Surgeon General's Report Table 29. Percentage of high school students who used tobacco, by participation on sports teams and steroid use, Youth Risk Behavior Survey, United States, 1991 Any Current Current Current cigarette cigarette frequent smokeless Category Number use* use* cigarette use? tobacco use’ Participation on sports teams* Total | 0 teams 5,738 73.6 31.3 17.2 6.6 21 team 6,429 67.2 24.3 8.9 13.5 Female | 0 teams 3,608 72,0 29.0 14.3 0.7 21 team 2,635 66.3 24.8 9.6 2.1 Male 0 teams 2,125 76.1 34.8 21.6 15.5 21 team 3,794 67.8 23.9 8.4 21.0 Steroid use? Total 0 times 11,868 69.7 26.8 12.1 9.7 21 time 382 . 87.2 54.8 35.7 38.7 Female 0 times 6,164 69.3 26.9 12.2 1.1 2 1 time 116 88.5 61.8 29.9 16.5 Male 0 times 5,700 70.0 26.6 12.0 18.1 > 1 time 265 86.8 52.6 27.0 44.6 Source: Centers for Disease Control and Prevention, Division of Adolescent and School Health (unpublished data). * During the respondent's lifetime. t Cigarette use on > 1 day during the 30 days preceding the survey. + Cigarette use on 2 20 days during the 30 days preceding the survey. 5 During the 30 days preceding the survey; includes chewing tobacco or snuff. 4During the 12 months preceding the survey; includes sports teams sponsored by school and other organizations. 1During the respondent's lifetime, without a doctor's prescription. 76 Epidemiology Preventing Tobacco Use Among Young People (under 20 years old) was highest among women aged 18 and 19 (24 percent) and lowest among women younger than 15 years of age (8 percent) (Table 30). White non- Hispanic adolescent mothers were more likely to have smoked during pregnancy than white non-Hispanic mothers 20 through 49 years old. Black non-Hispanic adolescent mothers were less likely to have smoked than those 20 through 49 years old; Hispanic adolescent moth- ers were about as likely as older Hispanic mothers to have smoked. Among the mothers who smoked during pregnancy, about 23 percent of those younger than 15 years of age smoked more than 10 cigarettes per day; 34 percent of mothers 15 through 19 years old, and 44 percent of mothers 20 through 49 years old smoked more than 10 cigarettes per day during the pregnancy (NCHS 1992b). Self-Reported Indicators of Health Status Among Smokers The MTFP collected data on self-reported indica- tors of health status among the nation’s high school seniors. A five-category scale of lifetime smoking history was constructed from questions on lifetime smoking and on the grade in which the respondent began smoking daily (Table 31). Nine measures of health status were analyzed in terms of lifetime smoking history. Adjusted odds ratios were calculated by regressing the logit-trans- formed prevalence of each health measure over the prior year on the variable for lifetime smoking history and on the covariates of current marijuana use, lifetime cocaine use, parental education, and time (Hosmer and Lemeshow 1989). Alcohol use was also included as a covariate for the measures of staying at home because of not feeling well and of overall physical health. Current smokers were more likely than never smokers to report all of the symptoms or indicators listed. A trend test (using the linear contrast of the estimated regression coefficients for smoking history [Miller 1986]) revealed that these adolescent smokers were more likely than never smok- ers to experience all but two of the health status measures (e.g., sinus congestion and sore throat). Self-Reported Indicators of Nicotine Addiction Among Smokers The research of McNeill (McNeill et al. 1986; McNeill, Jarvis, West 1987; McNeill 1991) has demon- strated the presence of nicotine addiction in young smok- ers (11 through 16 years old) in Great Britain. A majority of these young smokers experienced withdrawal symp- toms during abstinence or had some difficulty quitting (McNeill et al. 1986; McNeill, Jarvis, West 1987). The 1991 NHSDA asked 12- through 18-year-olds questions that probed various components ‘of nicotine addiction (USDHHS 1988b). Current smokers who had smoked at least 100 cigarettes in their lifetime were the most likely of adolescent smokers to report having experienced sev- eral indicators of nicotine addiction (Table 32). Four of every five of these heavier smokers who tried to cut down on cigarettes during the previous 12 months had failed. Seventy percent felt that they needed or were dependent on cigarettes. Persons who had smoked at least 100 cigarettes in their lifetime but none in the last month were the next most likely to report that they felt dependent on cigarettes and that they had experienced withdrawal during the previous 12 months. These persons were more likely to have become regular smokers than were those who had not yet smoked 100 cigarettes. Though these respon- dents were more likely to show signs of addiction, they were evidently able to discontinue smoking for at least one month—a finding consistent with the observation that less-addicted smokers are more able to quit (USDHHS 1988b). Respondents who had not smoked 100 cigarettes by the time they were surveyed appeared less likely to become addicted to nicotine than those who had smoked at least 100 cigarettes. Table 30. Cigarette smoking prevalence (%) during pregnancy among mothers of live-born infants, by age and race/Hispanic origin, 43 states and the District of Columbia, 1989 Age (years) Race/Hispanic origin <15 15-17 18-19 20-49 Overall 7.7 19.0 23.9 19.1 White, non-Hispanic 21.2 32.1 33.3 20.5 Black, non-Hispanic 2.7 6.2 10.4 20.2 Hispanic 5.9 7.5 8.7 8.0 Source: National Center for Health Statistics (1992b). Epidemiology 77 Surgeon General's Report Table 31. Adjusted odds ratios* (and 95% confidence intervals) for symptoms of diseases and smoking status among high school seniors who have smoked occasionally or regularly, Monitoring the Future Project, United States, 1982-1989 Self-reported sympton/ indicator* Have smoked occasionally, but not regularly Smoked regularly at one time, but not in the past 30 days Smoke regularly now, began daily smoking in grades 10-12 Smoke regularly now, began daily smoking by grade 9 Shortness of breath when not exercising Chest cold Sinus conges- tion, runny nose, sneezing Coughing spells Cough with phlegm or blood Wheezing or gasping Sore throat or hoarse voice Stayed home most or all of day because not feeling well? Overall physical health’ 1:38 (1.24, 1.52) 1.34 (1.23, 1.46) 1.31 (1.20, 1.44) 1.33 (1.24, 1.43) 1.42 (1.28, 1.56) 1.41 (1.26, 1.48) 1.36 (1.26, 1.48) 1.43 (1.31, 1.55) 1.47 (1.32, 1.63) 1.90 (1.56, 2.31) 1.34 (1.13, 1.60) 0.99 (0.83, 1.19) 1.28 (1.11, 1.48) 1.73 ( 1.44, 2.09) 2.45 (1.99, 3.01) 1.07 (0.92, 1.26) 1.38 (1.17, 1.62) 2.39 (1.98, 2.90) 2.32 (2.03, 2.64) 1.53 (1.35, 1.73) 1.17 (1.02, 1.34) 2.04 (1.83, 2.27) 2.31 (2.02, 2.63) 2.36 (2.06, 2.70) 1.34 (1.19, 1.52) 1.53 (1.35, 1.73) 1.98 (1.72, 2.28) 2.72 (2.40, 3.08) _ 1,72 (1.52, 1.93) 1.19 (1.05, 1.35) 2.20 ( 1.98, 2.45) 2.32 (2.04. 2.64) 2.57 (2.25, 2.95) 1.17 (1.04, 1.32) 1.56 (1.39, 1.76) 2.08 (1.81, 2.38) Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data). * Adjusted for past-month marijuana use, lifetime cocaine use, parental education, and time. Odds ratios are relative to those for seniors who had either never smoked cigarettes or had smoked cigarettes once or twice only. ‘Occurrence during the previous 30 days, with the exeption of overall physical health. tAlso adjusted for past-month alcohol use. SOdds ratios based on the percentage who reported that their health was poorer than average during the preceding year. 78 Epidemiology — preventing Tobacco Use Among Young People Table 32. Self-reported indicators of nicotine addiction among 42-18-year-olds (N = 1,589), by smoking history, National Household Surveys on Drug Abuse, United States, 1991 Smoking history* Have smoked Have smoked Have smoked Have smoked 1-99 2 100 1-99 2 100 cigarettes, cigarettes, cigarettes cigarettes but none in but none in and smoked in and smoked in past month past month past month past month Indicator* (%) (%) - (%) (%) Tried to cut down on 43.7 72.2 44.9 73.4 use of cigarettes Unable to cut down on 46.9 40.4 59.5 81.2 use of cigarettes* Felt need to have more 10.9 14.2 12.2 27.1 cigarettes to get the same effect Felt need to have cigarettes 12.2 37.2 16.2 70.1 or felt dependent on cigarettes Felt sick because of stopping 15.9 24.9 14.1 37.4 or cutting down on cigarettes* Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data). *Among people who smoked cigarettes at all in the past 12 months. Occurrence during the past 12 months. tAnalysis limited to people who tried to cut down on cigarettes during the last 12 months. Smokeless Tobacco Use Among Young People in the United States Recent Patterns of Smokeless Tobacco Use Ever Use of Smokeless Tobacco The overall national estimates for adolescents who had tried smokeless tobacco were 18 percent for 12- through 18-year-olds in the 1989 TAPS, 13 percent for the same age group in the 1991 NHSDA, and 32 percent for high school seniors surveyed by the MTFP in 1992 (Table 33). In all three surveys, males were much more likely than females to have tried smokeless tobacco. White males were more likely than any other subgroup to have tried this product. The prevalence of adolescents who had used smoke- less tobacco increased with increasing age. Twenty- eight percent of 17- and 18-year-old TAPS respondents, 21 percent of 17- and 18-year-old NHSDA respondents, and 32 percent of high school seniors in the 1992 MTFP survey reported that they had tried smokeless tobacco. Adolescents in the northeast region of the United States were less likely than those in the other regions to have tried smokeless tobacco. Current Use of Smokeless Tobacco Available data suggest that there was an increase in the use of smokeless tobacco among adolescents between 1970 and the mid-1980s. The prevalence of chewing tobacco use was 1.2 percent among 17- through 19-year-old males in the 1970 NHIS (USDHHS 1986, 1989b), 3.0 percent among 16- through 19-year-old males in the 1985 Current Population Survey (Marcus et al. 1989; USDHHS 1986), and 5.3 percent among 17- through 19-year-old males in the 1986 Adult Use of Tobacco Epidemiology 79 Surgeon General's Report Table 33. Percentage of young people who have ever used smokeless tobacco, by gender, race/Hispanic origin, age/grade, and region, Teenage Attitudes and Practices Survey (TAPS), National Household Surveys on Drug Abuse (NHSDA), Monitoring the Future Project (MTFP), United States, 1989, 1991, 1992 Characteristic TAPS* NHSDA' MTFP*S Overall 18.4 13.2 32.4 Gender Male 31.3 22.3 53.7 Female 4.4 3.5 12.1 Race/ Hispanic origin White, non-Hispanic 22.4 16.6 38.2 Male 38.6 28.4 61.6 Female 4.8 4.4 15.2 Black, non-Hispanic 7.6 4.5 10.7 Male 11.9 6.7 18.0 Female 3.1 2.1 4.9 Hispanic 8.1 4.8 NA‘ Male 13.4 8.8 NA Female 2.3 0.5 NA Age/grade 12-14 years 9.6 6.5 15-16 years 20.8 15.0 17-18 years 28.2 20.9 8th grade 20.7 10th grade 26.6 12th grade 32.4 Region Northeast 14.0 9.0 25.3 North Central 19.7 14.0 38.6 South 21.4 13.9 31.5 West 15.8 14.5 32.0 Sources: 1989 TAPS: Centers for Disease Control and Prevention (CDC), Office on Smoking and Health (OSH) (unpub- lished data); 1991 NHSDA: CDC, OSH (unpublished data); 1992 MTFP: Johnston, O'Malley, Bachman (in press); Institute for Social Research, University of Michigan (unpublished data). *1989 TAPS, aged 12-18 years. Based on response to the question, “Have you ever tried using chewing tobacco or snuff?” *1991 NHSDA, aged 12-18 years. Based on response to the question, “When was the most recent time you used chewing tobacco or snuff or other smokeless tobacco? (“Never used smokeless tobacco in lifetime” was a precoded response.) #1992 MTFP survey of high school seniors. Based on response to the question, “Have you ever taken or used smokeless tobacco (snuff, plug, dipping tobacco, chewing tobacco)?” Respondents who reported that they had taken or used smoke- less tobacco at least once or twice were classified as ever users. SWith the exception of data for 8th- and 10th-grade students, all other data points for the MTFP surveys reflect estimates for high school seniors. 4NA = Not available. 80 Epidemiology preventing Tobacco Use Among Young People Survey (AUTS) (USDHHS 1989b). The same surveys indicated that the prevalence of snuff use was 0.3 percent among 17- through 19-year-old males in 1970, 2.9 percent among 16- through 19-year-old males in 1985, and 5.3 rcent among 17- through 19-year-old males in 1986. In the 1986-1989 MTFP surveys, high school se- niors’ past-month use of smokeless tobacco declined slightly for all respondents (from 12 to 8 percent), for whites (from 13 to 10 percent), and for males (from 22 to 16 percent) (Bachman, Johnston, O’Malley 1987, 1991; Johnston, Bachman, O’Malley 1991, 1992). In the 1992 MTEP survey, however, past-month use of smokeless tobacco was 11 percent for all respondents, 14 percent for whites, and 21 percent for males (ISR, University of Michigan, unpublished data). In the NHSDA, the preva- lence of past-month use of smokeless tobacco among 12- through 17-year-old males was 6.6 percent in 1988 and 5.3 percent in 1991 (USDHHS 1989a, 1992a). In the same survey, use of smokeless tobacco in the past year was estimated to be 11.1 percent in 1985, 7.0 percent in 1988, 6.1 percent in 1990, and 6.1 percent in 1991. A parallel decline has been reported among young adults (18 through 25 years old): the prevalence of past-year use of smokeless tobacco in this group was 11.1 percent in 1985, 8.9 percent in 1988, 9.2 percent in 1990, and 8.7 percent in 1991 (USDHHS 1988a, 1989a, 1991a, 1992a). The reduction in the late 1980s may be attributed to increased awareness resulting from several events: (1) the much-publicized Sean Marsee case, in which a star high school athlete who used snuff died of oral cancer (Fincher 1985); (2) the 1986 convening of a major national conference on smokeless tobacco use and the 1986 release of a report by the Advisory Committee to the Surgeon General on smokeless tobacco (Journal of the American Medical Association 1986; USDHHS 1986); (3) the intro- duction in 1986 of health warnings on smokeless tobacco packages and advertising; and (4) the enactment in 1986 of a ban on the advertising of smokeless tobacco prod- ucts through the electronic media (USDHHS 1989b, 1992b). The overall national prevalence estimates for cur- rent smokeless tobacco use (within the 30 days preced- ing the survey) were 3 percent for past-month users among persons 12 through 18 years old surveyed in the 1991 NHSDA (reflecting about 800,000 users), 11 percent for high school seniors in the 1992 MTFP survey, and 11 percent for students in grades 9-12 in the 1991 YRBS (Table 34). Current use was substantially more preva- lent among males than females; 6 percent of the males in the NHSDA and 20 percent of the males in the other two surveys reported current use, whereas only about 1 per- cent of the females in the three surveys reported current use. Smokeless tobacco use was highest among white males; Hispanic males had the next highest prevalence, and black males had the lowest. Although reliable na- tional data are not currently available on smokeless to- bacco use among American Indian and Alaskan Native adolescents, local surveys have reported very high preva- lence (e.g., CDC 1987, 1988; Schinke et al. 1987; Hall and Dexter 1988; see also “Sociodemographic Factors in the Initiation of Smokeless Tobacco Use” in Chapter 4). Smokeless tobacco use increased with increasing age in the NHSDA survey of 12- through 18-year-olds and by grade in the 1992 MTFP survey, but did not change appreciably among students in the four high school grades surveyed by the YRBS. Individual YRBS surveys conducted in several state and local communities found that male high school stu- dents were far more likely than females to use smokeless tobacco (Table 35); nonetheless, smokeless tobacco was used by as much as 10 percent of female respondents in a given state survey. In some states (Alabama, Idaho, South Dakota, Colorado, Wyoming, and Montana), males were as likely to report current smokeless tobacco use as_ they were to report current cigarette use (see Table 3). The 1992 MTFP survey gathered data on the fre- quency of smokeless tobacco use among approximately 2,600 high school seniors (ISR, University of Michigan, unpublished data). Users were classified according to the number of days they had used smokeless tobacco over a period of 30 days. Thirty-eight percent of male users and 20 percent of female users reported that they had used smokeless tobacco at least once every day. Seventy percent of the female users reported that they had used the product less than once each week. Thirty- nine percent of white users and 12 percent of black users reported daily use of smokeless tobacco. Almost 60 per- cent of the black users reported that they had used the product less than once each week. Among past-month users, 46 percent of those living in the West and 43 percent of those from the South had used smokeless tobacco at least once each day. Thirty-three percent of users who lived in the north-central and 22 percent from the northeast United States used smokeless tobacco ona daily basis. Use of Smokeless Tobacco and Cigarettes As was shown in Table 23, 43 percent of male high school seniors who used smokeless tobacco also smoked cigarettes. Tobacco, either in the form of cigarettes or smokeless tobacco, was used by 15 percent of 12- through 18-year-olds in the 1991 NHSDA, 32 percent of high school students in the 1991 YRBS, and 33 percent of high school seniors in the 1992 MTFP (Table 36). Males were substantially more likely than females to use tobacco. Regardless of gender, the prevalence of tobacco use for Epidemiology 81 Surgeon General's Report Table 34. Percentage of young people who currently (within the past 30 days) use smokeless tobacco, by gender, race/Hispanic origin, age/grade, and region, National Household Surveys on Drug Abuse (NHSDA), Monitoring the Future Project (MTFP), Youth Risk Behavior Survey (YRBS), United States, 1991, 1992 Characteristic NHSDA* MTFP** Y¥RBSS Overall 3.4 11.4 10.5 Gender Male . 6.0 20.8 19.2 Female 0.6 2.0 13 Race/ Hispanic origin . White, non-Hispanic 4.4 13.5 13.0 Male 8.1 23.9 23.6 Female 0.5 2.5 1.4 Black, non-Hispanic 0.7 2.5 2.1 Male 0.5 5.2 3.6 Female 0.8 0.2 0.7 Hispanic 1.2 NA‘ 3.5 Male 2.1 NA 10.7 Female 0.3 NA 0.6 Age/grade 12-14 years 1.5 15-16 years 3.6 17-18 years 5.9 8th grade 7.0 9th grade 9.0 10th grade 9.6 10.1 11th grade 12.1 12th grade 11.4 10.7 Region Northeast 0.8 8.2 8.8 North Central 3.9 12.3 13.3 South 4.0 12.5 8.6 West 3.9 11.1 10.5 Sources: 1991 NHSDA: Centers for Disease Control and Prevention (CDC), Office on Smoking and Health (unpublished data); 1992 MTFP: Johnston, O'Malley, Bachman (in press); Institute for Social Research, University of Michigan (unpub- lished data); 1991 YRBS: CDC (1992c); CDC, Division of Adolescent and School Health (unpublished data). *1991 NHSDA, aged 12-18 years. Based on response to the question, “When was the most recent time you used chewing tobacco or snuff or other smokeless tobacco?” *1992 MTFP survey of high school seniors. Based on response to the question, “How frequently have you taken smokeless tobacco during the past 30 days?” With the exception of data for 8th- and 10th-grade students, all other data points for the MTFP survey reflect estimates for high school seniors. 51991 YRBS, grades 9-12. Based on response to the question, “During the past 30 days, did you use chewing tobacco, such as Redman, Levi Garrett, or Beechnut, or snuff, such as Skoal, Skoal Bandits, or Copenhagen?” “NA = Not available. 82 Epidemiology Preventing Tobacco Use Among Young People Table 35. Percentage of high school students who use smokeless tobacco, by gender, Youth Risk Behavior Surveys, United States and selected U.S. sites, 1991 Smokeless tobacco use* Site Female Male Total Weighted data National survey 1 19 10 State surveys Alabama 2 31 16 Georgia 2 22 12 Idaho 3 24 14 Nebraska 2 26 14 New Mexico 4 27 16 New York' 2 19 11 Puerto Ricot 0 5 2 South Carolina 2 20 11 South Dakota 10 29 20 Utah 2 12 7 Local surveys Chicago 2 5 3 Dallas 1 7 4 Fort Lauderdale 1 9 4 Jersey City 1 6 3 Miami 1 6 3 Philadelphia 2 6 4 San Diego 1 7 4 Unweighted data’ State surveys Colorado*t 6 32 19 District of Columbia* 2 5 4 Hawaii 2 14 8 Montana 7 33 20 New Hampshire 4 22 13 New Jersey* 2 14 7 Oregon 5 28 16 Pennsylvania‘ 2 29 16 Tennessee 1 34 17 Wisconsin 3 19 11 Wyoming 5 31 19 Local surveys Boston 1 5 3 New York City 1 5 3 San Francisco 2 6 4 Source: Centers for Disease Control (1992d). *Respondents used chewing tobacco or snuff on 1 or more of the 30 days preceding the survey. ‘surveys did not include students from the largest city. tCategorized as a state for funding purposes. SFourteen sites had overall response rates below 60 percent or had unavailable documentation; weighted estimates were not reported. Epidemiology 83 Surgeon General’s Report Table 36. Percentage of young people who currently (within the past 30 days) use cigarettes and/or smokeless tobacco , by gender, race/Hispanic origin, region, and age/grade, National Household Surveys on Drug Abuse (NHSDA), Monitoring the Future Project (MTFP), Youth Risk Behavior Survey (YRBS), United States, 1991, 1992 Characteristic NHSDA* MTFP* YRBS! Overall 15.1 33.2 31.8 Gender Male 17.1 38.8 35.8 Female 13.0 27.3 27.6 Race/ Hispanic origins White, non-Hispanic 17.9 38.4 36.2 Male 20.3 43.0 40.0 Female 15.4 33.3 32.0 Black, non-Hispanic 6.0 8.8 13.7 Male 6.6 14.3 16.0 Female 5.4 4.5 11.6 Hispanic 10.9 NAS 28.1 Male 10.8 NA 33.6 Female 10.9 NA 23.1 Age/grade 12-14 years 5.1 15-16 years 16.2 17-18 years 28.5 8th grade 20.5 9th grade 26.7 10th grade 27.6 29.6 11th grade 36.3 12th grade 33.2 34.7 Region Northeast 28.2 35.1 North Central 17.0 37.7 40.8 South 14.5 30.3 28.8 West 14.2 30.0 27.6 Sources: 1991 NHSDA: Centers for Disease Control and Prevention (CDC), Office on Smoking and Health (unpublished data); 1992 MTFP: Johnston, O'Malley, Bachman (in press); Institute for Social Research, University of Michigan (unpub- lished data); 1991 YRBS: CDC, Division of Adolescent and School Health (unpublished data). *1991 NHSDA, aged 12-18 years. Based on responses to the questions, “When was the most recent time you smoked a cigarette?” and “When was the most recent time you used chewing tobacco or snuff or other smokeless tobacco?” 1992 MTFP surveys of high school seniors. Based on responses to the questions, “How frequently have you smoked cigarettes during the past 30 days?” and “How frequently have you taken smokeless tobacco during the past 30 days?” *1991 YRBS, grades 9-12. Based on responses to the questions, “During the past 30 days, on how many days did you smoke cigarettes?” and “During the past 30 days, did you use chewing tobacco, such as Redman, Levi Garrett, or Beechnut, or snuff, such as Skoal, Skoal Bandits, or Copenhagen?” SNA = Not available. 84 = Epidemiology preventing Tobacco Use Among Young People white adolescents was higher than for Hispanics and placks. Tobacco use increased with increasing age and was most common in the north-central region of the United States. Sociodemographic Risk Factors for Smokeless Tobacco Use Current use of smokeless tobacco among male nigh school seniors varied according to several sociodemographic indicators, as shown by the 1986-1989 MTEP surveys (N [weighted] = 5,277). The prevalence of current smokeless tobacco use was 28 percent among those who lived alone, 29 percent among those living in father-only households, 16 percent among those living in mother-only households, and 20 percent among those living with both parents. Current use was more common among maleseniors living on farms (34 percent) and in the country (31 percent) than among those living in medium- ° sized to very large cities or suburbs (11 to 17 percent). The prevalence of current use was greater among students who rated their academic performance as average (25 percent) or below average (26 percent) than among those whorated their performanceasslightly aboveaverage (18 percent) or far above average (16 percent). Smokeless tobacco use was more common among male seniors who planned to enter the armed forces after high school than among those who did not have such plans (23 vs. 19 percent). Theself-reported importance of religion did not affect the prevalence of smokeless tobacco use among these MTFP seniors. , Grade When Smokeless Tobacco Use Begins The grade distribution for which MTFP seniors reported first trying smokeless tobacco was more similar to that reported for cigarettes than it was for those re- ported for alcohol, marijuana, and cocaine (Figure 8). Among seniors who had used smokeless tobacco, 23 percent had first done so by grade six, 53 percent by grade eight, and 73 percent by the ninth grade. Attempts to Quit Using Smokeless Tobacco Twenty-two percent of the male high school seniors in the 1986-1989 MTFP who had regularly used smokeless tobacco reported that they had not used the product during the 30 days preceding the survey. In the 1986-1989 TAPS, 12- through 18-year- olds who regularly used smokeless tobacco were asked to report the number of times they had tried to quit. Nineteen percent of males and 14 percent of females reported never making a quit attempt. Thirty- three percent of males and 72 percent of females had made one attempt to quit, 27 percent of males and 14 percent of females had tried quitting two or three times, and 21 percent of males and no females had tried to quit four or more times (1989 TAPS, CDC, OSH, unpublished data). Smokeless Tobacco Brand Preference TAPS also asked those who had regularly used smokeless tobacco what brand they usually bought. Among males in this subgroup (N = 300), 38 percent usually bought Copenhagen, 26 percent purchased Skoal or Skoal Bandits, 9 percent purchased Redman, 6 percent bought Levi Garrett, 2 percent purchased Beechnut, and 19 percent purchased other smokeless tobacco brands (1989 TAPS, CDC, OSH, unpublished data). Trends in Perceived Health Risks of Smokeless Tobacco Use High school seniors in the MTFP were asked, “How much do you think people risk harming themselves (physically or in other ways) if they use smokeless tobacco regularly (chewing tobacco, plug, dipping tobacco, snuff)?” Overall in 1991, 37 percent reported that great risk of harm is associated with smokeless tobacco use (ISR, University of Michigan, unpublished data); more females (43 percent) than males (32 percent) and more blacks (44 percent) than whites (36 percent) were of this opinion. Western respondents more frequently held this belief (43 percent) than respondents in the South (37 percent), the Northeast (36 percent), and the north-cen- tral United States (35 percent). Respondents who planned to attend college for four years were more likely to report this belief than those without college plans (39 vs. 33 percent). When the overall percentage of seniors in the 1986- 1989 MTEP who believed that great risk is associated with smokeless tobacco use is plotted against the percentage of seniors who had used smokeless tobacco, the trends of these percentages are inversely related (Figure 9). Between 1986 and 1988, the percentage of seniors who believed that great risk is associated with smokeless tobacco use increased from 26 to 33 percent. Between 1988 and 1989, this percentage remained rela- tively stable. The percentage of seniors who had used smokeless tobacco increased slightly between 1986 (31 percent) and 1987 (32 percent) and decreased by 1989 (29 percent). This finding is similar to that observed for cigarette smoking (Figure 5). In the 1989 TAPS, 94 percent of 12- through 18- year-old males reported that use of chewing tobacco and snuff can cause cancer. Ninety-three percent of those males who had never used smokeless tobacco and 96 percent of those who had regularly used the product endorsed that statement (Allen et al. 1993). Epidemiology 85 Surgeon General’s Report Figure 9. Trends in the percentage of high school seniors who believe that regular use of smokeless tobacco is a serious health risk and who have ever used smokeless tobacco, Monitoring the Future Project, United States, 1986-1989 40 38 36 34 32 30 Percent 28 26 24 22 == Ever use senraee Great risk 20 1986 1987 Year 1988 1989 Sources: Bachman, Johnston, O'Malley (1987, 1991); Johnston, Bachman, O'Malley (1991, 1992). Smokeless Tobacco Use and Other Drug Use Prevalence of Smokeless Tobacco Use and Other Drug Use The majority of male high school seniors in the 1986-1989 MTFP who used alcohol, marijuana, cocaine, or inhalants did not use smokeless tobacco (Table 37). Smokeless tobacco use, however, was from 1.5to3.9 times higher among users of these drugs than among nonusers. Most notably, 90 percent of smokeless tobacco users were also alcohol drinkers. Almost one-third (31 percent) of smokeless tobacco users also used marijuana, 7 percent used cocaine, and 5 percent used inhalants. The preva- lence of other drug use was from 1.4 to 1.9 times greater among smokeless tobacco users than nonusers. Grade When Use of Smokeless Tobacco and Cigarettes Begins In the 1986-1989 MTFP, 28 percent of all males had never tried cigarettes or smokeless tobacco by the 12th 86 Epidemiology grade; 44 percent had tried both; 18 percent had tried cigarettes but not smokeless tobacco; and 9 percent had tried smokeless tobacco but not cigarettes (Table 38). Of those male seniors who had tried both, 37 percent had tried cigarettes before smokeless tobacco, 24 percent had tried smokeless tobacco before cigarettes, and 40 percent had first tried both at about the same time. Smokeless Tobacco Use and Other Health- Related Behaviors In the 1991 YRBS, male high school students were more likely to report past-month use of smokeless tobacco if they rarely or never wore seat belts, were frequently involved in physical fights, carried weapons during one or more of the preceding 30 days, and had made one or more suicide attempts during the preceding 12 months (Table 27). These students were also more likely to currently use smokeless tobacco if they had ever had sexual intercourse (Table 28). Smokeless tobacco use did not vary appreciably (compared with cigarette smoking) preventing Tobacco Use Among Young People Table 37. Prevalence (%) of smokeless tobacco use among users of other drugs and prevalence of other drug use among smokeless tobacco users,* male high school seniors, Monitoring the Future Project, United States, 1986 -1989 Prevalence of Prevalence of Prevalence of Prevalence of smokeless smokeless other drug use other drug use tobacco use tobacco use among smoke- = among nonusers among users of among nonusers less tobacco of smokeless Other drugs other drugs of other drugs users tobacco Alcohol 26.3 6.8 89.6 63.8 Marijuana 27.6 17.6 30.9 20.0 Cocaine’ 28.7 19.6 7.4 4.6 Inhalantst 32.3 19.6 5.0 2.6 Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data). *Any use of smokeless tobacco or other drugs during the past month. tIncludes “coke,” “crack,” and “rock.” tGlue, aerosols, laughing gas, etc. Table 38. Percent distribution of male high school seniors (N [weighted] = 4,254), by grade in which they first used cigarettes and smokeless tobacco (used in the past 30 days), Monitoring the Future Project (MTEP), United States, 1986-1989 Grade when respondent first tried smokeless tobacco Grade when respondent first tried Never Row cigarettes $6 7-8 9 10 11 12 used total <6 7.1 4.9 2.3 1.4 0.7 0.3 5.8 22.4 7-8 2.1 5.8 2.5 1.3 0.8 0.3 4.7 17.5 9 13 2.0 2.3 0.9 0.4 0.2 3.2 10.3 10 0.6 0.7 1.0 1.5 0.2 0.1 2.3 6.4 11 0.1 0.5 0.7 0.5 0.5 0.1 1.5 3.9 12 * 0.3 0.2 0.1 0.1 0.3 0.9 19 Never used 2.0 2.7 19 1.1 1.3 0.2 28.3 37.6 Column total 13.3 16.9 11.0 6.9 4.0 14 46.7 100.0 Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data). *< 0.05. Note: Totals may not equal the sum of individual percentages because of rounding. by how many lifetime sexual partners these males had had or by whether they had used a condom during their most recent sexual intercourse. Lastly, students were consistently more likely to currently use smokeless to- bacco if they had participated on a sponsored sports team (Table 29). This finding is opposite to that found for cigarette smoking and sports. Smokeless tobacco use was also more likely among students who had used steroids without a doctor's prescription. Epidemiology 87 Conclusions Surgeon General's Report 88 Tobacco use primarily begins in early adolescence, typically by age 16; almost all first use occurs before the time of high school graduation. Smoking prevalence among adolescents declined sharply in the 1970s, but the decline slowed signifi- cantly in the 1980s. At least 3.1 million adolescents and 25 percent of 17- and 18-year-olds are current smokers. Although current smoking prevalence among fe- male adolescents began exceeding that among males by the mid- to late-1970s, both sexes are now equally likely to smoke. Males are significantly more likely than females to use smokeless tobacco. Nationally, Epidemiology white adolescents are more likely to use all forms of tobacco than are blacks and Hispanics. The decline in the prevalence of cigarette smoking among black adolescents is noteworthy. Many adolescent smokers are addicted to cigarettes; these young smokers report withdrawal symptoms similar to those reported by adults. Tobacco use in adolescence is associated with a range of health-compromising behaviors, including being involved in fights, carrying weapons, engaging in higher-risk sexual behavior, and using alcohol and other drugs. preventing Tobacco Use Among Young People Chapter 4: Psychosocial Risk Factors for Initiating Tobacco Use Introduction Tobacco use begins primarily through the dynamic interplay of sociodemographic, environ- mental, behavioral, and personal factors. These sychosocial risk factors increase a person’s chances both of beginning to use tobacco and of experiencing the immediate and long-term health problems associated with tobacco use. Young people (aged 10 through 18 years) are particularly affected by psychosocial factors and are thus particularly vulnerable to adopting tobacco use. Since psychosocial risk factors are the initial influences in the causal chain that leads to tobacco-related health consequences, primary prevention efforts to re- duce smoking prevalence must take these influences into account. Psychosocial risk factors for tobacco use can be viewed as a continuum of proximal to distal factors. Personal and behavioral factors that directly affect an individual’s choice to use tobacco (when a cigarette is offered, forexample) are considered proximal risk factors, whereas environmental and sociodemographic factors (such as billboard advertising and household income) that indirectly affect the accessibility or acceptability of tobacco use are classified as distal factors. Proximal factors are considered more immediate to a person’s decision to use tobacco than distal factors. Still, as is shown in Chapter 5 (see “Research on the Effects of Cigarette Advertising and Promotional Activities on Young People”), distal factors acquire potency if they are pervasive and provide consistent, repetitive messages across multiple channels. Distal factors are also powerful because, over time, they affect proximal factors as these influences become interpreted and internalized, particu- larly among adolescents as they try to shapea mature self- identity. This review examines each of these sets of risk factors to provide a comprehensive view of the anteced- ents of tobacco use, first for cigarette smoking, then for smokeless tobacco use. The database for this review includes research studies that have been published pri- marily in peer-refereed journals or books during the past 15 years. Results from these studies were grouped according to psychosocial risk factor, and conclusions were based on the availability and conclusiveness of the evidence for a given risk factor. Table 1 summarizes the major psychosocial risk factors examined in this chapter and in Chapter 5. Table 1. Psychosocial risk factors in the initiation of tobacco use among adolescents Smokeless Risk factors Smoking tobacco Sociodemographic factors Low socioeconomic status x Developmental stage x X Male gender x Environmental factors Accessibility x x Advertising x x Parental use Sibling use x Peer use x x Normative expectations x x Social support x Behavioral factors Academic achievement x x Other problem behaviors x x Constructive behaviors x Behavioral skills x Intentions x x Experimentation x x Personal factors Knowledge of consequences x Functional meanings x Subjective expected utility Self-esteem / self-image x Self-efficacy Personality factors Psychological well-being