bureau of Economic Research Working 

Paper No. W6348, 1998. 

Tauras, J.A., Chaloupka, F.J. Price, Clean Indoor Air, 

and Cigarette Smoking: Evidence from Longitudinal 

Data for Young Adults. National Bureau of 

Economic Research Working Paper No. W6937, 

1999a. 

Tauras, J.A., Chaloupka, F.J. Determinants of Smoking 

Cessation: An Analysis of Young Adult Men and 

Women. Manuscript presented at the Taipei 

International Conference on Health Economics, 

Taipei, Taiwan. National Bureau of Economic 

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U.S. Department of Education. The National 

Longitudinal Study of 1988. Washington, D.C.: 

U.S. Government Printing Office, 1988. 

199

The Role of Tobacco Advertising and 

Promotion in Smoking Initiation 

Lois Biener, Michael B. Siegel 

INTRODUCTION Tobacco industry spokespersons claim that the intent of tobacco 

advertising and promotion is to increase a brand’s market share among current smokers, and not to recruit new smokers. They claim most adamantly 

that their marketing activities are not directed toward the youth market 

(Bynum, 1998). The public health community has been equally adamant in 

insisting that 

1) tobacco companies purposely market to youths because they know 

that few people initiate smoking in adulthood, and 

2) the tobacco industry’s advertising and marketing strategies are 

indeed quite effective and are responsible for increasing the rate at 

which young people start smoking (Lynch and Bonnie, 1994; 

Giglio, 1996). 

This chapter reviews the research that has been brought to bear on the 

issue of tobacco advertising as it impacts smoking initiation among adolescents. It also presents findings from recent research on youths in 

Massachusetts. 

TOBACCO MARKETING Causation can never be proven beyond question. The 

AND YOUTH SMOKING: strongest evidence for causality comes from controlled 

EVIDENCE FOR A experiments in which individuals are randomly 

CAUSAL RELATIONSHIP assigned either to a group that will receive exposure to 

the causal agent—in this case, cigarette advertising—or to one or more control groups that are not exposed to the causal agent, but are identical to the 

exposure group in every other way. This kind of study is obviously impossible to arrange in the case of cigarette advertising and also for most other 

potentially harmful exposures of interest to public health professionals. 

However, even the randomized controlled trial, the sine qua non of scientific 

causal evidence, can allow for alternative explanations, and whole books 

have been written to enumerate the variety of threats to validity that can 

compromise interpretation of such trials (Campbell and Stanley, 1966; 

Kerlinger, 1985). The best that one can do is attempt to build a body of evidence that supports a causal inference. 

Three types of evidence must be brought to bear in support of a causal 

inference. At a minimum, evidence of causality must include correlation. In 

the case of advertising, correlational evidence would demonstrate, for 

example, that increases in advertising expenditures are associated with 

increases in smoking among youths or that, relative to youths with low levels of exposure to cigarette advertising, those with high levels of exposure 

are more likely to be smokers. The second type of evidence needed is that 

201

Smoking and Tobacco Control Monograph No. 14 

which rules out plausible alternative explanations for the correlation. The 

most obvious alternative explanation for the correlational evidence 

described above is that smoking, or the interest in smoking, is what causes 

the advertising exposure or is what stimulates the advertising expenditures. 

The most common sort of evidence to rule out this interpretation is that 

which demonstrates the temporal ordering of exposure to tobacco advertising on the one hand and indicators of smoking on the other—evidence 

that can be provided by longitudinal studies. The third type of evidence 

needed to support a causal inference is evidence relevant to a mechanism 

by which the advertising leads to smoking initiation. 

Correlational Evidence Historical analyses show that variations in advertising 

are associated with concomitant variations in smoking uptake among 

youths (Cummings et al., 1995; Gilpin and Pierce, 1997). Other studies have 

documented a correlation between the intensity of brand-specific cigarette 

advertising and brand awareness, brand preference, or brand market shares 

among youths (Pierce et al., 1991, 1994; Pierce and Gilpin, 1995; Chapman 

and Fitzgerald, 1982; McNeill et al., 1985; Aitken et al., 1987b; Goldstein et 

al., 1987; Aitken and Eadie, 1990; DiFranza et al., 1991; Hastings et al., 

1994; CDC, 1994; Pollay et al., 1996). Some of this evidence has been criticized for choosing controversial measures (should the measures of advertising and of behavior be simultaneous or should the behavior measure be 

lagged?), for showing small effects, or for frequently showing no effects 

(Schudson, 1993; Sullum, 1998). 

A large number of cross-sectional studies have reported associations 

between exposure to tobacco marketing on the one hand and attitudes 

toward smoking, susceptibility to smoking, smoking experimentation, or 

regular smoking among youths on the other (Charlton, 1986; Botvin et al., 

1991; Unger et al., 1995; Evans et al., 1995; Altman et al., 1996; Gilpin et al., 

1997; Feighery et al., 1998; O’Connell et al., 1981; Aitken et al., 1986a & 

1986b, 1987a; Potts et al., 1986; Klitzner et al., 1991; Botvin et al., 1993; 

Gallup International Institute, 1992; Roswell Park Cancer Institute, 1993; 

Slade, 1994; Coeytaux et al., 1995; Schooler et al., 1996; Sargent et al., 1997; 

Richards et al., 1995; Lam et al., 1998). These relationships persist even 

when other factors shown to predict smoking initiation are controlled. The 

1993 Massachusetts Tobacco Survey of youths provides evidence of this sort 

(Biener et al., 1994). The data are from a telephone survey of a representative sample of 1,606 Massachusetts residents, aged 12 to 17 years. The survey measured involvement in cigarette promotional activities by asking 

respondents whether they owned a piece of clothing, a hat or bag, or some 

other item with a cigarette brand logo on it. The survey also asked whether 

they had a catalog from a tobacco company that showed what items could 

be obtained with coupons or proofs of purchase on cigarette packs. 

202

Chapter 13 

Figure 13-1 

Ownership of Promotional Items among 12- to 17-Year-Old Youths—1993 

Massachusetts Tobacco Survey 

50


40


23 

44 

18 

Percentage 

30


20


10


0


Overall Smoker NonSmoker 

Twenty-three percent of the respondents indicated that they owned a 

promotional item. When ownership of promotional items was examined as 

a function of past-month smoking, multiple researchers have found a very 

strong relationship. Forty-four percent of adolescent smokers reported having a promotional item, compared to only 18 percent of non-smokers 

(Figure 13-1). It was also found that, among smokers, the greater their 

involvement with cigarette promotions, the more heavily they smoked 

(Figure 13-2). Those teen smokers who owned neither a catalog nor a promotional item reported smoking about 3 packs of cigarettes per month. 

Those who owned either an item or a catalog, but not both, reported smoking from 2 to 5 packs per month. Those who owned both an item and a 

catalog reported smoking an average of 17 packs of cigarettes per month, or 

approximately one-half pack per day. 

The establishment of positive correlations between involvement with 

marketing activities and adolescent smoking behaviors provides support for 

the contention that tobacco marketing is, to some extent, responsible for 

smoking initiation. If such correlations were the only evidence, however, it 

would be reasonable to argue that the causal arrow might point in the 

opposite direction—that is, becoming a smoker may lead young people to 

pay more attention to tobacco advertisements and promotional schemes. 

Only by establishing the temporal sequencing of the interest in promotions 

and smoking can the argument about reverse causation be addressed. If it 

can be demonstrated that nonsmoking adolescents who show more interest 

in tobacco advertising and promotion subsequently initiate smoking at 

greater rates than those who show less interest, it cannot be argued that the 

203 
Smoking and Tobacco Control Monograph No. 14 

Figure 13-2 

Smoking Intensity by Involvement with Tobacco Promotions—1993 Massachusetts

Tobacco Survey

18


16


14


Packs Per Month 12


10


8


6


N = 253 Past-Month Smokers 

4


2


0


No Item 

or Catalog 

Catalog 

Only 

Item 

Only 

Item and 

Catalog 

smoking came either before or simultaneously with the exposure to advertising. Providing this evidence requires longitudinal studies that make 

observations on the same individuals over time. 

Longitudinal Studies Longitudinal studies are less common than cross-sectional 

ones because they are more difficult and costly to mount. Three known 

studies have been conducted outside of the United States. Two of these 

were Australian studies that demonstrated that nonsmoking youths who 

either approved of cigarette advertising (Alexander et al., 1983) or reported 

that cigarette advertisements made smoking appear attractive to them 

(Armstrong et al., 1990) were significantly more likely to start smoking over 

the next year or two than youths who had more negative responses to cigarette advertising at baseline. The third study found that 11- to 14-year-old 

Scottish youths with higher awareness of, and liking for, cigarette advertisements at baseline were more likely to develop positive intentions to smoke 

after a 1-year follow-up period (Aitken et al., 1991). 

Only one longitudinal study on the effects of advertising on youths has 

been published in the United States. Pierce et al. (1998) found that receptivity to cigarette promotional activities (measured as having a favorite cigarette advertisement, being willing to use a tobacco promotional item, and 

owning a tobacco promotional item) was associated with movement along 

a four-point smoking initiation continuum over a 3-year follow-up period 

among 12- to 17-year-old adolescents in California. About one-third of the 

movement was from being a confirmed nonsmoker to being ambivalent 

about whether one would smoke in the future. Although changes in this 

204 
Chapter 13 

indication of “susceptibility to smoking” have been shown to reliably predict future smoking (Jackson, 1998; Pierce et al., 1995, 1996; Choi et al., 

1997), stronger evidence of advertising impact would link exposure at time 

one with actual smoking behavior at time two. 

A recent longitudinal study of Massachusetts youths has made that connection (Biener and Siegel, 2000). In 1997, this study re-contacted the 

respondents to the Massachusetts Tobacco Survey who were between the 

ages of 12 and 15 in 1993. It was not possible to trace 30.7 percent of this 

group, but interviews were completed with 83 percent of those who could 

be found, for an overall follow-up response rate of 57.8 percent. For this 

research, a subset of the sample was used, specifically those 529 respondents who indicated at baseline that they had smoked no more than one 

cigarette in their lifetime. 

The outcome measure was a dichotomous indicator of whether the 

respondent had become an established smoker, defined as having smoked 

100 or more cigarettes by follow-up. This is the criterion commonly used to 

define “ever-smokers” among adults. 

A three-level indicator of receptivity to marketing was constructed from 

the following two survey questions: 1) “Some tobacco companies make 

clothing, hats, bags, or other things with the brand on it. Do you have a 

piece of clothing or other thing that has a tobacco brand name or logo on 

it?” and 2) “Of all the cigarette advertisements you have seen, which 

brand’s ads do you think attract your attention the most?” 

The highest level of receptivity was assigned to those who reported 

owning a promotional item and who named a cigarette brand in response 

to the second question. Those who either owned an item or named a brand 

were scored as being moderately receptive to marketing. Those who neither 

owned an item nor named a brand were scored at the lowest level of receptivity. To rule out the possibility that some third factor could be responsible 

for causing both receptivity to tobacco marketing and subsequent progression to established smoking, the following baseline variables—shown to 

relate to both receptivity to marketing and becoming an established smoker—were included as covariates: whether the respondent reported having 

any close friends who smoked, whether the household included any adult 

smokers, and the respondent’s score on a six-item scale of rebelliousness. 

Finally, the level of the youth’s involvement with smoking at baseline 

was also controlled. Although the cohort consisted of youths who had 

smoked at most one cigarette in their lifetime, they were differentiated into 

three smoking-status groups based on whether they had ever had a puff of a 

cigarette and on their responses to three items measuring “susceptibility to 

smoking.” Respondents in the lowest risk group (confirmed nonsmokers) 

reported having never had even a puff of a cigarette and displayed a firm 

commitment not to smoke in the future. Respondents in the moderate risk 

group (ambivalent nonsmokers) had never puffed a cigarette, but gave less 

definitively negative responses to questions about the potential for smoking 

in the future. Respondents indicating that they had had a puff or a whole 

cigarette were classified in the highest risk group (early experimenters). 

205 
Smoking and Tobacco Control Monograph No. 14 

Results indicated that 21 percent of the respondents became established 

smokers during the 4-year follow-up period. Progression to established 

smoking was significantly more likely among Whites than among minority 

youths, youths who lived with at least one adult smoker, youths who 

reported that at least one of their close friends was a smoker, those who 

were early experimenters, and those scoring high in rebelliousness. 

The smoking initiation rate among those high in receptivity to tobacco 

marketing (owned an item and named a cigarette brand as attracting their 

attention) was 46 percent, compared to 18 percent among those of moderate receptivity and 14 percent among those of low receptivity (chi square = 

28.9, df = 2, p < 0.0001; Figure 13-3). The results of a multiple logistic 

regression that examined the impact of receptivity while controlling for all 

covariates revealed that adolescents who were highly receptive to marketing 

in 1993 were more than twice as likely to become established smokers by 

1997 compared to those who were low in receptivity (OR = 2.70; 95% CI = 

1.24-5.85). Being an early experimenter, having a close friend who smoked, 

and scoring above the mean on rebelliousness were also significant independent predictors of smoking initiation. 

These findings demonstrate that paying attention to cigarette advertising and becoming involved in tobacco product promotions by obtaining an 

item of clothing, a sports bag, or some other piece of gear with a cigarette 

brand logo on it precedes, and reliably predicts, smoking initiation, even 

when controlling for other factors that have been shown to influence 

smoking uptake. Thus, even though the group of youths who were highly 

receptive to tobacco marketing at baseline were more likely to be rebellious, 

to have experimented with cigarettes, and to be exposed to parental or peer 

smoking at baseline, these factors taken by themselves do not fully explain 

the observed differences in progression to established smoking. This study 

demonstrates that the associations uncovered in prior studies are not solely 

due to increased participation in tobacco promotions among youths who 

have already moved along the smoking initiation continuum. 

Evidence Regarding the Cigarette advertising has been so pervasive on billCausal Mechanism boards, in storefronts, and in magazines and entertainment weeklies that most young people can name a brand whose ads capture their attention. Indeed, 75 percent of the above-mentioned sample of 

nonsmokers could do so. It is unlikely that simply distributing a T-shirt 

with a cigarette brand on it to a random sample of youths would induce a 

large proportion of those adolescents to become smokers. How is it, then, 

that noticing cigarette ads or owning a promotional item makes some adolescents more likely to become smokers? 

A number of mechanisms have been hypothesized to account for the 

impact of tobacco advertising on youth smoking. It has been suggested that 

the pervasiveness of tobacco advertising gives the impression that most 

people are smokers (U.S. DHHS, 1994). Secondly, the advertisements undercut the fact that tobacco use is unhealthy, because the people pictured 

appear young, vibrant, and healthy. Thirdly, the messages conveyed by the 

advertising images are precisely those that would appeal to young people— 

206

Chapter 13 

Figure 13-3 

Progression to Established Smoking by Receptivity to Tobacco Advertising among 

Massachusetts Youths—Biener and Siegel, 2000 

50


% Became Established Smokers 

40


30


20


10


14 

18 

46 

0


No Ad/ 

No Item 

Ad or 

Item 

Ad and 

Item 

Receptivity to Advertising 

i.e., that smokers are independent, adventurous, popular, risk-taking, and 

attractive to the opposite sex (Altman et al., 1987). In other words, cigarette 

advertising increases the perceived social value of smoking and, by doing 

so, increases the rate of smoking among adolescents. Additional analyses of 

the Massachusetts data tested that hypothesis by examining the relationships between knowledge of cigarette advertising, perceived social value of 

smoking, and position on the smoking initiation continuum. 

The data for these analyses were primarily taken from the follow-up 

study of Massachusetts youths. A smoking initiation continuum was constructed from items on the baseline and follow-up surveys. This continuum 

combines items that assess susceptibility to future smoking, number of cigarettes smoked, and time since the last cigarette to yield an 11-point scale 

that ranges from 1 (has never had even a puff of a cigarette and is strongly 

committed to not smoking in the future) to 11 (has smoked more than 100 

cigarettes in one’s life and smoked on at least 20 days out of the previous 

30) (U.S. DHHS, 1994). 

Exposure to tobacco advertising was measured with a series of items on 

the follow-up survey that presented respondents with advertising slogans 

for various types of products with one word missing. For example: “Alive 

with BLANK,” “Welcome to BLANK Country,” and “I want to be like 

BLANK.” The respondent was asked to fill in the blank. If the respondent 

provided a word for the blank, he or she was asked what product was being 

advertised. Six of the slogans were for cigarettes. Respondents were given 

one point for each blank correctly filled and one point for each cigarette 

brand correctly named. The total score could range from 0 to 12. 

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Smoking and Tobacco Control Monograph No. 14 

The social value of smoking was measured with six questions that had 

the respondents indicate whether smoking was an advantage, a disadvantage, or neutral for young people; the questions addressed a variety of 

dimensions. Respondents were asked, for example, “In general, do you 

think smoking has a good effect on how kids look, a bad effect on how kids 

look, or do you think it doesn’t affect their looks one way or the other?” 

“Among people your age that you know, do you think those who smoke are 

more mature than those who don’t, less mature, or is it about equal?” 

Similar questions assessed the relative advantages and disadvantages of 

smoking for popularity, intelligence, independence, and “how kids look at 

parties.” Each item was scored 3 if smoking was seen as advantageous, 2 if it 

was seen as neutral, and 1 if it was seen as disadvantageous. The total score 

was the mean for all items and could range from 1.0 (smoking was seen as a 

disadvantage in all respects) to 3.0 (smoking was seen as an advantage in all 

respects). 

Other variables in the analyses were the same as those described in the 

first study—age, gender, whether or not the respondent reported having a 

close friend who smoked at baseline, whether the respondent lived with at 

least one adult smoker, the household income level, the education level of 

the adult informant, and the youth’s minority status. 

Hierarchical multiple regression analysis was employed to estimate the 

effect of exposure to tobacco advertising on each respondent’s position on 

the smoking initiation continuum at follow-up while controlling for position on the continuum at baseline and for the other control variables. 

Perceived social value of smoking was entered on the second step of the 

regression analysis. Change from Step 1 to Step 2 in the regression coefficient for exposure to tobacco advertising was computed. If the coefficient 

for tobacco advertising is reduced after adding perceived social value to the 

model, it would indicate that perceived social value is a mediating mechanism accounting for some proportion of the relationship between exposure 

to tobacco advertising and position on the smoking initiation continuum. 

The results of the regression analysis are displayed in Table 13-1. Model 

1 contains all predictors believed to be associated with adolescent smoking 

initiation, including the respondent’s position on the uptake continuum at 

baseline. Step 1 includes all predictors except perceived social value of 

smoking. Results indicate that, when adjusting for all other predictors in 

the model, being at a higher level of initiation at follow-up is predicted by 

being at a higher level at baseline, having a close friend who smokes, having an adult smoker in the household, and knowledge of tobacco slogans. 

The only other predictor that approached significance was race/ethnicity, 

indicating that being a member of a minority group was associated with 

lower positions on the initiation continuum at follow-up. Respondents’ 

scores on perceived social value of smoking were added in Step 2. As the 

results show (see Table 13-1), perceived social value of smoking was strongly 

related to position on the initiation continuum at follow-up, controlling for 

all other predictors. Furthermore, the coefficient for knowledge of tobacco 

slogans declined from 0.367 in Step 1 to 0.292 in Step 2, a reduction of 20 

percent. 

208 
Chapter 13 

Table 13-1 

Regression Coefficients for Predictors of Position on the Smoking Continuum at Follow-up for 

Cohort of Massachusetts Adolescents Surveyed in 1993 and 1997 

Model 1 Model 2 

Predictors Step 1 Step 2 Step 1 Step 2 

Age at baseline (12 to 17) -0.223 -0.199 — — 

Gender (Male = 1; Female = 2) 0.382 0.436 — — 

Ethnicity 

(Non-Hisp. White = 1; Minority = 2) -0.778 -0.572 -0.673*** -0.464 

Baseline initiation continuum (1 to 11) 0.669*** 0.583*** 0.651*** 0.574*** 

Close friend smokes (No = 0, Yes = 1) 1.030** 0.751* 1.084*** 0.861 

Adult smoker in household 

(No = 0; Yes = 1) 0.822* 0.673* 0.424 0.324 

Household income 

(Under 50K =1; Over 50K = 2) -0.225 -0.000 — — 

Education of adult informant 

(HS or less = 1; More than HS = 2) 0.029 0.082 — — 

Knowledge of tobacco slogans (0 to 12) 0.367*** 0.292*** 0.300*** 0.214*** 

Perceived social value of smoking 

(1 to 3) — 4.857*** — 4.776*** 

Adjusted R square (R2) 0.357*** 0.453*** 0.328*** 0.439*** 

* p < 0.05; ** p < 0.01; *** p < 0.001. 

Model 2 repeated the multiple regression analysis, this time including 

only those predictors from Step 1 that were significant to at least the 0.10 

level of confidence. In Step 2, when perceived social value of smoking was 

added to the model, the coefficient for knowledge of tobacco slogans 

declined from 0.300 to 0.214, a reduction of 32 percent. 

This analysis indicates that knowledge of tobacco slogans is a strong 

predictor of movement along the smoking initiation continuum among 15-

to 20-year-old Massachusetts adolescents, even controlling for their stage of 

initiation 4 years earlier. It also shows that, although reports of having a 

close friend who smokes and having an adult family member who smokes 

are also associated with becoming more committed to smoking, these factors do not remove or neutralize the impact of exposure to tobacco advertising. Furthermore, this analysis provides evidence that one of the reasons 

that tobacco advertising promotes smoking initiation among adolescents is 

that it increases their perception that smoking cigarettes confers social 

advantages to people their age. The more knowledge adolescents have 

about advertising slogans, the more likely they are to report that young 

people who smoke are more attractive, more mature and independent, and 

more popular than nonsmokers. The analysis suggests that from 20 to 30 

percent of the power of tobacco advertising to move adolescents along the 

smoking initiation continuum is due to its success in increasing the perceived social value of smoking. 

209 
Smoking and Tobacco Control Monograph No. 14 

SUMMARY The studies reviewed here comprise an impressive body of evidence 

that tobacco advertising and promotional activities are important catalysts 

in the smoking initiation process. Any particular study, taken alone, is subject to criticism and alternative explanations. When viewed as a group, 

however, the conclusion that there is a causal relationship between tobacco 

marketing and smoking initiation seems unassailable. This is not to say that 

the nature of the relationship is clear or simple. Tobacco advertising has 

been unavoidable in the environment of adolescents and most teenagers do 

not become smokers. It is proposed that tobacco advertisements are particularly attractive to adolescents who, for one reason or another, are looking 

for an identity that the images are carefully designed to offer. These are the 

youths who would retain promotional items, while those whose identity 

needs are met in other ways would likely lose, discard, or forget about 

them. Having the items offers the vulnerable group an opportunity to “try 

on the image of a smoker” (Feighery et al., 1998). Doing so is likely part of 

a longer term process of accepting the image and, eventually, the smoking 

behavior that goes with it. More careful examination of the differential 

effect of advertising on more and less vulnerable youths would be very useful in helping us gain a better understanding of its effect. 

What can be expected for the future? The multi-state agreement with 

the major tobacco companies includes some restrictions on billboard and 

transit advertisements and also on some forms of promotional items. 

However, tobacco advertising images are still widely displayed inside and 

outside of stores, in magazines, in the entertainment sections of newspapers, and at local sponsored events. Since it is the images that hold the 

power to influence adolescent behavior, a more comprehensive restriction 

on image advertising would be warranted. 

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212

African American Teen 

Cigarette Smoking: A Review 

Phillip S. Gardiner 

INTRODUCTION Smoking rates in African American adolescents continue to be 

the lowest among all racial and ethnic groups in the United States. From 

1978 to 1991, smoking rates declined for both males and females in this 

group (Bachman et al., 1991). The Monitoring the Future (MTF) study 

showed that in 1978, 24.9 percent of African American high school seniors 

had smoked a cigarette daily, whereas only 4.1 percent reported this activity 

in 1991 (Johnston et al., 1996). Similarly, the prevalence of smoking among 

African American adolescents has been substantially lower than the prevalence among White and Hispanic adolescents. This phenomenon is attested 

to by national, regional, and local surveys spanning the last 20 years 

(Bachman et al., 1991; U.S. DHHS, 1994; CDC, 1996a; Johnston et al., 1996; 

Sheridan et al., 1993; Greenlund et al., 1996). 

These smoking rates for adolescents are conspicuously lower than the 

high smoking rates for adult African Americans. As African American teens 

reach adulthood, they have the highest smoking rates compared to any 

other racial/ethnic group, except for American Indians; this is especially 

true among African American men. Research has already identified “lateonset” smoking by African American teens as a characteristic that distinguishes this demographic group from other young smokers (Geronimus et 

al., 1993; Robinson et al., 1997; Royce et al., 1993; Griesler and Kandel, 

1998). Because African Americans are disproportionately plagued by heart 

disease, stroke, hypertension, diabetes, and AIDS—and because smoking is a 

prime suspect in many of these maladies—it will be very important to discover why smoking rates among adult African Americans have become so 

high, when the rates had been so low in adolescence. 

During the 1990s, African American adolescent smoking rates jumped 

dramatically, as did all teenage smoking rates. In April of 1998, the Centers 

for Disease Control and Prevention (CDC) reported that African American 

youth smoking rates had increased sharply, from 12.6 percent to 22.7 percent—an 80 percent increase—from 1991 to 1997 (U.S. DHHS, 1998). The 

increases were most striking among young Black males, whose low cigarette-smoking rates were once deemed a public health success story. In 

1991, 14.1 percent of male African American high school students smoked 

cigarettes, but by 1997, twice as many of these youths (28.2 percent) reported smoking cigarettes. In contrast, smoking rates among African American 

teenage girls also rose, but less dramatically (11.3 percent to 17.4 percent). 

Even with the distinct possibility of underreporting, African American adolescent smoking rates remain conspicuously lower and different than those 

for all other adolescents. 

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Smoking and Tobacco Control Monograph No. 14 

This chapter explores the protective factors that enable African 

American adolescents to be initially resistant to influences that initiate 

tobacco use. Identifying these factors is no small matter. Certain circumstances accounting for the rise in African American teenage smoking rates 

during the 1990s are also discussed. Potential problems of reliability and 

generalizability are reviewed, and finally, outstanding questions are identified. Overall, this review is meant to give meaning and context to the statistics on African American smoking presented throughout the monograph. 

It should be noted that the African American population is not homogeneous. As a socially constructed “race,” African Americans historically are 

a people who range from persons with only a trace of African heritage to 

dark-skinned Black people. This socially constructed racial term is further 

complicated by the presence of Haitians, Puerto Ricans, other peoples from 

the Caribbean, and African immigrants, who, as separate groups, have their 

own distinct cigarette-smoking patterns and rates (Taylor et al., 1997). As 

Taylor and colleagues point out, ever-smoking rates among urban, foreignborn Blacks are considerably lower than those among American-born 

Blacks; among foreign-born Blacks, ever-smoking rates are lower among 

women relative to men (Taylor et al., 1997). 

PROTECTIVE FACTORS Many researchers have taken notice of the significant difference between the smoking behavior of African American youths and 

youths of other racial/ethnic groups, but few researchers have actually 

sought to tease out the predictors of this differential behavior (Gritz et al., 

1998). Even after controlling for school performance, drop-out rates, 

parental income, and drug use, Wallace and Bachman (1991) still reported 

that the observed ethnic differences in smoking rates remained among adolescent smokers. Though small, there is an emerging body of literature that 

seeks to identify the factors that have protected young African Americans 

from smoking initiation. Research has identified six protective factors: 1) 

the cost of cigarettes, 2) sports participation, 3) body-type preferences, 4) 

relative influence of peers and parental smoking status, 5) marijuana use, 

and 6) ethical and religious concerns. It seems that there is an intersection 

of socioeconomic, cultural, and racial factors that, when taken together, initially curtail African American adolescent smoking. 

One factor limiting African American youth smoking may be the cost of 

cigarettes. Some researchers have shown that an increase in cigarette prices 

will lead to lower consumption of cigarettes, especially among teens 

(Chaloupka and Pacula, 1999; Hu et al., 1995). Those same researchers have 

concluded that young Blacks are relatively more responsive to changes in 

price than are young Whites and young women. Similarly, Robinson and 

colleagues (1997) also found that “regular” smoking was heavily influenced 

by cost. The Morbidity and Mortality Weekly Report (MMWR) of the CDC concurs that not only would a 50-percent price increase cause a 12.5 percent 

decline in smoking, but that Hispanic smokers and non-Hispanic Black 

smokers were more likely than White smokers to reduce or quit smoking in 

response to a price increase (CDC, 1998). An important cautionary note is 

sounded by Stephens and colleagues (1997) from Canada, who have 

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demonstrated that, although cigarette prices are effective in controlling 

smoking rates, price changes will have less impact than desired unless coupled with anti-smoking ordinances. 

Another protective factor, especially for African American males, may be 

participation in high school sports programs. In a survey of high school 

athletes, Davis and associates (1997) pointed out that race was a significant 

determinant of tobacco use, with Whites being more likely to use tobacco 

products. Davis and associates also concluded that high-intensity athletes 

were significantly less likely to be heavy smokers than athletes participating 

in low-intensity sports (Davis et al., 1997). Since many African American 

males see participation in football, basketball, and track and field (highintensity sports) as a means toward future employment and avenues for 

escaping depressed inner cities, the Davis findings have a ring of authenticity. Other researchers reported that Black boys scored higher on dietary 

restraint than White boys. These authors speculated that, given African 

American males’ involvement in sports, such teens possibly smoked less 

and dieted more in comparison to their White middle school counterparts 

(Klesges et al., 1997). 

Cultural differences may also play a protective role in limiting African 

American adolescent girls’ use of tobacco products generally, and cigarettes 

in particular. Recent surveys have shown that one of the reasons young 

White girls start smoking is to control their weight (Klesges et al., 1997). On 

the other hand, African American girls don’t necessarily subscribe to the 

European model of beauty. Klesges and colleagues (1997) have shown that 

White adolescent girls are much more concerned with weight, and the 

potential for cigarette smoking to control it, than are young African 

American girls. Similarly, Camp and associates found that while 39 percent 

of White female and 12 percent of White male adolescents reported using 

smoking to control their appetite and weight, not a single Black male or 

female adolescent reported using cigarettes for this purpose (Camp et al., 

1993). Other researchers have shown that pregnancies among African 

American teenagers have played a role in lowering the smoking rates 

among this sector of the population. Land and Stockbauer (1993) analyzed 

the data files extracted from Missouri birth certificates, which revealed statistics on 41,544 Black and 105,170 White teenage mothers. They found 

that the rate of African American subjects who smoked during pregnancy 

decreased from 37 percent in 1978 to less than 22 percent in 1990. The 

authors go on to state that a large part of this reduction is attributed to 

changes among Black teenage mothers, whose smoking during pregnancy 

declined from 35.8 percent to 7.2 percent (Land and Stockbauer, 1993). 

The Black church historically has played an important role in the social, 

political, spiritual, and health lives of African Americans. In this regard, 

Brown and Gary (1994) found that low frequency of church attendance 

among African American males is associated with current smoking status. 

Since the parents and/or grandparents of many African American youths 

require them to attend church, religious involvement may be an initial 

brake on smoking. It is also possible that the many young Blacks who do 

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Smoking and Tobacco Control Monograph No. 14 

not attend church begin smoking earlier, but this hypothesis has yet to be 

investigated or tested. Taylor and colleagues (1999), drawing on 63 in-depth 

interviews of White and African American teenagers, found that Blacks 

ranked parental influence, death, and moral/ethical principles as major 

themes explaining why people choose not to smoke. Additionally, there is 

some research showing that African American high school seniors prefer 

dating nonsmokers and are less likely than Whites to state that they “don’t 

mind” being around people who are smoking (Lynch and Bonnie, 1994). 

There are differing findings on the role of family and friends in the etiology of African American teenage smoking. Some research suggests that 

African American youths are more influenced by their families’ and friends’ 

beliefs about cigarette smoking than are their White counterparts (Gritz et 

al., 1998; Mermelstein et al., 1999; U.S. DHHS, 1994 & 1998). Although 

Gritz and colleagues (1998) found that African American adolescents were 

significantly less susceptible to smoking, they also found that, across 

Whites, Latinos, and African Americans, the most important predictor of 

both ever-smoking and susceptibility to smoking was the smoking status of 

a youth’s three best friends. Similarly, Botvin and associates (1994) reported 

that friends and peers were the most important social influences in predicting smoking behavior among inner-city African American and Latino 7th 

graders. In another study, Botvin and colleagues found that friends’ smoking, attitudes concerning the harmful effects of smoking, and low selfesteem concerning school performance were predictive of behavioral intention to smoke among young African Americans (Botvin et al., 1992). More 

broadly, Gritz and associates (1998) speculate that African American community norms may protect adolescents from smoking initiation. 

On the other hand, Landrine and colleagues (1994) reported, as distinct 

from Gritz and Botvin, that smoking among peers was the best predictor of 

smoking among White adolescents. These authors showed that peer smoking accounted for 23.5 percent of the variance among White adolescents, 

but accounted for only 15 percent of the variance for Latino subjects, 9.6 

percent of the variance for Asian American subjects, and none of the variance for African American youths (Landrine et al., 1994). Other researchers 

have discovered similar findings. Headen and associates (1991) sought the 

correlates and potential causes of adolescent smoking among 1,277 current 

nonsmokers aged 12 to 24 years. They found that having a best friend who 

smoked increased the odds of initiating smoking more than two-fold for 

Whites, but had no effect on the odds of smoking for Blacks. Griesler and 

Kandel (1998) also suggested that that lack of maternal smoking effects and 

perceived peer pressure to smoke affected African American adolescents differently compared with Whites. These authors maintained that role-modeling and interpersonal influence may be more important determinants of 

smoking for White than for African American adolescents. 

Discrepancies in interpreting the role of depression also exist when 

assessing African American teen smoking. Several researchers determined 

that depression is a predictor of African American youth smoking, whereas 

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Gritz and colleagues reported that depression is not a predictor of African 

American smoking (Gritz et al., 1998; Landrine et al., 1994; Landrine and 

Klonoff, 1996; Klonoff and Landrine, 1996). Furthermore, Landrine and 

Klonoff (1996) found that racial discrimination is highly correlated with 

depression and smoking. Clearly, more research is needed on these relationships and the role of social and psychological factors in the initiation of 

smoking among African American teens. 

An unexpected factor that may initially temper cigarette smoking 

among African American youths is the use of marijuana prior to smoking 

cigarettes. Charyn Sutton, President of the Onyx Group in Philadelphia, 

calls the phenomenon the reverse gateway effect (Gross, 1998). 

Traditionally, White youths have proceeded from the use of legal substances 

to that of illegal substances. Sutton found that many African American 

youths were smoking marijuana before trying tobacco, taking the opposite 

path. Though this is counterintuitive and not to be applauded, the use of 

marijuana by African American teens may initially be delaying the onset of 

cigarette smoking in this population. Unfortunately, it may truly serve as a 

gateway to tobacco (see the discussion of marijuana and “blunts” below). 

The above review shows the complex interaction of class, culture, and 

race. It is clear that some of these protective factors began to break down 

with the rise of tobacco smoking in African American teenagers during the 

1990s. 

AN INCREASE IN RISK FACTORS AND A Smoking rates have increased across the 

DECLINE IN PROTECTIVE FACTORS board for teens from all ethnic groups 

EQUALS AN INCREASE IN AFRICAN (U.S. DHHS, 1998). Many of the factors 

AMERICAN TEEN SMOKING RATES driving the overall increase in teenage 

smoking rates also affect adolescent African Americans, including the glamorization of tobacco products (especially cigars) in the movies and on television in the 1990s (Stockwell and Glantz, 1997). At the same time, there are 

unique circumstances surrounding the increase in African American teenage 

smoking and these must be addressed. Research suggests that seven factors 

are converging to raise smoking rates in this population: 

1) the tobacco industry marketing directly to African Americans 

generally, and to teens specifically; 

2) tobacco industry sponsorships; 

3) the adoption of cigarettes, cigars, and marijuana (i.e., smoking) 

by segments of the commercial hip-hop culture; 

4) cigarettes used in conjunction with marijuana; 

5) greater access to tobacco products; 

6) greater access to cheaper tobacco; and 

7) the increasing impoverishment, racial discrimination, and marginalization of inner-city African American youths. 

The recent release of tobacco industry documents has confirmed years 

of suspicion that tobacco companies had directly targeted African 

Americans for tobacco and cigarette consumption, and that they continue 

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Smoking and Tobacco Control Monograph No. 14 

to do so. Documents show that, as early as the 1960s, the motivations of 

the “Negro” tobacco consumer were a major concern of R.J. Reynolds 

(Meier, 1998; Randall, 1998). Moreover, other documentation confirms that 

R.J. Reynolds (manufacturer of Salem) and Brown & Williamson (manufacturer of Kools) were constantly contending over the African American mentholated cigarette market (Meier, 1998; Randall, 1998). In the 1990s, alcohol and cigarettes remained the most advertised products in African 

American communities (Goldstein, 1991; Randall, 1998). Billboards advertising tobacco products are placed in Black communities four to five times 

more often than in White communities (Skolnick, 1993). Additionally, such 

advertisements targeted to the African American community usually promote menthol cigarettes (Law, 1992; Randall, 1998). Menthol cigarettes 

tend to be higher than nonmenthol cigarettes in tar and nicotine, and they 

also may catalyze independent effects on addiction and dependency, effects 

which have not been adequately studied (Randall, 1998). 

Billboard advertising is just one way that the tobacco industry has targeted African American youths. Special brands of cigarettes also have been 

created for African Americans. In 1990, R.J. Reynolds planned to market a 

new menthol cigarette called “Uptown” (Ramirez, 1990; Randall, 1998). 

Only the pressure of public outrage forced the company to suspend production of the product. In 1997, R.J. Reynolds came out with a mentholated 

version of Camel that was clearly aimed at the African American community (Greene, 1997; Randall, 1998). 

The impact of years of targeted advertising is seen in the brand loyalty 

of African American teenagers. About 75 to 90 percent of Black smokers 

report a preference for menthol cigarettes, compared with only 23 to 25 

percent of White Americans (CDC, 1994; Randall, 1998). Generally speaking, Marlboro and Camel portray White images and characters, and these 

are the brands of choice among White teens. On the other hand, Kool and 

Newport use Black and other minority images and are favored by African 

American teens. Additionally, it is known from previous research that teens 

mimic their parents in their smoking habits; White adults smoke Marlboro 

and Camels, African American adults smoke mentholated brands. 

The tobacco industry’s sponsorship of African American community 

events has increased in the 1990s as well, especially those activities attended by Black teens. One of the more conspicuous expressions of targeted 

marketing is the Kool Jazz Festival, which annually travels the country promoting cigarette smoking and attracting large numbers of young African 

Americans (Randall, 1998). 

Broad sectors of the Rap music industry have adopted smoking images 

as part of the rebellious argot of the hip-hop generation. Musical artists are 

seen smoking marijuana, cigarettes, or cigars in promotions, in videos, and 

in person. Just a walk through many African American inner-city communities will show multiple images of rappers smoking cigarettes and cigars. 

DuRant and colleagues (1997) found that at least one fourth (25.7 percent) 

of MTV videos portrayed tobacco use. It would be interesting to do the 

same type of analysis of Black Entertainment Television (BET), Music BoxTM, 

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and other Black media dedicated to young African American audiences. 

Moreover, popular African American, youth-oriented magazines not only 

carry cigarette advertisements, but also pepper their fashion and lifestyle 

spreads with pictures of Black youths smoking. These latter pictures do not 

necessitate the Surgeon General’s warning since they aren’t directly sponsored by the tobacco industry. 

An increase in tobacco use among young African Americans has also 

been linked to marijuana use. Robin Mermelstein, Ph.D., of the University 

of Illinois at Chicago, speaking of the findings from focus groups held 

among 1,200 teenagers, points out that many Black teens were drawn to 

cigarettes because nicotine intensifies their marijuana high (Gross, 1998). 

As was pointed out above, initial marijuana use may postpone the use of 

cigarettes by African American teens while preparing youths for adoption of 

the more deadly habit. In addition, some young African Americans empty 

out the insides of cigars and refill them with marijuana and/or crack 

cocaine, among other substances. These concoctions— called variously 

“Philly Blunts,” “blunts,” or sometimes “Caviar”—have augmented cigar 

and tobacco use among teenage Blacks. It is important to note that, while 

crack cocaine use has declined, marijuana and, increasingly, tobacco use 

appear to be growing among African American youths. 

Some research suggests that African American youths had greater access 

to tobacco products in the 1990s. In a large bi-racial sample of 7th graders, 

Robinson and associates (1997) found that the best predictor of experimentation with cigarettes was the perception that they were easily available. In 

another study of White, Latino, and African American adolescents who 

attempted to buy cigarettes in southern California convenience stores, 

researchers found that older Black children (16 years of age), irrespective of 

gender, were the single most likely group to be sold cigarettes (Klonoff et 

al., 1997). MMWR reports confirm that adolescent access was easiest in 

small stores (CDC, 1996a & 1996b). Landrine and colleagues found the 

same result in a follow-up to the above-referenced Klonoff study, namely a 

bias toward selling cigarettes to Black youngsters, but not White ones 

(Landrine, 2000). 

Another factor that may increase smoking rates among young African 

Americans is the availability of loose, single cigarettes (“loosies”). There is a 

scarcity of studies on this issue, but Landrine and associates speculate that, 

despite California laws banning the sale of single cigarettes, minors’ rate of 

access to them in poorer communities—and, hence, the rate of access by 

African American youths—is probably significantly higher than for nonminority youths (Landrine et al., 1998). Similarly, in a convenience sample 

of 206 stores, Klonoff and colleagues (1994) have demonstrated that single 

cigarettes were least likely to be sold in White neighborhoods, more likely 

to be sold in integrated neighborhoods, and most likely to be sold in 

minority neighborhoods. These investigators go on to show that minors 

were able to purchase single cigarettes in 34.4 percent of the visits to White 

neighborhoods, but could do so in 71.2 percent of the visits to minority 

neighborhoods. 

219 
Smoking and Tobacco Control Monograph No. 14 

On the other hand, other researchers have shown that the availability 

of cheaper cigarettes is not likely to be a cause of increased smoking initiation by adolescents (Gilpin and Pierce, 1997). These authors suspect that 

tobacco industry marketing probably plays a larger role in adolescent smoking uptake than increased access. While it would seem to be a reasonable 

assumption that cheaper generic cigarettes would be used frequently by 

young African Americans, research shows this not to be the case. Cavin and 

Pierce (1996) have demonstrated, in a cross-sectional sample of California 

smokers, that non-Hispanic Whites, rural residents, and lower income 

smokers were twice as likely to buy generics compared to other smokers. 

Moreover, even though access may be greater for African American teens, 

research shows that 7th-grade African American boys were less likely to 

have purchased cigarettes than their White counterparts (Robinson et al., 

1998). This later finding is consistent with the lower smoking rates found 

among African American teens. 

Some authors suggest that there is a relationship between poverty, 

racism, segregation in the inner cities, and increases in African American 

youth smoking. It seems intuitive that the stress and oppression arising 

from racial discrimination would give rise to cigarette smoking. Landrine 

and Klonoff (1996) tackled this understudied phenomenon in a groundbreaking article, demonstrating that “racism is rampant in the lives of 

African Americans and is strongly linked to psychiatric symptoms and to 

cigarette smoking.” These authors found that African American smokers 

reported significantly more frequent racist discrimination throughout their 

lives than did nonsmokers. The growing marginalization and heightened 

racial oppression of many inner-city African American youths may be one 

of the main factors increasing their cigarette smoking during the 1990s. 

Other authors identify the changing, difficult, and demanding living 

conditions of African American youths as predictors of risk-taking behavior. 

Richardson and colleagues (1993) found that adolescents who were unsupervised at home were slightly more likely to engage in problem behavior 

than youths with home supervision. This is an important finding since 

many African American families are living in increasingly impoverished and 

marginalized conditions in the inner city and cannot tend to their children 

24 hours a day. Swing and graveyard shifts, reliance on public transportation, long distances to and from work, lack of affordable childcare, few 

after-school programs, multiple jobs, or no jobs all contribute to the unsupervised character of many adolescent African Americans and may, therefore, create the conditions for increasing their smoking rates (Richardson et 

al., 1993). 

Plainly, some of the protective factors that surrounded African 

American teens have broken down and their risk factors have increased. 

Most likely, it is some combination of the two. 

220

Chapter 14 

VALIDITY OF AFRICAN The two articles reviewed for this chapter come to diverAMERICAN SELF- gent conclusions as they relate to the validity African 

REPORTS ABOUT Americans self-report about tobacco consumption. One 

CIGARETTE SMOKING study, using biochemical measures to compare the validity of self-reports of tobacco use of 1,823 Black and White adolescents, 

found that African American adolescents were more likely than White 

American adolescents to underreport tobacco use, and that White adolescents were more likely than their African American counterparts to overreport tobacco use (Bauman and Ennett, 1994). On the other hand, Wills and 

Cleary (1997) found that the lower smoking rates reported by African 

American adolescents are real and are not substantially a consequence of 

reporting artifacts. Both studies reported higher biochemically confirmed 

rates of tobacco use among White adolescents compared to African 

American adolescents. These investigators compared the validity of selfreports of cigarette smoking for African American, Hispanic, and White 

respondents. Self-reported cigarette smoking was compared to a measure of 

carbon monoxide among the multiracial sample of 8th, 9th, and 10th 

graders. The validity of self-reports of smoking was generally comparable 

across ethnic groups (Wills and Cleary, 1997). The above contradictory findings are further complicated by other research that has demonstrated that 

Whites exhibit digit preference (the tendency to report rounded numbers of 

cigarettes per day—i.e., 10, 15, 20, etc.) significantly more than African 

Americans in self-reported smoking (Klesges et al., 1995). 

Another potential threat to the validity of African American youth selfreported smoking lies with the identities of the people asking the questions. 

African American youths may be hesitant to reveal any illegal practices, 

even if their interviews are covered by human subjects protections and 

immunity. 

There are many potential threats to the generalizability of self-reported 

data of African American teen smoking. Since nearly a third of all African 

American male teens are incarcerated either in prisons, juvenile facilities, or 

halfway houses, we know that they have not been part of any sample of 

cigarette smoking behavior. Moreover, incarcerated adolescents, both male 

and female, generally have been those involved in risk-taking behavior, 

which includes smoking cigarettes. Cigarettes often function as currency in 

prisons, are highly valued, and are exchangeable for most other goods and 

services. Olubodun, in reporting the inmate health at a community prison, 

showed that not only was blood pressure proportionately related to the 

length of an inmate’s stay, but that 67 percent of all prisoners reported 

smoking (Olubodun, 1996). The above fact, coupled with the historic 

under-representation of African Americans in survey research (the U.S. 

Census included), should be of some concern for tobacco researchers. It 

seems that large sectors of African American teens that are not part of the 

many national samples are smoking. 

It may be possible that there is a bi-modal distribution of cigarette 

smoking among African American adolescents. Although rising, rates 

among African American teens who are not in jail remain lower than rates 

221

Smoking and Tobacco Control Monograph No. 14 

among any other racial/ethnic group. On the other hand, incarcerated 

Black youths probably have significantly higher smoking rates than their 

counterparts on the outside, though this hypothesis is yet to be tested. 

OUTSTANDING QUESTIONS Just from the review presented above, numerous 

questions stand out. For example, the community norms and the African 

American church may not be exerting the same strong protective influence 

that they did in the past. Amey and associates (1996), using Monitoring the 

Future data, report that, although religion does provide some protection 

from drug use (i.e., marijuana, cigarettes, and illegal drugs), religiosity has 

less of an impact on the drug use of Black adolescents compared to White 

youths. 

It seems that, with the rise in educational status of African Americans, 

cigarette smoking rates are also increasing. Heretofore, it has been shown 

that higher educational levels were consistent with lower cigarette smoking 

levels (see Chapter 2). Now, some researchers are showing that smoking differences between Blacks and Whites may be inversely related to education, 

with greater smoking risk associated with less education for Whites and 

more education for Blacks (Werch et al., 1997; U.S. DHHS, 1998). Increased 

educational attainment has brought African Americans into greater contact 

with Whites and other ethnic groups and has increased the possibilities of 

racist encounters. It seems logical that “middle class stress” and enduring 

increased racist remarks would predispose this group of African Americans 

to greater cigarette smoking and tobacco use generally. 

African American teen tobacco smoking coupled with marijuana usage 

also presents new challenges and thorny questions that tobacco control 

experts and nicotine addiction researchers will have to grapple with. 

Scientists know that both nicotine and tetrahydrocannabinol (THC), the 

active ingredient in marijuana, influence the dopaminergic pathway, which 

is involved in the neural reward mechanism. Is it possible there is a synergistic effect of these two drugs on brain chemistry? Does the combined use 

of tobacco and marijuana produce greater neuropharmacological effects 

than if the two drugs are used separately? Does THC extend the addictive 

qualities of nicotine? Behavioral scientists are faced with still other questions. Why do White youths typically proceed from tobacco to marijuana 

while many Black youths proceed from marijuana to tobacco? Has the cigar 

smoking craze, promoted by the tobacco industry and Hollywood, exacerbated “Philly Blunt” use among African American teens? 

There still remains the task of understanding the neuropharmacological 

effects of menthol in cigarettes. Does menthol bolster the addictive qualities of nicotine? Might the fact that African Americans often smoke menthol cigarettes contribute to their high rates of lung cancer, heart disease, 

and mortality from cigarette smoking? Why is it that African Americans 

have more illness associated with smoking, despite the fact that they start 

smoking later in life and smoke fewer cigarettes (Randall, 1998)? 

222

Chapter 14 

Furthermore, comparative research would go a long way toward teasing 

out the differences between young African Americans who are incarcerated 

and those who are not. This is no small question. Since mandatory/minimum sentences have confined nearly a third of African American males 

behind bars, it is necessary for tobacco researchers to study the prison population and compare it with its counterpart on the outside. Unfortunately, 

the prison population will not diminish soon. Those African American 

youths who are not in prison remain, for the most part, in America’s urban 

inner cities. Is the greater poverty and marginalization experienced by these 

youths driving increased smoking rates? On the other hand, some states 

and many counties have established prohibitions against smoking. The 

impact of these laws and their differential impact on the smoking practices 

of African Americans and others behind bars still need to be looked into. 

KEY QUESTION Plainly, the key question facing those researchers interested in 

youth smoking is, “How can African American rates of smoking be so low 

during adolescence and then become so high in adulthood?” It seems that 

many of the protective factors that keep the most devastating aspects of 

racism and discrimination away from African American youths begin to 

erode when they venture out into the “real world.” This is a world of little 

opportunity, low-paying jobs, and the possibility of an increase in police 

harassment. Many young adults fight back, and many to no avail. 

An old adage states: “Why not smoke, I am going to die anyway.” That 

comes from the life experience of Black people and they are right. African 

American people live shorter and less healthy lives. It may not start out 

that way, but by the time that they are adults, they suffer from disproportionate rates of heart disease, stroke, diabetes, hypertension, AIDS, and 

death from gun shots, among other maladies and incidents. In addition, 

smoking cigarettes is a major culprit in the etiology of many of the abovementioned maladies. Understanding and deciphering the puzzle surrounding the low-youth, high-adult smoking rates among the African American 

population remains the key question facing tobacco-use researchers. 

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225

Understanding Tobacco-Use Research 

among Hispanic/Latino Adolescents: A 

Sociocultural Perspective 

Lourdes Baezconde-Garbanati 

INTRODUCTION According to the Surgeon General’s Report (U.S. DHHS, 1998; see 

Chapter 2), smoking rates in the United States among adolescent 

Hispanics/Latinos have been on the rise after what had been several years of 

substantial decline. Even in California, where smoking rates for 

Hispanic/Latino high school students traditionally have been low, there has 

been an increase in the prevalence of current smoking among adolescents. 

Between 1993 and 1996, there was a 52.1 percent increase in the number of 

those aged 12-17 years who reported smoking in the last 30 days (Pierce et 

al., 1998). Due to the large and growing numbers of Hispanics/Latinos and 

the youthfulness of this population around the country, this substantial 

increase in adolescent smoking is particularly troubling. Among older teens 

(16-17 years of age), overall smoking rates historically have been higher 

and, in 1998, this continued to be the case nationwide. 

There are well over 12 million Hispanic/Latino children and youths in 

the United States, representing one of the largest segments of the 

Hispanic/Latino population (Campbell, 1996). Increases in the number of 

Hispanics/Latinos throughout the country are predicted to continue 

unabated due in part to high immigration and high fertility rates (HayesBautista et al., 1994). By the year 2020, it is predicted that there will be over 

54.3 million Hispanic/Latino adults, children, and youths in the United 

States. By the year 2080, the population will have expanded into well over 

140 million (Marin and Marin, 1991). However, in many states, 

Hispanics/Latinos, and youths in particular, have not received the needed 

attention in terms of culturally competent research, services, or languageappropriate prevention and cessation programs designed to effectively curb 

smoking rates. 

If we are to better understand these increases and the methods for preventing adolescent Hispanics/Latinos from further uptake of smoking, there 

is a need for research that is more refined and tailored to the realities of 

Hispanic/Latino adolescent life. Research with this population group calls 

for a clear understanding of the sociocultural context in which 

Hispanic/Latino adolescents lead their lives. Such research may be useful in 

understanding smoking rates in the Hispanic population. It may also be 

useful in the development of research questions, the language and youthcentered idiomatic expressions used in surveys, the recruitment and reten227 
Smoking and Tobacco Control Monograph No. 14 

tion of Hispanic/Latino adolescents into research studies, the conduct of 

research and analyses of data in culturally and age-appropriate ways, and 

the culturally specific interpretation of data for the Hispanic/Latino population. 

This monograph presents an important effort across the country to 

understand youth tobacco use and the research that supports it. This document will serve to better inform program planning for the nation as a 

whole, and to identify gaps in research for this population. This monograph includes findings from some of the largest data sets available on 

smoking behaviors of Hispanic/Latino adolescents. 

Unfortunately, until recently, data for Hispanic/Latino adolescents have 

been lacking, not just in terms of tobacco use, but in general. When it is 

available, much of the information lacks the level of specificity needed to 

better understand the realities of youth smoking (Castro and BaezcondeGarbanati, 1987). For example, it is often hard to find information on 

youth smoking prevalence among the various sub-Hispanic/Latino groups 

by country of origin (i.e., Mexican versus Puerto Rican, Cuban, or Central 

American, among others), by gender, or by predictors of Hispanic/Latino 

youth smoking in particular. This lack has been due in part to the limitations of existing data collection systems and to a lack of uniformity in 

methods, conceptualization, operationalization of terms, and analyses 

(Nuno et al., 1998). Other studies contain small sample sizes and varying 

sampling schemes that make it difficult to draw conclusions. Even though 

much progress has been made in study design, the different degrees of 

sophistication and scope of existent tobacco-use data collection systems in 

various states make it hard to obtain comparable data. Even more difficult 

is obtaining information compiled in culturally competent ways, particularly so in the case of Hispanic/Latino youths. One attempt at culturally competent data collection is the recent focus group research effort conducted by 

the Centers for Disease Control and Prevention (CDC). These data promise 

to address some of the specificity needed to better understand larger scale 

studies on Hispanic/Latino adolescents (Crawford et al., 1998). 

The data from various states presented in this monograph represent 

another attempt at understanding youth smoking rates from a broader perspective. But to better grasp these data on Hispanic/Latino adolescent 

tobacco use rates, it is important to provide a culturally relevant framework 

that places these rates into the context of Hispanic/Latino adolescent life 

across the country. This framework will help to address the complex scenario in which Hispanic/Latino adolescent smoking is initiated, proceeds 

from experimentation to intermittent use, on to regular use, and ends in 

addiction (U.S. DHHS, 1994). At the same time, it may help to shape an 

understanding of the complexities of research that must take into account 

the interactions among culture, gender, acculturation, immigration, socioeconomic status, and the historical and environmental factors that impact 

Hispanic/Latino adolescent smoking. An examination of these data within a 

cultural perspective may generate new questions and open new avenues for 

research and practice. In turn, this may help to better shape the understanding of tobacco use among Hispanic/Latino adolescents throughout the 

228 country. 
Chapter 15 

A SOCIOCULTURAL Hispanics/Latinos in the United States have been charFRAMEWORK FOR acterized by their heterogeneity based on a series of 

HISPANIC/LATINO variables that include, but are not limited to, country 

ADOLESCENT TOBACCO of origin, the geographic region in which they reside, 

USE RESEARCH	 immigration status, language capabilities, acculturation levels, age, education, and socioeconomic status, 

Hispanic/Latino among others (Castro and Baezconde-Garbanati, 

Heterogeneity 1987). While some Hispanics/Latinos in specific 

regions of the country have been characterized as having high poverty 

rates, low educational attainment, elevated numbers of high school drop 

outs, and high levels of unemployment (Chapa and Valencia, 1993; Perez 

and Salazar, 1993), others have achieved a prominent status in society. 

Nevertheless, newly arrived immigrant population groups, especially 

adolescent Hispanics/Latinos, often struggle between traditional family values and the lure of the new culture. Newly arrived Hispanic/Latino adolescents may experience high levels of acculturative stress (Mena et al., 1987). 

For some Hispanic/Latino adolescents and their families, the stress of being 

undocumented (Melville, 1978; Mirowsky and Ross, 1987) and the limitations it imposes are critical constraints in their lives. For example, undocumented youths may not be able to obtain a valid California driver’s 

license—an important right of passage for Hispanic/Latino adolescents. 

Hispanic/Latino heterogeneity is also apparent in terms of immigration 

and documentation, since some adolescents may have overstayed student 

or tourist visas or may have entered the country illegally, undocumented, 

or on a seasonal status. Others (i.e., Cuban and some Central Americans) 

are political refugees. Still others, such as Puerto Ricans, are considered U.S. 

citizens. Some may come from families in which parents may be undocumented while the children or some of the children were born in the United 

States. Therefore, within the same family, a younger sibling may be a U.S. 

citizen while an older child may be in the country illegally. Other youths 

may trace their roots back four or five generations to a time when 

California was a part of Mexico. Still others consider themselves of Spanish 

descent (i.e., from Spain) rather than Latin American. Therefore, the reasons 

for immigration and the experiences of each adolescent Hispanic/Latino 

group in the various states in the United States may vary widely. 

Some adolescent Hispanics/Latinos may have come with family members fleeing political persecution or with families that feared their young 

children would be recruited into guerrilla warfare groups. Others may have 

immigrated with their families looking for economic or educational 

advancement and a better life in the United States. Some adolescents may 

have not had a choice and may have immigrated into the United States 

involuntarily, while others may have come willingly. The voluntary nature 

of immigration helps to frame the experiences in this country (Salgado de 

Snyder and Padilla, 1987) for these young people. 

Latino heterogeneity is also exemplified by urban versus rural differences and by regional variations based on country of origin. For example, 

Hispanics/ Latinos tend to concentrate in nine (9) different states across the 

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United States. Individuals of Mexican origin tend to concentrate in 

California, Illinois, Colorado, New Mexico, and Arizona. Central Americans 

tend to concentrate in California, as well as in the northeastern part of the 

United States, such as Washington, D.C. and New York. Cubans, on the 

other hand, concentrate in Florida, and have spread through other parts of 

the United States. Puerto Ricans and Dominicans are often found in New 

York, New Jersey, and Pennsylvania. These groups have attained various levels of education, political strength, and economic stability and have influenced American life in multiple ways. 

Although little is available on adolescent Hispanic/Latino subgroups, 

data presented in this monograph show that Hispanic/Latino adolescent 

smoking seems to vary by state. However, there are few data on how rates 

vary within the United States by country of origin. The California Youth 

Survey data point to wide variations in daily smoking among 12th graders, 

from 22 percent among those of Cuban origin to 16 percent among South 

Americans and 10 percent among Mexican and Central American youths 

(Johnson, 2000). Smoking level variations by acculturation have also been 

noted among Hispanics in general (Marin et al., 1989), as has the presence 

of strong parental sanctions against adolescent smoking (California 

Department of Health Services, 1998). 

Sociodemographic Factors With its high rates of poverty, unemployment, and 

and Hispanic/Latino high school drop outs, Hispanic/Latino adolescents 

Adolescent Tobacco Use are particularly vulnerable to engaging in tobacco 

use in its various forms. One study conducted in California (Morris, 1993) 

revealed that disadvantaged Latino youths (ages 9-12) were three times 

more likely to smoke or experiment with tobacco than non-Latino youths. 

In another study (Johnston et al., 1996), Latino 8th graders had the highest 

rates of lifetime and 30-day cigarette smoking. Early tobacco experimentation may be linked to alcohol and to experimentation with other drugs 

among Latino youths (Escobedo and Peddicord, 1996). 

According to the Surgeon General’s Report (U.S. DHHS, 1998), there are 

multiple factors associated with smoking among Hispanics and Latinos. 

Some of these factors include drinking alcohol, working and living with 

other smokers, having peers who smoke, being in poor health, enduring 

acculturative stress, being depressed, and being exposed to tobacco advertising and promotion strategies. 

Among Hispanic adolescents, the interaction of many complex factors 

within the various Hispanic/Latino communities accounts for observed patterns of tobacco use. Thus, data for Hispanic/Latino adolescents that appear 

in this monograph need to be interpreted within the context of the complex interaction and the cultural and socioeconomic realities of this population group. 

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Cultural Factors Some factors that influence smoking among Hispanic/Latino 

adolescents are socioeconomic, but others are cultural in nature, and both 

types interact with other important factors. Some factors are environmentally determined, such as excessive tobacco promotion in sporting and cultural events by the tobacco industry or heavy advertising and promotion of 

pro-tobacco messages in magazine ads and movies. Other factors are cultural and these include language spoken at home, highly traditional versus less 

traditional norms, the quality of family functioning, household composition, attitudes about smoking, and the smoking status of parents and peers 

(including familial peers, such as cousins). 

Language Language capabilities and preferences of Hispanic/Latino adolescents 

need to be considered at all levels of tobacco control, from the conduct of 

research to the development and delivery of anti-tobacco messages to this 

special group. Ad Americas (1999) research, for example, shows that, in 

California, Hispanic/Latino adolescents live in a true bilingual, bicultural 

world. Data showed 54 percent of Hispanic/Latino teens surveyed by Ad 

Americas were bilingual, 19 percent were English dependent, while another 

27 percent were Spanish dependent. How these numbers vary by state is 

still unclear. 

These data suggest that, to reach a Hispanic/Latino teen population in 

California, one must survey in both languages. They also suggest a need to 

segment advertising that is directed at these youths. Male Hispanic/Latino 

immigrant teens, for example—who prefer Spanish and who tend to smoke 

more than immigrant females—may need to be recruited for surveys in a 

different way than those youths who are bilingual or prefer English. English 

language surveys could potentially target the more acculturated 

Hispanic/Latino girls, who tend to smoke more than their less acculturated 

counterparts. 

In addition, language issues among Hispanic/Latino adolescents go 

beyond Spanish/English level variations to incorporate terms and concepts 

of the Hispanic/Latino youth culture. Idiomatic expressions with varying 

meanings may be found for otherwise identical words. This is an area that 

needs further exploration if instruments developed to grasp the realities of 

Hispanic/Latino adolescent tobacco use are to be relevant to those completing such surveys. 

Other cultural factors among Hispanic/Latino adolescents may be common to other groups as well. Recent reports (U.S. DHHS, 1998; Penn, 1998; 

Lew, 1998) show that some of the same factors that contribute to adolescent smoking in other racial/ethnic groups, such as African Americans, 

American Indians, and Asian/Pacific Islanders, also contribute to tobacco 

use in Hispanic adolescents. Specifically, peers and parents who smoke 

(California Department of Health Services, 1998; Penn, 1998) and cultural 

norms that favor smoking in various ethnic/racial groups, such as giving 

cigarettes at weddings or as gifts in the Asian/Pacific Islander groups (Lew, 

1998), also have been associated with adolescent smoking among 

Hispanics/Latinos. For example, among Hispanic/Latinos, pricey American 

cigarettes and liquor may be highly valued and often requested as gifts during periodic visits back to the home country. 

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The Role of Acculturation Income, education, and acculturation may interact in 

significant ways to promote smoking among Hispanic/Latino adolescents. 

Higher acculturation levels have been closely tied to higher education and 

higher income in the Hispanic/Latino community. When individuals have 

been in the United States for a number of years, they tend to become more 

similar to the general culture in terms of income and education. For example, there is higher educational attainment among Mexican Americans than 

among Mexican immigrants (Hayes-Bautista, 1992). In the same manner, 

Latino immigrants with initially lower smoking rates, especially among 

women, upon arrival to the United States, tend to increase their smoking as 

they become more educated and more acculturated (Marin et al., 1989). 

This characteristic, which is found mainly among Hispanic/Latinos and 

African Americans, is the reverse of that found among non-Hispanic 

Whites, who generally exhibit lower smoking rates with increasing educational attainment. The need to belong and assimilate into the general culture, to absorb the norms and reap the benefits and promises of the new 

culture motivates Hispanic/Latino women—and adolescent girls in particular—to be more likely to smoke the longer they are in the United States. 

To understand these and other influences of acculturation, data for 

Hispanic/Latino adolescents need to be dissaggregated. Data that are dissaggregated will help to clarify varying patterns in smoking rates among 

Hispanic/Latino adolescents. This clarification is important because research 

among adults (Cantero et al., 1999) has already shown that more acculturated Latinas, for example, especially those in their middle years (45-64), tend 

to engage in less preventative health behaviors than their immigrant counterparts. Cantero et al. (1999) showed that acculturated Latinas (45-64 years 

of age) participated less in physical activity programs, had less healthy eating patterns, got less sleep, and smoked more than their less acculturated 

counterparts. Disaggregating data for Hispanic/Latino adolescents may help 

both to better identify consistent patterns among several differing groups 

and to understand their differences. 

Immigration Status Once they arrive in the United States, immigrant communities are especially at risk for increased rates of smoking. Although rates for 

immigrant women and adolescent girls appear to be initially relatively low, 

some of these rates may be masked in part by immigration characteristics 

(Baezconde-Garbanati et al., 1999a). Such masking characteristics may 

include, but are not limited to, original smoking rates in the countries of 

origin, exposure to promotion and advertising by the immigrant group, age 

at immigration, and positive attitudes toward the tobacco industry. Positive 

industry attitudes are often the result of seeing the industry as a major 

source of economic wealth for a country that sends immigrants into the 

United States or of seeing it as a friend in the community. 

For example, varying smoking prevalence rates are found in various 

Latin American countries that send immigrants into the United States, 

ranging from a low of 11 percent to a high of 20 percent in some regions. 

According to data from the Pan American Health Organization (Baezconde232

Chapter 15 

Garbanati et al., 1999a), 1987 smoking rates for women in Costa Rica were 

11 percent, 12 percent for women in El Salvador, 11 percent for women in 

Honduras, 18 percent for women in Mexico and Guatemala, and 20 percent 

for women in Nicaragua. 

Depending on cultural attitudes about tobacco promotion and advertising, it is possible that individuals with low smoking rates in countries of 

origin will have largely different smoking patterns once in the United 

States. Among those with already high smoking rates, the influence of 

advertising and promotion in the United States may not be as marked. 

However, little research addresses these issues in tobacco control or compares population groups in countries of origin with immigrants in the 

United States. 

New research from the Transdisciplinary Tobacco Use Research Center 

(TTURC) at the Institute for Prevention Research at the University of 

Southern California promises to offer some insights into variations in cultural norms among adolescents of Asian/Pacific Islander and 

Hispanic/Latino origin in the United States and abroad (Johnson, 1999). 

Gender Issues in Marin et al. (1989) found some gender differences with 

Tobacco Use among acculturation on the attitudes, norms, and expectations 

Hispanic/Latino regarding tobacco use. They also report that more acculturAdolescents ated females tend to smoke more than their less acculturated counterparts. Hispanic/Latino adolescent females who are trying to fit 

into the dominant culture will tend to take on the values of that culture in 

their attempts to break away from the more traditional nonsmoking norms. 

As in other population groups, more Hispanic/Latino adolescent males 

than females smoke. However, although smoking rates may still be relatively low among Hispanic/Latino girls, especially immigrants, these rates are 

increasing rapidly (U.S. DHHS, 1998). A high level of teen pregnancy only 

adds to the complexities of Hispanic/Latino adolescent girls’ smoking 

behavior (LCHC, 1999; Baezconde-Garbanati et al., 1999a). Although smoking among pregnant Hispanic/Latino adolescent girls is not a large problem 

at this time, increasing smoking rates among a population at risk for early 

pregnancy means we may see more cases of fetal and newborn problems 

related to smoking within the Hispanic/Latino community. Other problems 

confronted by pregnant teens may be exposure to secondhand smoke from 

either their peers, their boyfriends, or a parent who smokes. Exposure to 

secondhand smoke has been linked to the delivery of low-birth-weight 

babies, Sudden Infant Death Syndrome (SIDS), and high infant mortality 

rates (CDC, 1994). 

Special attention needs to be given to Hispanic/Latino adolescent girls 

and exposure of the fetus to cigarette smoking. There is a high percentage 

of Puerto Rican women and adolescent girls who deliver low-birth-weight 

infants; these problems are less prevalent among those of Mexican origin 

(Zambrana, 1991). But these statistics are cause for concern, as data from 

the UCLA Center for Health Policy Research (Brown et al., 1997) reveal that 

one of every three Latinas younger than age 17 is uninsured. Furthermore, 

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rates of early prenatal care among Mexican-origin women in California are 

even lower than rates of prenatal care for women in Mexico (Secretaría de 

Gobernación, 1996). If smoking rates do not decline, education and 

research on maternal smoking among this young population will be vital to 

the continued health of the Hispanic/Latino community. 

Hispanic/Latino According to several authors (Hayes-Bautista, 1992; HayesSocial Networks Bautista et al., 1994; Vega et al., 1998; Gilbert and Cervantes, 

1986; Marin et al., 1989; Baezconde-Garbanati, 1994), in spite of some serious risk factors, immigrant Latino subgroups experience some very positive 

behaviors. These include low levels of alcohol consumption, relatively low 

overall rates of adult smoking, less psychopathology, and less depression. 

Some of these positive behaviors have been tied to traditional cultural values and the strong presence of familial networks (Hayes-Bautista et al., 

1994; Baezconde-Garbanati, 1994). These networks are reinforced by the 

continuous communication back and forth between the United States and 

the immigrants’ countries of origin. This contact with extended families 

and often with a nonfamilial fictive kin system offers support and helps 

preserve the values of the culture among adolescent Hispanic/Latinos; it 

may also at times protect these youths from engaging in unhealthy behaviors (Golding and Baezconde-Garbanati, 1990; Baezconde-Garbanati, 1994). 

However, these mechanisms often erode as young people live longer in the 

United States, move across the country to different areas, or achieve mobility within the social and educational strata of society (Vega et al., 1998). 

Peer and family influences are considered the strongest predictors of 

smoking initiation among Puerto Rican and Central American adolescents 

(Morris et al., 1993). For example, data show that peer, parental, and familial modeling are all critical aspects of adolescent smoking among 

Hispanic/Latinos. In California, significantly more of the youths who 

smoke, versus those who do not smoke, report living with a parent who 

also smokes (55 percent versus 33 percent). Research has shown (Marin et 

al., 1989) that, in the Hispanic/Latino population, males tend to smoke 

more than females, and there are varying attitudes about parental and 

youth smoking, many of which are gender based. 

Spanish-speaking adults, for example, are more likely than other groups 

to believe that smoking is not addictive and that, as smokers, they themselves are not addicted (Palinkas et al., 1993). They perceive themselves as 

being less susceptible to addiction than other groups. Although they may 

recognize the harmful effects of nicotine, there is a certain belief of invulnerability, such that they feel they can quit at any time. These beliefs are 

passed on to younger members of the family, especially when living 

arrangements for Hispanic/Latino adolescents may include the presence of 

other same-age or older extended-family members, such as cousins and 

uncles, inside the home. 

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Chapter 15 

Hispanic/Latino individuals with lower incomes have better possibilities 

of economic survival if they live together with other individuals and/or 

family members. It is not uncommon for Hispanic/Latino adolescents to 

live in a household in which the home has been opened to newly arrived 

immigrant relatives, for example, in an effort to facilitate the process of 

adaptation and provide financial means while exchanging goods and services (Baezconde-Garbanati et al., 1999a). It is possible, however, that these 

extended familial arrangements are composed of individuals of several generations that may have varying norms and rules about smoking within the 

same Latino households, and some may even see smoking as a “right of 

passage” for the Latino youth. 

In focus groups conducted among Hispanic/Latino adolescents in 

California by Ad Americas (1999), both male and female youths expressed 

being highly influenced in their decision to smoke by familial peers, such 

as older brothers, cousins, and other such extended-family members. 

Parental norms against smoking significantly affect the smoking patterns of adolescents. Testimony before the U.S. Congress by a panel of 

youths, including Hispanic/Latino teens, revealed that one of the most 

important factors to influence teen smoking is the value their parents and 

families place on youth smoking (Penn, 1998). Even though the majority of 

smoking and nonsmoking parents (90 percent) have rules against youth 

smoking, only 41 percent of smoking parents versus 70 percent of nonsmoking parents actually prohibited smoking in the home (Pierce et al., 

1998). This is an important fact for Hispanic/Latinos, due to the traditional 

values placed on the family and the high influence of familial members, 

including extended family members. The lack of enforcement of parental 

household rules on smoking among Hispanic/Latinos may also be tied to 

the traditional values of “simpatía” and “personalismo” (Marin and Marin, 

1991), which emphasize respect and politeness and frown on confrontational situations and direct criticisms (Marin et al., 1989, Marin and Marin, 

1991). Furthermore, Hispanic/Latinos highly value family relationships. 

This value of “familismo” defines families within nuclear and extended kinship networks, such as compadres (godparents), that promote feelings of 

loyalty and reciprocity for the exchange of goods and services among family members and those who associate closely with them as fictive kinships 

(Bird and Canino, 1982). It is important to Hispanic/Latinos to maintain 

these ties throughout life. 

Inasmuch as Hispanic/Latinos value smooth social relationships and 

smooth social personal interactions with people, it may be difficult in some 

families to ask other extended-family members, especially if it is a father or 

grandparent, not to smoke. This reluctance may translate into a lack of 

enforcement on household rules, which may in turn imply easy access by 

Hispanic/Latino teens to cigarettes around the home. It may also promote 

the purchase of tobacco products for Hispanic/Latino adolescents by familial social sources. 

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While peer and family influences are considered critically important 

(Nuno et al., 1998), broader environmental influences affect 

Hispanic/Latino youths and their peers and families alike. For example, the 

relationship between tobacco use among Hispanic/Latino adolescents is 

highly influenced by the extensive media advertising and promotion campaigns that have targeted youths, women, and ethnic minorities in the 

United States, especially African American and Hispanic/Latino youths. 

ENVIRONMENTAL FACTORS: Hispanic/Latino youths are particularly vulnerable 

TOBACCO ADVERTISING to the extensive pro-tobacco advertising and proAND PROMOTION motion that has targeted communities with large 

minority populations. The influence of advertising and promotion, and of 

the entertainment industry, is particularly important among adolescent 

Hispanic/Latinos. Advertising, promotion, and movies portray highly acculturated heroes and models living a life of glamour and success that is very 

appealing to Hispanic/Latino youths. It is especially appealing to those 

striving to “fit in” to the dominant culture. Advertising, promotion, and 

the entertainment industry present those who smoke as living a life of 

glamour and sexual prowess. They appeal to a sense of manliness or 

“machismo” among Hispanic/Latino boys and a sense of freedom and 

breaking away from traditional cultural and family norms for 

Hispanic/Latino girls. This promotion has come in many forms and is 

increasingly focusing on the distribution of attractive gear with smoking 

messages and on the sponsorship of cultural events at which 

Hispanic/Latino youths tend to participate. According to the Federal Trade 

Commission (1995), the tobacco industry, in 1993, spent over $6 billion on 

advertising and promotion, much of it in minority communities, including 

Hispanic/Latino communities. The CDC (1994) reported that the tobacco 

industry advertises heavily in ethnic communities using ads that are particularly appealing to youths and women. Evans et al. (1995) revealed that 

adolescents have a greater probability of taking up smoking if exposed to 

heavy advertising and promotion of cigarettes. According to this study, the 

influence of advertising is even more critical than peer pressure, family 

members who smoke, or scholastic behavior. 

But with the new multi-state Master Settlement Agreement, promotion 

and advertising by the tobacco industry may soon take a different shape in 

minority communities. According to the Hispanic/Latino Tobacco 

Education Network (Baezconde-Garbanati et al., 1999b), there has been an 

increase in the number of alcohol and tobacco messages that appear in 

much of the print advertising in magazines widely read by 

Hispanics/Latinos. 

In addition, industry promotion in Hispanic/Latino communities has 

taken the shape of providing funds and scholarships for students to be able 

to attend college or trade schools, a direct targeting of 18- to 24-year-old 

Hispanic/Latino young adults. In the Hispanic/Latino community, the 

industry has been strategic in associating themselves with trusted community gatekeepers in order to promote the image of a contributor to the 

financial stability of impoverished communities (Durazo Communications, 

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Chapter 15 

1998). They do so through the funding of cultural events, Hispanic/Latino 

chambers of commerce, and other grassroots-level organizations and community groups. Due to these types of activities, communities see the tobacco industry as a partner with trusted organizations that have traditionally 

attracted youths, and this view helps to shape community attitudes that 

favor tobacco use. 

In the fall of 1999, the industry invested over $100 million in an imageremaking campaign (Brown and Houseman, 2000). Apparently, one of the 

expected outcomes of this campaign was to change people’s attitudes about 

the industry itself, so it would be seen as a good corporate citizen that cares 

about the causes communities care about. The purpose seems to be to focus 

attention on what the industry does for the community rather than on its 

continuous sale of a deadly product. As part of the campaign, television 

advertising was released regarding programs to feed the hungry, assist flood 

victims, and fund anti-domestic violence programs. However, Brown and 

Houseman (2000) point out that, almost simultaneously, the industry 

released a $40 million advertising campaign targeting women and produced 

a new brand of cigarettes, Marlboro Milds, which attracts a predominantly 

African American and Hispanic market. These authors point out that, 

although the industry invested some $2 million in anti-domestic violence 

programs, it spent close to $100 million to let communities know about it. 

This is the kind of media environment youths are exposed to when making 

decisions about smoking. Due to the poverty and domestic violence issues 

existing in many minority communities, these are powerful conflicting 

messages that youths may not know how to counter. 

RESEARCHING TOBACCO If we are to change Hispanic/Latino adolescent 

USE AMONG HISPANIC/ smoking behavior, it is imperative to understand the 

LATINO ADOLESCENTS sociocultural environment, the heterogeneity of the 

population, its cultural values and norms regarding tobacco use, and to 

interpret data within the context of Hispanic/Latino adolescent life. 

Hispanic/Latino adolescents are not a monolithic population. They are 

influenced by cultural smoking norms in their own homes and respective 

countries of origin, as well as by the influence of American culture once in 

the United States. Although there is a youth culture that seems to unite 

Hispanic/Latino adolescents with other groups, subcultural and ethnic variations permeate Hispanic/Latino adolescent life. 

Regardless of the stage at which we find Hispanic/Latino youths—some 

are trying to break away from cultural traditions, some struggling to find 

their center in later adolescence, while others fit in with more acculturated 

groups—the prevalence of Hispanic/Latino adolescent smoking needs to be 

researched and interpreted within the historical, demographic, environmental, cultural, and socioeconomic context of their lives. The consideration of 

sociocultural issues in the planning, development, conduct, analyses, and 

interpretation of scientific data will lead to better program planning that 

may directly impact adolescent smoking rates. 

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Research data on Hispanic/Latino adolescent tobacco use cannot be 

interpreted in isolation from the realities that make Hispanic/Latinos in the 

United States who they are today. For example, the interaction between 

acculturation, education, and smoking rates among Hispanic/Latino adolescents needs to be explored further. Several authors have shown that, when 

research data are analyzed accounting for variations and interactions 

between different levels of acculturation with varying degrees of education, 

significant differences are observed in the various Latino subgroups (Flores 

et al., 1995; Balcazar et al., 1995). This is especially true related to socioeconomic indicators, such as income, employment, health insurance, self ratings on health and perceptions of satisfaction, and attitudes toward healthy 

behaviors. 

Tobacco-use data for Hispanics/Latinos, and especially Hispanic/Latino 

adolescents, should be considered a product of the historical, political, 

social, and economic realities of the population (Flores et al., 1995). The 

migration history of Hispanic/Latino adolescents is important, as are the 

sociocultural, environmental, and psychological impacts of migration 

(Williams, 1990) and the ways in which this migration may have influenced attitudes about smoking and cultural smoking norms. According to 

Flores et al. (1995), the culturally appropriate interpretation of data for 

Hispanic/Latinos must begin with an understanding of the geographical 

areas from which Hispanic/Latinos originate. This understanding must 

include their geographic distribution throughout the United States and the 

historical underpinnings and conditions of immigration by the various 

Hispanic/Latino groups into the United States. These are important because 

they provide for Hispanic/Latino adolescents the context of acceptance 

within the United States. The experiences of children of highly educated 

Cuban refugees, versus those of Puerto Rican U.S. citizens, undocumented 

immigrants, or of individuals fleeing conditions of war or economic hardships in countries of origin are all incredibly different. Yet, in unique ways, 

they form the context for resiliency in engaging in risk behaviors or challenge-coping strategies of adolescents during a critical stage of their lives. 

Once in the United States, the conditions and quality of life for 

Hispanic/Latino adolescents working in fields and labor camps as part of 

migrant farm-working families are also very different realities from those for 

young Hispanics/Latinos in the inner city. The context of Hispanic/Latino 

children and adolescents includes variations by neighborhood or cities, 

safety issues within those neighborhoods, engagement in gangs, and other 

risk behaviors that adolescents are exposed to. This context goes beyond 

tobacco-specific issues that may include policies within the schools and 

communities and enforcement of laws and regulations against smoking; 

there are also interactions between sociocultural, environmental, and psychological factors that affect adolescent groups. Sociocultural and socioeconomic factors (income, education, occupation, age, gender, acculturation, 

and high school dropout rates) are also important to consider when interpreting Hispanic/Latino adolescent smoking data. 

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Chapter 15 

In essence, tobacco use research among Hispanic/Latino adolescents 

needs to be planned to consider the complexities of adolescent life in the 

United States. As Hispanic/Latino children grow and mature, traditional 

norms from their younger years that protect against smoking are challenged 

by the broader society. Societal engagement of Hispanic/Latino adolescents 

implies interactions with multiple ethnic and racial groups, various cultures, and individuals with varying social and cultural norms regarding 

tobacco use. The mixture of values and norms creates new expectations and 

challenges at a time when young people are truly beginning to define 

themselves and are searching for who they are as individuals. Pro-tobacco 

media has deceptively portrayed experimentation with tobacco use, smoking uptake, and having a choice in continued tobacco use as important 

parts of the exploration in becoming an adult. The influences exercised by 

these conditions are important areas for research among Hispanic/Latinos 

and other adolescent groups. These are critical aspects of the contextual 

environment of adolescent life that all have important effects on smoking 

behavior. If we are to develop better program planning and implementation, and to evaluate the successes of programmatic tobacco control activities, the scientific foundation for these endeavors needs to be grounded in 

the cultural and social realities of Hispanic/Latino adolescent life. Doing 

otherwise will delay Hispanic/Latino adolescents from reaping the benefits 

of a life free of tobacco-related diseases. The real choice for our youths is to 

use their culture and adolescent energy in protecting their health and that 

of others. It is time for adolescent awakening grounded in scientific endeavors helping to create a new generation of tobacco-free adults that will live 

free of tobacco-related diseases well into the 21st century. 

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Asian American and Pacific Islander


Adolescent Cigarette Smoking: 


A Review


Betty M. Hong 

INTRODUCTION Tobacco use is the leading cause of preventable death and illness 

in the United States. Despite declines in the smoking rates among adults 

over the past few decades, smoking rates have begun to increase again in 

the 1990s among adolescents of all racial and ethnic groups. Of the more 

than 1 million Americans who become new smokers each year, or nearly 

3,000 who start smoking each day, the majority are recruited from the 

ranks of children and adolescents (Pierce et al., 1989; CDC, 1998). As stated 

by U.S. Surgeon General, Dr. David Satcher, “If tobacco use continues to 

increase among minority adolescents, we can expect severe health consequences to begin to be felt in the early part of the next century” (U.S. 

DHHS, 1998). 

Patterns of tobacco use and exposure among and within Asian 

American and Pacific Islander (AAPI) communities are of particular concern. 

Because of the diversity found among the various ethnic subgroups of 

AAPIs—including differences in lifestyles, cultural beliefs and practices, and 

environmental exposures—no single factor can be considered the determinant of tobacco use or exposure. For this reason, rigorous surveillance and 

prevention research must be conducted in order to unveil the many specific 

factors that influence tobacco use and exposure among AAPIs, particularly 

the influences resulting from differences between ethnic subgroups and 

from the effects of acculturation to “Western lifestyles.” 

DEMOGRAPHICS AAPIs are the fastest growing racial/ethnic group nationwide. 

On July 1, 1998, AAPIs represented approximately 3.8 percent of the U.S. 

population and its associated Pacific Island Jurisdictions compared to only 

0.4 percent of the nation’s population in 1960. From 1980 to 1990, the U.S. 

AAPI population increased by over 95 percent. In the same time period, the 

Hispanic population increased 51.5 percent, the Native American population 27.7 percent, the African American population 13.2 percent, and the 

non-Hispanic White population 4.2 percent. Between July 1, 1990 and July 

1, 1998, AAPIs again had a higher rate of population growth than any other 

race in the nation—37 percent. The Census Bureau projects that size of the 

AAPI population will reach 34.4 million by the year 2050, representing 

almost 10 percent of all Americans. Immigration to the United States and 

resettlement of refugees from Southeast Asia in the mid-1970s have 

accounted for much of the population growth (86 percent). However, several Asian groups, such as the Chinese and Japanese, have been in the United 

States for generations; relatively few Pacific Islanders are foreign-born, and 

Native Hawaiians are the indigenous people of the state of Hawaii, having 

settled there more than 2,000 years ago (U.S. Bureau of the Census, 1995). 

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According to the 1990 U.S. Census, the single racial category referred to 

as “Asian American and Pacific Islander” is comprised of almost 30 percent 

youths and children (0-17 years old) and just over 6 percent elderly (65 

years and over). Of the 13 AAPI ethnic subgroups reported in the 1990 

Census, recent immigrant populations, such as the Hmong, had the highest 

percentage of children and youths—60 percent. By comparison, youths 

within the same age band represented less than 20 percent of the JapaneseAmerican population. 

The AAPI population is extremely heterogeneous and has a high proportion of immigrants and refugees. The AAPI single racial classification 

consists of approximately 30 Asian and 25 Pacific Island nationalities, all 

with distinct languages, cultures, immigration histories, and community 

norms, many of which have impacts on community members’ health and 

well being. Some of the ethnic subgroups included in the category “Pacific 

Islander” are the Chamorro (Guam/Commonwealth of Northern Mariana 

Islands), Chuukese, Fijian, Hawaiian, Kosraean (Federated States of 

Micronesia), Melanesian, Palauan (Republic of Palau), Pohnpeian, Samoan 

(American and Western Samoa), Tongan, and Yapese. Ethnic subgroups in 

the category “Asian” include Afghani, Asian Indian, Bangladeshi, Burmese, 

Cambodian, Chinese, Filipino, Hmong, Indonesian, Iwo-Jiman, Japanese, 

Korean, Laotian, Malaysian, Mien, Nepali, Okinawin, Pakistani, Sikkim, Sri 

Lankan, Thai, and Vietnamese. The six largest AAPI subgroups are from 

China, the Philippines, India, Japan, Korea, and Vietnam (Gardner, 1994). 

Nearly 40 percent of the nation’s AAPI population live in California. 

Other states with large AAPI communities include New York (9.3 percent), 

Hawaii (8.3 percent), Texas (4.7 percent), New Jersey (3.9 percent), Illinois 

(3.8 percent), and Washington (3.0 percent) (National Center for Health 

Statistics, 1995). According to the March 1994 Current Population Survey, 

AAPIs were more likely than non-Hispanic Whites to reside in metropolitan 

areas (95 percent versus 75 percent). Although over 50 percent of all AAPIs 

live in the western part of the United States, the AAPI population has 

increased significantly in other regions: by 139 percent in both the South 

and Northeast, and by 97 percent in the Midwest (Takeuchi and Young 

1998). 

Another example of a variable distribution within the AAPI population 

is evident through examination of English proficiency. The 1990 U.S. 

Census shows that almost 60 percent of the U.S. Hmong population live in 

households in which no persons over 14 years of age speak English “very 

well.” Yet only 1 percent of the Hawaiian population lives in similar conditions. Based on the 1990 Census, approximately 95 percent of AAPIs living 

in the United States were employed; yet, a sizable proportion of the AAPI 

population was uninsured—28 percent, compared to 20 percent of nonHispanic Whites (National Center for Health Statistics, 1995). 

The many distinct AAPI ethnic subgroups reflect not only cultural 

and linguistic differences, but also socioeconomic, educational, and generational differences, all of which influence the decision-making skills and 

social support networks necessary for prevention of adolescent tobacco use 

and exposure in the AAPI community. 

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AAPI TOBACCO It is difficult to produce an accurate, nationwide profile of the 

RESEARCH: current tobacco use prevalence among youths of AAPI descent 

EPIDEMIOLOGY due to the absence of published research conducted with this 

& BEHAVIORAL racial/ethnic group. Because national data are aggregated, the 

data that do exist often mask health disparities between different ethnic 

AAPI sub-populations. Moreover, the generalizability of results is limited by 

the lack of adequate sample sizes for AAPIs within national data systems 

(e.g., National Health Interview Survey) and in epidemiological and behavioral research studies. Of particular concern is the fact that AAPIs are historically and persistently under-represented in federal and state government, 

academic, and foundation research studies. More often than not, an entire 

segment of the AAPI immigrant population is overlooked because research 

studies limit their design solely to English-speaking populations. 

National survey data reveal that adult smoking prevalence was lower 

among AAPIs (15.3 percent) than among Hispanics (18.9 percent), Whites 

(25.9 percent), African Americans (26.5 percent), and American Indians and 

Alaskan Natives (39.2 percent) (U.S. DHHS, 1998). However, significant variations in smoking prevalence emerge when AAPI data are disaggregated. In 

particular, higher smoking rates are seen among Asian men, ranging from 

Korean males (30 percent; Han et al., 1989) to Laotian males (70 percent; 

Levin, 1985), Kampuchean males (71 percent; Rumbaut, 1989), and 

Chinese-Vietnamese males (71 percent; Rumbaut, 1989). 

Reviewed literature shows considerable variation in AAPI sample size, 

and the majority of studies have been conducted with adults only. The following are highlights of some of the tobacco-related AAPI studies that have 

been completed: 

AAPI Adults Only 

•	 A study conducted in Boston during 1994 and 1995 showed that 32 

percent of the study population—99 recent Vietnamese immigrants—were smokers. Smoking prevalence was substantially different between Vietnamese men and Vietnamese women (54 percent 

versus 9 percent respectively; Nelson et al., 1997). 

•	 A 1994 Korean American Community Health Survey found that 39 

percent of men and 6 percent of women were current smokers. 

Level of English proficiency impacted the awareness of smoking as a 

health hazard. Eighty-seven percent of the study population who 

were English proficient knew that smoking is related to heart disease, while only 76 percent of those who spoke little or no English 

understood that fact (Wismer et al., 1997). 

•	 AAPI immigrants who are limited in their English proficiency are 

more likely to be smokers than their American-born counterparts. A 

study in Oakland’s Chinatown found that 40 percent of Chinese 

men did not know that smoking could cause heart disease (Chen, 

1992). 

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Smoking and Tobacco Control Monograph No. 14 

AAPI Youth Only 

•	 Approximately 21 percent of Asian American high school boys 

smoke compared to 14 percent of Asian American high school girls 

(U.S. DHHS, 1998). 

•	 Asian youths’ susceptibility to smoking has increased by 30-50 percent, and their smoking rates have also increased dramatically—by 

more than 50 percent in California from 1993 to 1996 (CDHS, 

1997). 

•	 A 1993 study in San Diego, California found that the highest average number of tobacco displays was found in Asian-American stores 

(6.4), compared to Hispanic (4.6) and African-American (3.7) stores 

(Elder et al., 1993). 

•	 Data from the 1990-1996 California Youth Tobacco Survey can be 

examined for patterns of smoking behavior among subgroups of 

Asian-American youths in California (grades 7-12). As illustrated in 

Table 6-1, different ethnic subgroups of Asian-Americans vary widely in their smoking behaviors. In addition, higher levels of acculturation are associated with higher smoking prevalence rates and earlier age of smoking onset. Breakdowns of this type are important 

because few studies exist that directly examine Asian and Pacific 

Islander immigrant versus AAPI American-born youth populations 

with respect to levels of acculturation and associated smoking 

prevalence rates. 

Clearly, these studies suggest that, in order to support the refinement of 

tobacco control programs, we need to more clearly investigate factors like 

age, gender, language barriers, and cultural differences, both between AAPI 

ethnic subgroups (e.g., Korean versus Chinese youth) and within the AAPI 

subgroups themselves (e.g., Vietnamese immigrant versus Vietnamese 

American-born youth). The challenge in building a successful tobacco control program for such a diverse population will be to clearly understand the 

factors affecting AAPI youth smoking. In addition to understanding the differences between and among AAPI ethnic subgroups, it will be necessary to 

establish a level of “trust” with the AAPI youth and to build within them a 

sense of both self and community. With that foundation, it will be possible 

to design effective tobacco control prevention and intervention strategies 

that are culturally and linguistically accessible and appropriate for AAPI 

youth. 

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Chapter 16 

Table 16-1 

Disaggregated AAPI Subgroup-Specific Analyses Revealed Significant Lifetime Smoking 

Prevalence Differences among AAPIs in California: 1990-1996 California Youth Tobacco Survey 

Lifetime 30-Day 

Smoking Prevalence Smoking Rate 

Aggregated 16.1% for Asians 

26.1% for non-Asians 

Filipinos 18.9% 8.6% 

Japanese 17.3% 7.4% 

Koreans 16.3% 8.3% 

Chinese 11.0% 2.8% 

Asian Americans 13.7% 7.2% 

FACTORS AFFECTING Factors that influence the initiation of tobacco use 

AAPI YOUTH SMOKING among AAPI youth are both complex and interrelated. 

Such factors include experimentation and peer pressure, cultural norms and 

family smoking, and the environment. 

Experimentation A California tobacco survey was conducted with 454 Filipinoand Peer Pressure American youths in Southern California in 1999 (Youth 

UNITE, 1999). Of the youths surveyed, 45.5 percent were born outside of 

the United States (the majority of those were born in the Philippines) and 

the remaining 54 percent were born within the United States. Of those who 

smoked, 86.7 percent had smoked for more than 1 year, and more than half 

of the smokers smoked at least one pack a day. According to the youths 

who identified themselves as smokers, the two biggest factors influencing 

their decision to become smokers were experimentation (48.3 percent) and 

peer pressure (22.8 percent). An overwhelming majority of Filipino youths 

preferred Marlboro as their brand of choice (63 percent). Of the smokers 

who preferred Marlboro, most did so because they liked the taste and the 

advertisements. It is noteworthy that, even though the distribution of single cigarettes is illegal in California, the youths surveyed reported single cigarettes from liquor stores to be their major source of tobacco. 

In recent tobacco control work conducted by the Asian and Pacific 

Islander American Health Forum in California, focus group findings of 

Chinese (Mandarin and Cantonese), Vietnamese, and Korean youths 

revealed that immigrant Asian youths are highly influenced by their friends 

(U.S. DHHS, 1999). Consistently, these Asian youths commented that they 

understood both the financial burden of cigarettes and the negative impact 

of smoking (health hazards, social problems related to smoking around 

nonsmokers, environmental tobacco smoke issues, etc.). 

Overall, few of the smokers or nonsmokers knew that cessation clinics and free cessation hotlines were available. The majority of youths interviewed were never advised by a health professional to quit smoking. Some 

of the smokers believed that they would be able to quit with no assistance 

from family or peer support groups and also believed they could quit without using nicotine replacement therapy (e.g., nicotine gum, patches, etc.). 

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Similar to previous research conducted with adolescents, the findings revealed that teens tend to view life as black or white, rely on their 

immediate experience, often have an attitude of invincibility, and do not 

necessarily believe in preventative health measures. It is clear from the 

focus group results that influencing these teens to deter or stop their smoking requires multi-dimensional strategies in support of tobacco-use cessation (e.g., integration of culturally and linguistically acceptable tobacco control messages from peers, family, and the environment). 

Cultural Norms Socioeconomic and cultural factors play important roles in 

and Family Smoking self-identification and behavioral risk towards tobacco use 

or acceptance among AAPI youths; cultural factors include language, cultural beliefs, and immigration status. Because a majority of AAPIs are immigrants and refugees, it is essential to understand the cultural context of 

tobacco and how that context influences acceptance, or lack thereof, 

among AAPI youths. In Asia, cigarette smoking is common in men, ranging 

from 30 to 70 percent. For Asian women, smoking prevalence is much 

lower, approximately 3-10 percent (U.S. DHHS, 2001). 

For some developing countries (e.g., Vietnam and China), tobacco 

use is culturally accepted and is often considered an attribute of wealth. For 

other Asian and Pacific Rim countries (e.g., Cambodia), tobacco is used as a 

gift and is provided, much like alcohol, to guests in one’s home. In some 

Asian traditions, cigarettes are distributed at social gatherings and are used 

in healing practices. 

As noted earlier, AAPI adult smoking patterns vary across ethnic 

subgroups. One study showed that, among Southeast Asian men, those who 

had higher English language proficiency and had lived in the United States 

longer were less likely to be smokers (Chen et al., 1993; McPhee et al., 

1993). Using questionnaire items from the Youth Risk Behavior Survey 

translated into Vietnamese for a school-based sample of Vietnamese adolescents in Worcester, Massachusetts, Weicha (1996) found that the prevalence 

of cigarette smoking among Vietnamese boys (27.9%) was similar to that 

for White boys (28.3%) and was higher than that for Hispanic boys (19.7%) 

or African American boys (18.9%). Vietnamese girls smoked rarely (3.7%). 

They were also significantly less likely than others to have smoked their 

first cigarette at age 12 years or younger. Among Vietnamese adolescents 

over age 16, increasing length of time in the United States was associated 

with decreasing smoking prevalence. To uncover the factors that influence 

smoking initiation among AAPI youths, more research is needed that not 

only disaggregates national AAPI data in order to more closely monitor different ethnic subgroups, but also dissects acculturation influences such as 

age of arrival in the United States, English language proficiency, educational 

experiences, and cultural norm changes. Little tobacco control research has 

been conducted to compare and contrast newly arrived AAPI immigrants, 

acculturated AAPI immigrants (with 5 years or more of residency), and AAPI 

American-born youths. 

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Chapter 16 

Studies have shown that a majority of adolescent smokers have parents who smoke. Consistent with other research focusing on adolescents is 

the finding that teenagers are three times more likely to smoke if their parents and at least one older sibling smoke (Moss et al., 1992). In a tobacco 

survey conducted among Filipino youths in Southern California, a significant number of youth smokers had family members who were also smokers 

(59.7 percent). Of those surveyed, 22.7 percent had more than four other 

family members who smoked. 

Members of traditional Asian cultures place great value on social 

order and control of emotions and feelings (Hirayama and Hirayama, 1986). 

Like youths of other minority groups for whom respect of elders is an 

important cultural norm and practice, AAPI youths value parental acceptance and are loath to take actions that could be seen as bringing shame to 

their family. This makes tobacco use by other family members an especially 

strong obstacle to overcome, particularly when it is the parents or other elders who smoke. Although surveyed youths may have knowledge that smoking is harmful to both their health and that of others, respect for their elders and the acceptance of tobacco within their family do not provide an 

environment within which behavior modification could be easily accomplished. 

Environment Successful strategies to prevent the use of tobacco, alcohol, and 

other drugs have incorporated the following approaches in modifying 

behavior among adolescents (Perry, 1987): 

•	 Transfer knowledge of why people of their age smoke cigarettes or 

use other drugs; 

•	 Provide information to youths on how the tobacco industry has 

manipulated the public in associating positive characteristics with 

smoking through film, advertising, older role models, and peers; 

•	 Educate youths on how to resist the influences urging them to 

smoke or use other drugs; and 

•	 Provide opportunities for using life skills and competencies to 

counterbalance the functions served by cigarette smoking and other 

drug use. 

Recent research has shown improved effectiveness of health education 

and other prevention measures when the age level of adolescents is considered. For example, general communication-based prevention is more likely 

to succeed with younger teens before they become addicted and socially 

entwined in peer reinforcements (Worden et al., 1988). In order to effectively understand the influences on AAPI youths and tobacco uptake, research 

must consider the age segment of the youth population, immigration and 

the number of years in the United States, culture, language, and the environment of the AAPI community itself (geographic, socioeconomic, etc.). 

To further support the rationale for community participation models, it 

has been documented within the literature that adults are more likely to 

pursue community change when they believe that change is worthwhile 

and achievable and that they have the skills to achieve the desired change 

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Smoking and Tobacco Control Monograph No. 14 

(Zimmerman, 1995). Similarly, teens who have a strong sense of self-determination and of being in control can benefit from community participation and youth empowerment models that build their skills and competencies. 

For example, the Asian Pacific Islander Tobacco Education Network convened a conference to bring together Pacific Islander youths to increase 

their awareness of how tobacco issues impact their community and to provide a forum for these youths to begin building life skills within a Pacific 

Islander community context. When queried about new information learned 

at the Gathering of Pacific Islanders forum, Pacific Islander youths stated 

that they learned that “Pacific Islanders do care about youth learning to 

improve their lives and the lives of others.” 

Although Pacific Islander Americans as a whole tend to be fluent in 

English and to share a strong belief in the importance of both the family 

unit and traditional values, different ethnic groups tend to have experienced different degrees of marginalization due to various social, political, 

and economic histories in the United States (e.g., Hawaiians, Samoans, 

Tongans, Chamorros, etc.). Forums like the Gathering of Pacific Islanders 

are beneficial in allowing youths from diverse cultures to have a sense of 

community with others of their own racial/ethnic background. 

In 1995, a community-needs assessment study was conducted in selected AAPI communities to identify the extent and scope of alcohol, tobacco, 

and other substance abuse (Bueno and Lau, 1996). The select AAPI ethnic 

subgroups included Chinese, Filipino, Japanese, Korean, and Vietnamese 

communities in Los Angeles County. A survey instrument that was culturally acceptable and accessible was designed. In addition, researchers collected 

data through three methods: a) door-to-door survey; b) survey of participants in community events/sites; and c) surveys that were supported by the 

elementary school authorities who facilitated the process of getting the students to bring home the surveys for their parents to complete. 

From every aspect of the research project, designated community participants were integrated into the various levels of decision-making. These levels included the variables to be surveyed, the methods to be used in data 

collection, the times for conducting the surveys, the flyers to be used in 

promoting the survey in the target areas, and the feasibility of the areas to 

be surveyed (e.g., venue selection such as cultural events). 

When asked the question, “Why do people abuse alcohol, tobacco, and 

other drugs (ATOD)?” respondents among all AAPI target areas identified 

the following factors that they felt contributed to ATOD abuse: 

• Emotional problems 

• Moral weakness/easy access 

• Peer pressure 

• Adjustment to problems of immigration 

• Family smokes/drinks 

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Another important finding of this community-needs assessment was 

that all respondents from the five AAPI target communities stated that they 

would hesitate to seek out services designed to assist those attempting to 

overcome alcohol, tobacco, or other drug abuse. The basis for low utilization of social services may be due to lack of confidence in existing services 

that may not be culturally appropriate or to the lack of awareness on the 

value of these services (Bueno and Lau, 1996). 

DOMESTIC AND AAPI youths, like other minority youths, are susceptible to 

INTERNATIONAL tobacco advertising and promotion. The lure for minority 

ADVERTISING youths is marketing “American” themes such as sophisticaAND PROMOTION tion, stardom, sexual prowess, “being cool,” and “fitting in.” 

As the U.S. tobacco market declines due to restrictions on advertising and 

promotions, the tobacco industry is unveiling new strategies for promoting 

its products, including a large amount of indirect advertising. Indirect 

advertising includes sponsorship of sporting events and teams, ethnic culture events, discos, and the arts. In addition to sponsorship, the tobacco 

industry has pushed “brand stretching,” which markets its logos on products such as clothing lines, racing boats, back packs, coffee, and umbrellas 

(Economic Research Services, 1997). To further gain market share with girls 

and women, both domestically and internationally, Philip Morris launched 

a $40 million advertising campaign for Virginia Slims targeting African 

American, Hispanic, and Asian American women. The theme of the ad campaign is “Find Your Voice” and centers on magazines that will display the 4-

to 6-page insert. Participating magazines include Glamour, Ladies’ Home 

Journal, People, Essence, Vibe, and Latina (Virginia Slims Has Come A Long 

Way, Bebe, 1999). Such indirect advertising requires new strategies to combat its influence. In California, for example, the Asian Pacific Islander 

Tobacco Education Network has worked closely with cultural event organizers to persuade them to adopt policies refusing tobacco sponsorship. 

Given the current global trends, more than 10 million people will 

die worldwide from tobacco-related disease by the year 2025. As three out 

of the five countries in the world that have the largest cigarette markets are 

Asian countries (China sold 1.7 trillion cigarettes in 1996), it is projected 

that a majority of these deaths will originate from Asia and the Pacific Rim 

(Hammond, 1998). Given these projections, the AAPI youth population— 

both those who have recently immigrated and those who are continuously 

exposed to overseas print, videos, and film from their countries of origin— 

are at risk from unregulated tobacco advertising and promotions overseas. 

As tobacco control expert Judith Mackay notes, “If multinational tobacco 

companies could capture the China market, it wouldn’t make a difference if 

every American stopped smoking tomorrow” (Lin, 1997). The global aspects 

of tobacco use prevalence are far reaching and impact the AAPI youth 

directly because mediums of communication across borders cannot be controlled (e.g., cigarette promotional items, no bans on selling cigarettes to 

minors in many Asian countries, and no health warnings required by law 

on cigarette packs overseas). 

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CONCLUSIONS Research investigating tobacco use and exposure among AAPI 

youths has been extremely limited. Understanding the differences among 

and between AAPI ethnic subgroups is essential in designing relevant qualitative tobacco control research nationwide—for both youths and adults. In 

order to conduct community-based research in the AAPI community, 

researchers will need to consider many factors, including socioeconomic 

status; cultural characteristics; acculturation factors; stresses; advertising targets, both domestic and international; prices of tobacco products; and 

capacities of communities to mobilize against tobacco influences (e.g., the 

roles of community, schools, and family and social networks). 

As the nation moves into the 21st century, it is clear that the AAPI population will continue to contribute to the multicultural fabric of this society. As tobacco control advocates and researchers, it is necessary that we take 

responsibility within and across the borders of the United States to protect 

the health of all our children from tobacco health hazards. 

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253

American Indian and Alaska Native 

Teen Cigarette Smoking: A Review 

Felicia Schanche Hodge 

INTRODUCTION Although high cigarette smoking rates have been documented 

among all racial/ethnic groups, American Indian and Alaska Native (AI/AN) 

teens in particular have consistently been reported to have the highest percentage of cigarette smokers in the nation (Bachman et al., 1991; U.S. 

DHHS, 1998). The 1998 United States Surgeon General’s Report documents 

American Indian teen smoking rates of 41.1 percent for males and 39.4 percent for females (U.S. DHHS, 1998). Not only is this smoking statistic the 

highest in the nation, it also closely mirrors that reported for adult 

American Indians and Alaska Natives (39.2 percent). Table 17-1 shows 

smoking prevalence rates for various different North American Indian 

groups. 

Several studies suggest that smoking rates are particularly high among 

the Native American population in the northwestern regions of the United 

States, in Canada, and in Alaska. Smoking rates have been documented to 

fall between 40 and 50 percent for northern California urban and rural 

Indians (Hodge et al., 1995) and to be over 50 percent for Alaskan and 

Canadian Natives (Gaudette et al., 1993). Among Arctic youths, research has 

documented smoking rates as high as 70 percent among the Inuit and 64 

percent among the Dene (Millar, 1990). In the Southwest, Navaho youth 

smoking rates have been reported to be 54 percent (Wolfe and Carlos, 

1987). A 1988–1990 U.S. National Youth Survey documented smoking rates 

of 80 percent among reservation 12th graders and 74 percent among reservation 8th graders. Non-reservation Indian smoking rates were 10 percent 

lower and White smoking rates were 50 percent lower (Beauvais, 1992). 

TRADITIONAL USE Tobacco has long played a significant role in the American 

OF TOBACCO Indian culture (Seig, 1971; Paper, 1989). Historically, tobacco 

was used in medicinal and healing rituals, in ceremonial or religious practices, and as an instructional or educational device. Traditionally, tobacco 

was seen as a gift of the earth. It was burned and the rising smoke was used 

to cleanse and heal. Symbolically, smoke from tobacco was called “Spirits 

paths” (Linton, 1924). It served to channel the evil or bad spirits. Tobacco 

was often sprinkled around the beds of ailing individuals to protect and to 

act as a healing agent. In addition, tobacco was used for social and peaceful 

purposes to promote well-being and good thoughts. Prior to important 

meetings, tobacco was smoked as a ritualistic exchange. Furthermore, tobacco was also used as a powerful teaching tool (Linton, 1924). Elders, healers, 

and tribal leaders used tobacco leaves in their storytelling. Tobacco was also 

tossed into the air to demonstrate that the wind travels just as humans do. 

255

Smoking and Tobacco Control Monograph No. 14 

Table 17-1 

North American Indian Smoking Prevalence Rates 

Sample Percentage 

Population (Adults) Size Use Associations Source 

US Probability 300,540 44.5 (Indian men) Indians smoked fewer CDC, 1992 

Sample of Adults 22.6	 26.6 (Indian women) cigarettes per day. Rates 

25.7 (White men) related to social class for 

23.0 (White women) Indians— inversely related 

for Whites. 

Northwest Territories 20,000 70.0 (Inuit) Inuit women have the Gaudette et al., 

Of Canada: Adults 60.0 (Status Indian) highest rate of lung cancer 1993 

50.0 (White) ever recorded 

30.0 (All Canada) 

Western US: Blackfeet 463 34.0 (men) None listed Goldberg et al., 

Of Montana: Adults 50.0 (women) 1991 

Southwest and Plains 805 18.1 (SW men) None listed Sugarman et al., 

Adults 14.7 (SW women) 1992 

48.4 (Plains men) 

57.3 (Plains women) 

South Central: Cherokee144 27.8 (Indian) None listed Hill et al., 1994 

Adult sample 

Western: California 1,369 47.0 (Indian men) Hodge et al., 

Adult sample 37.0 (Indian women) 1995 

Population Sample Percentage


(Adolescents) Size Use Associations Source


US High School 

Seniors: 1976–1989 

US Indian Health 

Service Reservation 

Areas: Grades 7–12 

US National Youth 

Survey: 1988–1990 

Canadian Arctic Youth 

Ages 15–19 

North Central USA: 

7th Grades 

17,000 

13,454 

102,194 

230 

4,319 

36.8 (Indian males) 

20.5 (Alaska area) 

10.6 (Other areas) 

80.0 (Reservation 

12th graders) 

74.0 (Reservation 

8th graders) 

75.0 (Inuit) 

64.0 (Dene/Metis) 

43.0 (Non-Indian) 

33.0 (Indian) 

54.0 (Navaho) 

38.1 (Indian) 

25.8 (Whites) 

Indian students had Bachman et al., 


highest rate among all 1991


ethnic groups


Students with “below Blum et al., 1992


average” grades had 


highest rates


Non-Reservation Indian Beauvais, 1992


rates were 10% lower.


“White” rates were 50% 


lower


None listed Millar, 1990


None listed Murray et al., 

1987 

None listed Wolfe et al., 

1987 

Indian users had Soloman et al., 

lower expectations 1994 

for college, lower 

school, religion, and 

family involvement, 

and higher alcohol 

and marijuana use. 

Southwest Indian Youth 226


South Central: 972


Cherokee 


Youth Grades 9-12


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Chapter 17 

There were specific rules to the smoking of tobacco, which were just as 

important as the act of smoking itself. Small puffs of smoke were taken and 

held in the mouth. Deep inhaling was not encouraged, as the smoke was 

not to be enjoyed, but was a symbolic gesture meant to cleanse the air, the 

heart, and the mind. It became a facilitator to the spirits, so that peaceful 

exchange could be obtained and prayers could be heard. 

CULTURAL FACTORS There is a rich diversity in the American Indian and Alaska 

Native culture. Over 500 federally recognized tribes are concentrated in 25 

reservation states (U.S. Bureau of the Census, 1990). Over 150 Indian languages continue to be spoken today. These native languages—coupled with 

Indian customs, values, and beliefs—provide a wealth of cultural richness. 

But the diversity in culture also presents a challenge as we address the 

needs, concerns, and culturally specific issues in the various communities. 

Several culturally specific factors have been found in recent studies to 

influence patterns of tobacco use. These factors include a group’s changing 

lifestyles and its levels of knowledge, attitudes, and beliefs toward tobacco. 

A prevalence survey of 1,369 adult Indians in northern California found 

that, although levels of knowledge were high regarding the harmful effects 

of smoking, this knowledge did not influence attitudes or behavior regarding tobacco use. 

Further, attitudes held by Indians were lenient with regard to smoking 

behaviors (Hodge et al., 1995). Ninety-five percent of the sample was reluctant to be assertive in issues surrounding smoking (e.g., asking others to 

stop smoking). In particular, Indian adults were reluctant to prohibit youths 

from smoking. American Indians have a tradition of non-interference that 

influences behaviors even in situations regarding smokers. It is often not 

culturally acceptable to tell elders, guests, or even youths not to smoke— 

even in one’s own home. This cultural value has presented a challenging 

element in the tobacco control movement. 

The values held by many tribal groups may be in conflict with those of 

the larger society. Acknowledging the rights of individuals while retaining a 

strong sense of tribal identity is common practice in Indian communities. 

Behavior that is non-assertive and non-interfering is held in high esteem. 

The long historic role that tobacco has played in traditional ceremonial and 

medicinal uses, along with the values of the culture, may have an impact 

on a tribal group’s attitude and behavior toward smoking. 

Relocation from traditional lands to an urban environment has added 

to the abusive use of tobacco products. This is a major issue as urban 

Indians now constitute a larger group than rural or reservation Indians. As 

many as 100 tribes may be represented in one urban site. Once in the cities, 

lifestyles change and a different set of stresses exists. Housing needs, unemployment, and the lack of nearby relatives and social support mechanisms 

become important stresses as well as acculturation factors. Habits such as 

cigarette smoking are readily adopted by adults and teens alike. Indeed, 

research has documented that the rate of smoking increases dramatically in 

urban sites (Hodge et al., 1996). 

257 
Smoking and Tobacco Control Monograph No. 14 

The Federal Relocation and Termination Program of 1947 created a sudden population explosion of American Indians in urban areas. Under this 

program, people were moved from reservations to cities, where they were to 

be quickly trained and placed into employment. However, lack of information for survival and subsequent poor planning resulted in acculturation 

problems that have remained throughout the years. The transition from the 

predictable routine of reservation life to the unknown urban setting resulted in isolation, loneliness, and inadequate provision for the maintenance of 

health services, housing, and economic assistance. The isolation factor was 

also compounded by acculturation. With subsequent generations in the 

cities, many are removed from the traditions of the reservation and rural 

life—they are more influenced by peers who may not be Indian or who 

may hold different values and beliefs. Exposure to targeted media campaigns and more access to television stations and advertisements resulted in 

pressures to adopt the lifestyles and habits of the mainstream. The roles of 

family members, the close-knit communities, the authority of the tribe to 

reinforce accepted behaviors, and the protective circle of a teenager’s life 

were all severely disrupted in the urban setting. No provisions were made to 

develop programs to reinforce these cultural elements. Although the new 

urban population is multi-tribal—and although Indians of various tribes 

can be grouped together—a sense of isolation can remain. 

SMOKING PREVENTION Over the past 20 years, there has been a national effort 

AND CONTROL to decrease the dependence that smokers have on 

tobacco products. This campaign for tobacco control includes extensive scientific research, education, and prevention strategies. Although these public 

health efforts directed at reducing the prevalence of smoking have been 

somewhat successful, the rate of decline in tobacco use has varied among 

diverse socio-demographically defined groups such as the American Indians 

and Alaska Natives (Rhoades, 1990). The smoking patterns of these groups 

are of special concern because of their poor health status, high smoking 

rates, and slower smoking quit rates. The Public Health Service has also 

reported that impoverished populations have very high rates of tobaccoproduct use, due in part to the lack of information on the harmful effects of 

tobacco (U. S. DHHS, 1991). 

American Indians may not be fully aware of the health hazards associated with tobacco abuse. Not only are adult Indians at high risk for smoking 

and for smokeless tobacco use, but American Indian and Alaska Native 

youths have been identified as having significant increases in their use of 

tobacco products. Shelton (1993) reports that American Indian adolescents 

smoke cigarettes more heavily than non-Indians. Thus, there is an ongoing 

need for the development and implementation of smoking cessation and 

control programs. A stronger proactive leadership is needed to confront and 

halt multi-media efforts of targeted advertising. 

Efforts are also required to decrease the social acceptability of smoking. 

In a study in northern California, adult Indian smokers and non-smokers 

were shown to be statistically more lenient in their attitudes toward the 

acceptability of smoking (Hodge et al., 1995) than the general California 

258

Chapter 17 

population. They were reluctant to tell others to quit smoking, to move 

away from smokers, and even to establish a no-smoking policy in their 

homes. The cultural value of non-interference may be a significant factor in 

the social acceptability of smoking in some Indian communities. 

POLICY ISSUES American Indians are in a unique situation in that the development and enforcement of smoking cessation policies may be more viable in 

their communities than in other non-Indian communities. In general, 

Indians residing on reservations do not have to follow state regulations 

since federal law governs reservations. Tribes develop and enforce their own 

policies for the general welfare of their community. Many reservation tribes 

have their own court system and jurisdiction that govern their land and 

their tribal members. 

New policies are now needed to govern the sale, distribution, and use of 

cigarettes and chewing tobacco products. There are two areas in which policy development and enforcement are recommended. The first area involves 

economic issues and the second is concerned with the social acceptance of 

the abusive use of cigarette smoking. 

To discuss the economic issues surrounding cigarette smoking among 

American Indians, one must realize that there are two major pathways for 

tobacco to enter reservation lands. The first is through the on-site tribal 

smoke shops and the second is via the local markets and shops. Limiting or 

prohibiting the establishment of smoke shops would provide a strong message regarding the restricted support for cigarettes on reservations. The loss 

of the smoke shop revenue would require some other income-generating 

project to counteract the effect of the closed smoke shops. Furthermore, 

requiring a license for the sales and distribution of cigarettes would provide 

some control regarding the selling of such products to minors. Other activities could include prohibiting cigarette sales to youths, banning the distribution of free tobacco samples, prohibiting cigarette vending machines, 

and enforcing the minimum age for the purchase of cigarettes. 

There is a need for tobacco control efforts in American Indian communities that include information sharing, education, intervention, and policy 

making. Assisting American Indians to reduce and control the abusive use 

of cigarettes will go a long way toward combating the health hazards of 

addictive cigarette abuse. 

SUMMARY The implications of American Indian teen smoking rates are very serious. The health consequences of cigarette smoking are well documented. 

The lack of sanctions from the family and community bodes of increasing 

or sustained trends in smoking rates. The upward trend in teenage Indian 

smoking rates reported in this chapter calls for culturally appropriate intervention and targeted research in terms of health education, smoking cessation, and prevention intervention. 

There is a special relationship between tobacco and Indian ceremonial 

activities and beliefs. Tobacco continues to play an important role in 

American Indian communities. Once seen as the symbol for peace and heal259 
Smoking and Tobacco Control Monograph No. 14 

ing among American Indians, tobacco is quickly becoming a symbol for 

death and has been transformed from a healing herb to a life-threatening 

habit. Cigarette smoking has become one of the leading causes for death 

and disability for the Indian population. 

In contemporary times, the use of cigarettes can no longer be seen solely in a cultural context. Traditionally, tobacco was not used on a daily basis 

and not just any member of the tribe could smoke. The ashes were not 

stepped on once the tobacco was burned, nor was it flung away to be forgotten. Today, cigarette smoking serves a different function. Tobacco has 

become an abusive habit in which the traditional practices are no longer 

employed. 

Our challenge is to retain the cultural value of tobacco products and to 

reduce the harmful effects of smoking in a manner that is culturally appropriate, informative, and non-threatening. American Indian and Alaska 

Native teens can take an active role in the leadership of tobacco control initiates. Opportunities need to be developed for American Indians to lead 

their nations to a healthier lifestyle by controlling the abusive use of tobacco while allowing their traditions to continue. This may result in a substantial reduction in the high smoking rates among Indian teenagers. 

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