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Predictors of Change on the Smoking Uptake Continuum Among Adolescents
Nancy J. Kaufman, MS;
Brian C. Castrucci;
Paul D. Mowery, MS;
Karen K. Gerlach, PhD, MPH;
Seth Emont, PhD;
C. Tracy Orleans, PhD
Arch Pediatr Adolesc Med. 2002;156:581-587.
ABSTRACT
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Context Understanding how advertising and other risk and demographic factors
affect adolescent susceptibility to smoking would allow for the development
of more effective youth-targeted tobacco prevention and cessation programs
and policies.
Objective To examine the effect of various demographic and risk factors on different
stages of smoking among adolescents.
Design A nationally representative cross-sectional survey, The Robert Wood
Johnson Foundation's Survey of Tobacco Price Sensitivity, Behavior, and Attitudes
Among Teenagers and Young Adults.
Subjects The Robert Wood Johnson Foundation's Survey of Tobacco Price Sensitivity,
Behavior, and Attitudes Among Teenagers and Young Adults included 17 287
adolescent respondents (aged, 13-19 years) in 1996.
Main Outcome Measures Stage of susceptibility and correlates of progression toward regular
smoking.
Results Of all nonsmoking adolescents, 32% were susceptible smokers (have never
smoked, but might) with younger adolescents almost 3 times more likely than
older adolescents to be susceptible. Female subjects were 54% more likely
than male subjects to be susceptible. In addition to exposure to others' smoking,
owning or willingness to own tobacco promotional items, having a favorite
cigarette advertisement, skipping school, poor school performance, and lack
of attendance in religious activities were associated with progression along
the uptake continuum.
Conclusions Improved understanding of the tobacco use trajectories of adolescents
and the risk factors associated with progression will help clinicians and
tobacco control advocates create effective youth-targeted interventions and
policies. Findings suggest that physicians and other health care providers
should redouble their efforts to ask preadolescents and young adults about
smoking or the likelihood of their smoking. Nonsmokers should also be advised
about the addictive nature of tobacco products and the resulting loss of control
that accompanies addiction.
INTRODUCTION
IN 1996, THE TOBACCO industry spent $5.11 billion on cigarette advertising
and promotion.1 The effect of this marketing
investment is evident in more favorable attitudes toward smoking and increased
smoking that are associated with increased exposure to tobacco advertising.2-3 This marketing investment makes it
nearly impossible for adolescents to avoid exposure to some form of tobacco
advertising or promotion. The tobacco industry states that its purpose in
tobacco marketing is to maintain brand loyalty and not to encourage adolescent
smoking, arguing that susceptibility to cigarette use is chiefly the result
of influence by family members and/or peers.4-5
The documents released as a result of the Minnesota lawsuit and the Master
Settlement Agreement between state attorneys general and the tobacco companies
confirm that the tobacco industry cultivated the youth market. These documents
reflect the tobacco industry's recognition of the 14- to 18-year-old consumers
as a growing segment of the smoking population critical to the industry's
long-term performance and profitability.6
Several studies have indicated the effectiveness of the tobacco industry's
marketing strategies. Studies have shown that brand name cigarette use is
more concentrated among adolescents,7 and adolescents
who smoke are more adept at identifying tobacco advertising than their nonsmoking
peers.8 Furthermore, regardless of their smoking
status, adolescents report that the imagery in cigarette advertisements makes
cigarette smoking appear appealing.9 Exposure
to tobacco advertising and promotion not only increases an adolescent's knowledge
of cigarettes, but also increases susceptibility to tobacco use3, 5, 10-12
and the likelihood of experimentation12-13
and initiation.12 One estimate suggests that
tobacco advertising and promotion accounts for approximately 34% of new experimenters
representing about 700 000 adolescents each year.2
As adult market share declines, due to cessation and death, advertising that
draws the attention of adolescents helps to recruit new smokers who will replace
the lost adult consumers.
In addition to advertising and the influence of family and peers asserted
by the tobacco industry,5 the school environment
and religious activities have also been previously shown to influence smoking
behavior. Previous research in school settings has found that an absence of
school rules,14 poor school performance,15-16 and an absence of attendance were
associated with increased smoking among adolescents. Additionally, religious
activities have been shown to promote better health behaviors and overall
declines in substance abuse among adolescents.17-18
Using nationally representative data for high school students in the
United States, this study examines the distribution of adolescents among 7
stages of smoking uptake. The analysis also tests whether there exists an
association between 8 risk factors (smoking in the home, smoking behavior
of friends, school rules about smoking, poor school performance, skipping
school, lack of attendance in religious activities, whether the respondent
had a favorite cigarette advertisement, and the influence of tobacco industry
promotions) and progression along the smoking uptake continuum when controlling
for the influence of smoking among family and peers.
SAMPLE SUBJECTS AND METHODS
The Robert Wood Johnson Foundation's National Survey of Tobacco Price
Sensitivity, Behavior, and Attitudes Among Teenagers and Young Adults (RWJF
Survey) was administered to a broad cross-section of adolescents in 1996.
The sample sizes, respondent selection procedures, and weighting procedures
were designed to develop national estimates of smoking behaviors and attitudes.
DESCRIPTION OF DATA SOURCE, SAMPLE SIZE, AND RESPONSE RATE
The RWJF Survey was conducted from March through July 1996. The survey
sample was stratified by region, race, ethnicity, and socioeconomic status.
Students in grades 9 through 12 were selected based on a multistage sample,
with selection probability proportional to the size of the target population
in each sampling unit. Respondents completed an anonymous, self-administered
questionnaire, administered in schools. The RWJF Survey included 17 287
respondents, ages 13 through 19 years, with 73% of the schools agreeing to
be surveyed. In those schools included in the sample, 80% of the students
completed the questionnaire. The response rate for this survey was similar
to the 1995 National Youth Risk Behavior Survey, for which the school response
rate was 70% and the student response rate 86%.19
MEASUREMENT OF STAGE OF PROGRESSION TO REGULAR SMOKING
A 7-level variable was constructed to measure progress toward regular
smoking (Figure 1). Never smokers
were defined as persons who had never smoked a cigarette and had never tried
or experimented with smoking, even a few puffs. Never smokers were further
categorized by susceptibility to smoking uptake.2, 20-21
Susceptibility to smoking uptake was measured by 3 questions: (1) If one of
your best friends were to offer you a cigarette, would you smoke it? (2) At
any time during the next year do you think you will smoke a cigarette? (3)
Do you think you will ever smoke a cigarette in the future? "Not susceptible"
never smokers were defined as those who answered "definitely not" to all 3
questions. Any other valid response to either of the 3 questions resulted
in a "susceptible" designation. Experimenters were defined as those who had
never smoked a whole cigarette but had tried smoking. Persons who had smoked
a whole cigarette were categorized by whether they had smoked at least 100
cigarettes in their lifetime and by whether they had smoked on 1 or more days
during the last 30 days. Regular smoking was defined as having smoked 100
cigarettes during one's lifetime and having smoked on 1 or more of the 30
days preceding the survey.
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Figure 1. Definitions of 7 stages of smoking
uptake.
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MEASUREMENT OF CORRELATES OF PROGRESSION TO REGULAR SMOKING
Eight risk factors shown by previous studies to be predictors of smoking
in adolescence were used in this analysis. These factors included measures
of (1) smoking in the home, (2) smoking behavior of friends, (3) school rules
about smoking, (4) poor school performance, (5) skipping school, (6) lack
of attendance in religious activities, (7) whether the respondent had a favorite
cigarette advertisement, and (8) the influence of tobacco industry promotions.
Smoking in the household was defined by the question: Besides yourself,
does anyone who lives in your household now smoke cigarettes? Friends' smoking
was defined as whether 1 or more of the respondent's 4 best male and 4 best
female friends smoked. These variables were combined to create a 4-level variable
measuring exposure to smoking. A dichotomous school rule about smoking risk
factor was defined by the questions: Is there a rule at your school that students
are not allowed to smoke anywhere on school property? How many students who
smoke obey that rule? Responses indicating no rule, a missing response, or
that there is a rule but none or only a few obey the rule were combined. Self-reported
school performance was defined as a risk for smoking uptake if the response
was "average," "below average," or "do not know" to the question: How do you
do in school? The variable skipping school was rated equal to 1 if the respondent
skipped or cut 1 or more days of school during the last 4 weeks. School performance
and skipping school were combined to create a 4-level variable. A religous
attendance risk factor was set equal to 1 if the respondent reported that
in the past year, he or she had gone to church, synagogue, or some other type
of religious service "never" or "only a few times in the last year." Respondents
were asked whether they have a favorite cigarette advertisement, and if they
ever received or owned a cigarette promotional item and will ever use a promotional
item if offered. These questions were also used on the 1993 California Tobacco
Survey to measure receptivity to tobacco marketing.5
For the favorite cigarette advertisement question, respondents were asked
to check the brand of their favorite advertisement, or the one that gets their
attention the most. The favorite advertisement risk factor was set equal to
1 if the respondent checked a brand, and set equal to 0 if he or she checked
"none/don't like any ads" or "don't know." The influence of tobacco industry
promotions was assessed by the question: Some tobacco companies give away
items or coupons for items, such as hats, tee shirts, jackets, caps, or other
gear. Have you ever received or owned such items from a tobacco company? The
tobacco industry promotions risk factor was set equal to 1 if the respondent
had received or owned promotional items or would ever use a tobacco industry
promotional item, and 0 otherwise. These advertising variables were combined
to yield a 4-level variable.
STATISTICAL ANALYSIS
The RWJF Survey responses were weighted before computing estimates of
smoking stage. The weights included the probability of selection, an adjustment
for nonresponse, and a poststratification ratio adjustment to make the demographic
distribution of the samples approximately equal to the distribution of the
US population. Our analyses included only respondents aged 13 to 18 years
and was restricted to respondents with valid data (nonmissing) for age, race,
and sex.
Three logistic regression models were estimated to examine which variables
were associated with the 3 different stages of smoking uptake. The independent
variables, which are identical for each model, were chosen based on the existing
literature and exploratory bivariate analyses. Since the goal of the models
was to examine the independent association between each variable while adjusting
for other variables previously shown to be associated with the outcome, even
those variables that were not statistically significant remained in each model.
Data were analyzed using SAS and SUDAAN software to compute point estimates
and SEs, respectively.22-23 All
values are reported as proportions (SE).
RESULTS
AGE, RACE, AND SEX DISTRIBUTION BY STAGE OF SMOKING UPTAKE
Estimates of the percentages of the 1996 US adolescent population in
each of 7 stages of progression to regular smoking reveal that among all never
smokers, younger adolescents are the most susceptible (Table 1). Susceptibility declined with age (Figure 2). Among the youngest group (aged, 13-14 years), 40.7% (2.9%)
of never smokers were susceptible compared with 26.3% (1.7%) of 17- to 18-year-olds.
A greater percentage of white (33.1%) and Hispanic (36.5%) never smokers were
susceptible compared with black subjects (26.8%). Female never smokers were
also more likely than male never smokers to be susceptible (34.1% vs 29.9%).
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Table 1. Percentage Distribution of 7 Stages of Smoking, 1996*
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Figure 2. Percentage of all respondents
who never smoked who are susceptible and all former smokers who might smoke
in the next year.
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In 1996, 8.6% of all adolescents aged 13 through 18 years were experimenters
(Table 1). The proportion of experimenters
was relatively constant across all age groups. A greater percentage of blacks
(14.4%) were experimenters than any other racial group.
Among former smokers (those who had smoked previously but not in the
past 30 days), more than half reported that they might smoke in the next year.
This was highest among 13- to 14-year-olds (60.0%) and declined with age to
50.3% (1.3%) among 17- to 18-year-olds. The propensity to reinitiate smoking
varied by racial or ethnic background of the respondent, with blacks the least
likely and whites being the most likely (Figure 2).
The proportion of regular smokers varied inversely with age. While 13.2%
of 13- to 14-year-olds were regular smokers, one quarter of 17- to 18-year-olds
were regular smokers. The greatest proportion of regular smokers was among
white adolescents (25.6%), more than 14 percentage points greater than the
next highest group (Hispanics, 12.1%)
Sex differences were examined by stage of smoking uptake. Except for
greater susceptibility among female never smokers (Figure 2), there were no differences between male and female respondents
in any of the other levels of smoking uptake.
PREDICTORS OF 3 STAGES OF SMOKING
Logistic regression was used to examine the influence of various risk
factors on probabilities of being in each of 3 distinct stages of progression
to regular smoking—susceptible never smoker, experimenter, and regular
smoker. Older adolescents were less likely than the youngest (13- and 14-year-olds)
to be susceptible but more likely to be experimenters or regular smokers (Table 2). Nonwhites were more likely to
be experimenters, but significantly less likely to be regular smokers.
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Table 2. Risk Factors and Associated Adjusted Odds Ratios for 3 Stages
of Smoking Among Adolescents, 1996*
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Apart from demographics, various risk factors were also associated with
smoking uptake. Exposure to friends' smoking and exposure to both family's
and friends' smoking were significantly associated with being a susceptible,
an experimenter, and a regular smoker. The strongest association was among
regular smokers for whom both friends' smoking and family's and friends' smoking
were significant.
Skipping school and performing poorly in school were both significantly
associated with the likelihood of being an experimenter and a regular smoker.
The lack of attendance in religious activities was only significantly associated
with regular smoking. There was no association between the presence or the
enforcement of school no smoking policies on smoking and uptake.
All levels of receptivity to advertising were significantly associated
with being a susceptible never smoker. The same was seen for the other 2 categories
of smoking, except being an experimenter was not significantly associated
with owning an item and being a regular smoker was not associated with having
a favorite advertisement.
COMMENT
Several of the findings presented herein have implications for primary
care physicians, nurses, and dentists—all of whom have regular contact
with adolescents. First, while an adolescent may not be smoking, he or she
may be susceptible to smoking. As these data indicate, almost 50% of all adolescents
who have never smoked can be defined as susceptible. When interacting with
adolescents who do not smoke, physicians may want to consider screening for
an adolescent's susceptibility to this behavior. Also, a significant proportion
of former smokers report that they may smoke in the next year. This is an
opportunity for physicians to support an adolescent's initial cessation and
encourage adolescents to not return to this unhealthy behavior.
The tobacco industry has long held that susceptibility to cigarette
smoking is the result of family and peer smoking.4-5
While the data presented indicate that environmental exposures are highly
associated with varying stages of smoking uptake, they also identify several
other variables that also contribute to smoking uptake. Receptivity to advertising,
skipping school, poor self-assessed school performance, and lack of religious
attendance were all found to be significantly associated with 1 or more stages
of smoking uptake.
Exposure to smokers in the household and among best friends was highly
associated with susceptibility to smoking and progression. This information
can be used by physicians to engage parents in a discussion about their own
quitting. In addition, all parents can be made aware of the influence of peer
groups with which their children become involved and the need to watch for
warning signs like skipping school and poor school performance. To assist
adolescents who are already smoking, physicians should counsel and assist
teen smokers in quitting using methods recommended for adults but modified
to be developmentally appropriate,24 until
further research points to more effective programs for adolescent cessation.
Since the proportion of susceptible nonsmokers is highest among 13-
and 14-year-olds and declines as age increases, interventions in late childhood
and early adolescence should be emphasized. Preventive guidance and assessment
of smoking status should be a routine component of every visit for adolescents
of all ages, as approximately 8% of adolescents of all ages are experimenters.
Since approximately 30% of these experimenters could be expected to become
established smokers,25 we project that 587 000
experimenters aged 13 to 18 years will go on to smoke at least 100 cigarettes.
Experimentation is an important part of smoking uptake, and preventive guidance
could greatly influence those who persist in smoking and those who cease.
Nonwhite adolescents were significantly more likely to be experimenters,
but significantly less likely to be regular smokers. The cross-sectional nature
of these data do not allow for assessing why this occurs, but one possibility
is that white adolescents may progress more quickly from experimenter to more
established smoker.26 If this is the case,
then white adolescents would spend less time in the experimenter phase and
a cross-sectional survey would find fewer whites in this stage. Only longitudinal
studies can adequately address this question.
These results underscore the need to counter the influence of protobacco
messages aimed at or received by younger adolescents. Tobacco control policies
are needed to limit the exposure of children and young adolescents to tobacco
advertising and promotion, such as print advertisements, counter displays,
and promotional signs in or outside of places where tobacco is sold. With
the demise of billboard advertisements, it is likely that these other forms
of marketing will increase. Tobacco company promotional items and sponsorship
of community events and organizations should be monitored for their effects
on youth progression. While provisions of the Master Settlement Agreement
have restricted the tobacco industry from using some common advertising techniques,
in 1999, the first full year following the Master Settlement Agreement, spending
on tobacco advertising exceeded $8 billion, a 22.3% increase over 1998 spending
levels.27-28 This marked the largest
increase in spending on tobacco advertising since the Federal Trade Commission
began tracking advertising expenditures in 1970.29
Further research is also needed on the long-term effectiveness of countermarketing
campaigns, such as those used in Arizona, California, Florida, and Massachusetts.30-31
This study offers important insights into stages of smoking trajectories
that are useful for clinical and policy interventions. However, the limitations
of these analyses must be noted. As with all surveys, there is the potential
for bias related to issues of social desirability and recall. Respondents
were assured of the anonymity of their responses, which would limit the possible
effect of either bias. In addition, this study uses a cross-sectional design,
which limits the ability to make causal inferences. For example, it is unclear
if skipping school and/or poor school performance preceded smoking or occurred
afterward. Therefore, while exposure to friends' smoking is significantly
associated with smoking uptake, these data cannot determine if an adolescent
began smoking and then became friends with other smokers or if the pathway
is reversed. However, for advertising and promotion, longitudinal studies
conducted in California and Massachusetts have shown that adolescents who
were receptive to tobacco industry promotion at baseline were more likely
to have progressed further toward established smoking than nonreceptive adolescents.2-3 The vast expenditures of the tobacco
industry on advertising and promotion ensure that children and adolescents
will continue to be exposed to messages that encourage them to smoke. While
research in the medical literature has focused on the relationship between
receptivity to advertising and smoking uptake, there is a scarcity of information
on the differentiating characteristics of those adolescents who are receptive
as compared with those who are not. Future research should examine this question
to develop interventions to assist adolescents in resisting the lure of advertising
and promotion.
| What This Study Adds
The tobacco industry has alleged that its purpose in advertising is
to maintain brand loyalty and not to encourage adolescent smoking, arguing
that susceptibility to cigarette use is chiefly the result of influence by
family members and/or peers. To test this assertion using a nationally representative
data set, this study examined the association between 8 risk factors and progression
along the smoking uptake continuum when controlling for family and peer smoking
influences.
This analysis shows that several factors including tobacco advertising
and promotion, poor school performance, skipping school, and lack of religious
attendance are all associated with increased likelihood of being in various
stages along the smoking uptake continuum. Improved understanding of the tobacco
use trajectories of our young and the risk factors associated with progression
will help clinicians and public health advocates create targeted interventions
and policies to prevent progression toward more established smoking.
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AUTHOR INFORMATION
Accepted for publication Feburary 24, 2001.
Corresponding author and reprints: Nancy J. Kaufman, MS, The Robert
Wood Johnson Foundation, Route 1 and College Road E, Princeton, NJ 08543.
From The Robert Wood Johnson Foundation (Ms Kaufman, Mr Castrucci,
and Drs Gerlach, Emont, and Orleans), Princeton, NJ; and the Research Triangle
Institute, Research Triangle Park, NC (Mr Mowery).
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