Tobacco Documents Online

The task is by no means easy. This report underscores the commitment all of us must have to the liealth of young people in the United States. Substantial work will be required to translate the justification, the means, and the will into a world in which young people no longer want to smoke. I, for one, relish the task. M. Joycelyn Elders, M.D. Surgeon General `U TIMN 0138850

Preventing Tobacco Use Among Young People CENTERS FOR DISEASE COHiRCL AND PREVENTK)N A Report of the Surgeon General 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 TIMN 0138843

Preventing acco Tob Use Among Young People A Report of the Surgeon General 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 Offlce on Smoking and Health TIMN 0138844,

Suggested Citation U.S. Department of Health and Human Services. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, Georgia: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control'and Prevention,lVational Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994. For sale by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C., 20402, S/N 017-001-00491-0. Use of trade names is for identification only and does not constitute endorsement by the Public Health Service or the U.S. Department of Health and Human Services. TIMN 0138845

Chapter 1 Introduction, Summary, and Chapter Conclusions Introduction 5 Development of the Report 5 Major Conclusions 5 Summary 6 Introduction 6 Health Consequences of Tobacco Use Among Young People 6 The Epidemiology of Tobacco Use Among Young People 7 Efforts to Prevent the Onset of Tobacco Use 8 Summary 8 Chapter Conclusions 9 Chapter 2. The Health Consequences of Tobacco Use by Young People 9 Chapter 3. Epidemiology of Tobacco Use Among Young People in the United States 9 Chapter 4. Psychosocial Risk Factors for Initiating Tobacco Use 9 Chapter 5. Tobacco Advertising and Promotional Activities 10 Chapter 6. Efforts to Prevent Tobacco Use Among Young People 10 References 11 TIMN 0138858

?I Health Consequences of Smokeless Tobacco Use Among Young People 39 Introduction 39 Epidemiologic Evidence 39 Health Consequences 39 Nicotine Addiction 40 Smokeless Tobacco Use as a Risk Factor for Cigarette Smoking 40 Smokeless Tobacco Use as a Risk Factor for Other Drug Use 41 Conclusions 41 References 42 TIMN 0138867

THE SECRETARY OF HEALTH AND HUMAN SERVICES WASHINGTON, O.C. 20201 The Honorable,Albert-Gore, Jr. President of the Senate Washington, D.C. 20510 Dear Mr. President: it is my pleasure to transmit to the Congress the Surgeon General's report on the health consequences of smoking entitled Preventing Tobacco Use Amo gYoung People. This report is mandated by section 8(a) of the Public Health Cigarette Smoking Act of 1969 (Public Law 91-222) and includes the health effects of smokeless tobacco products as mandated by section 8(a). of the Comprehensive Smokeless Tobacco Health Education Act of 1986 (Public Law 99-252). The report.was prepared by the Centers for Disease Control and Prevention's Office on'Smoking and Health. This report focuses on the vulnerable adolescent ages of 10 through 18 when most users start smoking, chewing, or dipping and become addicted to tobacco. It examines the health effects of early smoking and smokeless tobacco use, the reasons that young men and women begin using tobacco, the extent to which they use.it, and efforts to prevent'tobacco use by young people. Smoking kills 434,000 Americans each year. Adolescent smoking and smokeless tobacco use are the first steps in this totally preventable public health tragedy. The facts are simple: one out of three adolescents in the United States is using tobacco by age 18, adolescent users become adult users, and few people begin to use tobacco after age 18. Preventing young people from starting to use tobacco is the key to reducing the death and disease caused by tobacco use: This report documents that intervention programs targeting the broad social environment of adolescents are both effective and warranted. A great:'opportunity lies before us to prevent millions of premature deaths and improve the quality of lives. This report points out the overwhelming need in public health for efforts directed toward stopping young people before they start using tobacco. Donna E. Shalala Enclosure TIMN 0138847

Chapter 2 The Health Consequences of Tobacco Use by Young People Introduction 15 Health Consequences of Smoking Among Young People 15 Introduction 15 Overview of the Toxicology of Tobacco Smoke 15 Epidemiologic Evidence of Respiratory Effects 16 Respiratory Symptoms 16 Lung Function 17 Respiratory Morbidity 24 Epidemiologic Evidence of Nonrespiratory Effects 25 Cardiovascular Disease 25 Physical Fitness 28 Health Outcomes in Pregnancy 28 Epidemiologic Evidence of the Health Effects of Passive Smoking 28 Adult Health Implications of Smoking Among Young People 29 Respiratory Diseases 29 Cardiovascular Disease 29 Cancer 29 Nicotine Addiction in Adolescence 30 Introduction 30 Background and Nomenclature 30 Severity of Nicotine Addiction 31 Chemistry and Addiction Potential 1 Pathophysiology of Nicotine Dependence 32 Tolerance 32 Physical Dependence 33 The Clinical Course of Nicotine Dependence 33 Nondrug Factors in Nicotine Dependence 34 Smoking as a Risk Factor for Other Drug Use 34 Introduction 34 Progression of Drug Use 34 Cigarette Smoking and Other Drug Use 35 Smoking as a Facilitator for Other Drug Use 36 TEWIN 0138866

Preventing Tobacco Use Among Young People Chapter 1. Introduction, Summary, and Chapter Conclusions 3 Chapter 2. The Health Consequences of Tobacco Use by Young People 13 Introduction 15 Health Consequences of Smoking Among Young People 15 Adult Health Implications of Smoking Among Young People 29 Nicotine Addiction in Adolescence 30 Smoking as a Risk Factor for Other Drug Use 34 Health Consequences of Smokeless Tobacco Use Among Young People 39 Chapter 3. Epidemiology of Tobacco Use Among Young People in the United States 53 Introduction 55 Cigarette Smoking Among Young People in the United States 58 Smokeless Tobacco Use Among Young People in the United States 95 Chapter 4. Psychosocial Risk Factors for Initiating Tobacco Use 121 Introduction 123 Initiation of Cigarette Smoking 124 Initiation of Smokeless Tobacco Use 140 Implications of Research for Preventing Tobacco Use: Modifying Psychosocial Risk 147 Chapter 5. Tobacco Advertising and Promotional Activities 157 The Role of Advertising and Promotion in the Marketing of Tobacco Products 159 A History of Cigarette Advertising to the Young 164 Historical Content Analyses of Cigarette Advertising 179 Promotional Efforts of the Tobacco Industry 185 Research on the Effects of Cigarette Advertising and Promotional Activities on Young People 188 Chapter 6. Efforts to Prevent Tobacco Use Among Young People 205 Introduction 209 Public Opinion About Preventing Tobacco Use Among Young People 210 Educational Efforts to Prevent Tobacco Use Among Young People 216 Public Policies to Prevent Tobacco Use Among Young People 245 List of Tables and Figures 293 Glossary 297 Index 299 I TIMN 0138857

Preveutiitg Tobacco Use Among Young People References US DEPARTMENT OF HEALTH AND HUMAN SERVICES. The health consequences of using smokeless tobacco. A report of the advisory committee to the Surgeon General. US Department of Health and Human Services, Public Health Services, National Institutes of Health. NIH Publication No. 86-2874,1986. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. The health consequences of smoking: nicotine addiction. A report of the Surgeon General, 1988. US Department of Health and Hu- man Services, Public Health Service, Centers for Disease Con- trol, Center for Health Promotion and Education, Office on Smoking and Health. DHHS Publication No. (CDC) 88-8406, 1988. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. Reducing the health consequences of smoking: 25 years of progress. A report of the Surgeon General. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS Publication No. (CDC) 89-8411,1989. , TIMN 0138865 Introduction 11

Surgeon General's Report J.P. Peddicord, M.S.,'Computer Scientist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Richard Ray, Director of Computer Services, Circle Solutions, Inc., McLean, Virginia. John Robey, Word Processing Specialist, Circle-Solutions, Inc., McLean, Virginia. Kathleen L. Schroeder, D.D.S., Associate Professor of Oral Pathology, West Virginia University School of Medicine, Morgantown, West Virginia. Maggie Shelby, Secretary, HCR Consulting Group, Atlanta, Georgia. Michael B. Siegel, M.D., M.P.H., Epidemiologist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Renee E. Sieving, M.S.N., Doctoral Student, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota. Michael J. Staufacker, M.P.H., Doctoral Student, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota. Scott L. Tomar, D.M.D., Dr.P.H., Epidemiologist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Traci L. Toomey, M.P.H., Doctoral Student, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota. Laura Williams, Student, Northeast Ohio University College of Medicine, Rootstown, Ohio. Rebecca B. Wolf, M.A., Program Analyst, Office of Program Planning and Evaluation, Centers for Disease Control and Prevention, Atlanta, Georgia. Bao-Ping Zhu, Ph.D., Research Scientist, Battelle Memorial Institute, Atlanta, Georgia. x TIMN 0138856

THE SECRETARY OF HEALTH AND HUMAN SERVICES WASHINGTON. 0 L 20201 The Honorable Thomas S. Foley Speaker of the House of Representatives Washington, D.C. 20515 Dear Mr. Speaker: It is my pleasure to transmit to the Congress the Surgeon General's report on the health consequences of smoking entitled Preventing Tobacco Use Among Young People. This report is mandated by section 8(a) of the Public Health Cigarette Smoking Act of 1969 (Public Law 91-222) and includes the health effects of smokeless tobacco products as mandated by section 8(a) of the Comprehensive Smokeless Tobacco Health Education Act of 1986 (Public Law 99-252). The report was prepared by the Centers for Disease Control and Prevention's Office on Smoking and Health. This report focuses on the vulnerable adolescent ages of 10 - through 18 when most users start smoking, chewing, or dipping, and become addicted to tobacco. It examines the health effects of early smoking and smokeless tobacco use, the reasons that young men and women begin using tobacco, the extent to which they use it, and efforts to prevent tobacco use by young people. Smoking kills 434,000 Americans each year. Adolescent smoking and smokeless tobacco use are the first steps in this totally preventable public health tragedy. The facts are simple: one out of three adolescents in the United States is using tobacco by age 18, adolescent users become adult users, and few people begin to use tobacco after age 18. Preventing young people from starting to use tobacco is the key to reducing the death and disease caused by tobacco use. This report documents that intervention programs targeting the broad social environment of adolescents are both effective and warranted. A great:,-opportunity lies before us to prevent millions of premature deaths and improve the quality of lives. This report points out the overwhelming need in public health for efforts directed toward stopping young people before they start using tobacco. Enclosure TIMN 0138846

Preface from the Surgeon General, U.S. Department of Health and Human Services The public health movement against tobacco use will be successful when young people no longer want to smoke. We are not there yet. Despite 30 years of decline in overall smoking prevalence, despite widespread dissemination of information about smoking, despite a continuing decline in the social acceptability of smoking, substantial numbers of young men and women begin to smoke and become addicted. These current and future smokers are new recruits in the continuing epidemic of disease, disability, and death attributable to tobacco use. When young people no longer want to smoke, the epidemic itself will die. This report of the Surgeon General, Preventing Tobacco Use Among Young People, delineates the problem in no uncertain terms. The direct effects of tobacco use on the health of young people have been greatly underestimated. The long-term effects are, of course, well established. The addictive nature of tobacco use is also well known, but it is perhaps less appreciated that early addiction is the chief mechanism for renewing the pool of smokers. Most people who are going to smoke are hooked by the time they are 20 years old. Young people face enormous pressures to smoke. The tobacco industry devotes an annual budget of nearly $4 billion to advertising and promoting cigarettes. As this report so well describes, there has been a continuing shift from advertising to promo- tion, largely because of banning cigarette ads from broadcast media. The effect of the ban is dubious, however, since the use of promotional materials, the sponsoring of sports events, and the use of logos in nontraditional venues may actually be more effective in reaching target audiences. Clearly, young people are being indoctrinated with tobacco promotion at a susceptible time in their lives. A misguided debate has arisen about whether tobacco promotion "causes" young people to smoke-misguided because single-source causation is probably too simple an explanation for any social phenomenon. The more important issue is what effect tobacco promotion might have. Current research suggests that pervasive tobacco promotion has two major effects: it creates the perception that more people smoke than actually do, and it provides a conduit between actual self-image and ideal self-image- in other words, smoking is made to look cool. Whether causal or not, these effects foster , the uptake of smoking, initiating for many a dismal and relentless chain of events. Ort the brighter side, a large portion of this report is devoted to countervailing influences. We have the justification: there is a substantial scientific basis for primary prevention of cigarette smoking and smokeless tobacco use. A number of successful prevention programs, based on the psychological and behavioral factors that create susceptibility to smoking, are available. We have the means: the report defines a coordinated, effective, nonsmoking public health program for young people. And we have the will: schools, communities, legislatures, and public opinion all testify to the growing support for encouraging young people to avoid tobacco use. itt TIMN 0138849

Sur'gcun General'> ReEorP Table 1. Continued Reference Location/year Study population Stanhope and Prior 1975 New•Zealand, 1972 Maori and European high school students aged 13-15 years Bewley and Bland 1976 England, 1971 5,355 schoolchildren aged 10-12 years Bland et al. 1978 England, 1974 5,835 schoolchildren; first-year level in secondary school Weiss et a1.1980 Massachusetts, 1975 650 children aged 5-9 years, population sample Kujala 1981 Finland, 1976 1,075 male military recruits, mean age = 20 years . Charlton 1984 England, 1982 15,709 students aged 8-19 years Adams et al.1984 .='-`;. England,1975-1979 405 secondary schoolchildren 141 Rim eIs 2985 ela and Rim Finland 1983 4,279 16- and 17-year-olds p p • , in a national sample Oechsli, Seltzer, California, 1977-1979 1,445 children in a cohort van den Berg.1987 study "Smoking at least one cigarette weekly. Percentages combine data reported separately in authois'`table V for urban and rural children. "RR = Relative risk for children smoking ? one cigarette weekly vessus children who had never smoked, adjusted for parental smoking. xSmoking at least one cigarette weekly. 20 Health Consequences TIMN 0138873

Foreword This Surgeon General's report on smoking and health is the twenty-third in a series that was begun in 1964 and mandated by federal law in 1969. This report is the first in this series to focus on young people. It underscores the seriousness of tobacco use, its relationship to other adolescent problem behaviors, and the responsibility of all citizens to protect the health of our children. Since 1964, substantial changes have occurred in scientific knowledge of the health consequences of smoking and smokeless tobacco use. Much more is also known about programs and policies that encourage nonsmoking behavior among adults and protect nonsmokers from exposure to environmental tobacco smoke. Although con- siderable gains have been made against smoking among U.S. adults, this progress has not been realized with young people. Onset rates of cigarette smoking among our youth have not declined over the past decade, and 28 percent of the natiori s high school seniors are currently cigarette smokers. The onset of tobacco use occurs primarily in early adolescence, a developmental stage that is several decades removed from the death and disability that are associated with smoking and smokeless tobacco use in adulthood. Currently, very few people begin to use tobacco as adults; almost all first use has occurred by the time people graduate from high school. The earlier young people begin using tobacco, the more heavily they are likely to use it as adults, and the longer potential time they have to be users. Both the duration and the amount of tobacco use are related to eventual chronic health problems. The processes of nicotine addiction further ensure that many of today's adolescent smokers will regularly use tobacco when they are adults. Preventing smoking and smokeless tobacco use among young people is critical to ending the epidemic of tobacco use in the United States. This report examines the past few decades' extensive scientific literature on the factors that influence the onset of use among young people and on strategies to prevent this onset. To better understand adolescent tobacco use, this report draws not only on medical and epidemiologic research but also on behavioral and social investigations. The resulting examination of the advertising and promotional activities of the tobacco industry, as well as the review of research on the effects of these activities on young people, marks an important contribution to our understanding of the epidemic of tobacco use in the United States and elsewhere. In particular, this research on the social environment of young people identifies key risk factors that encourage tobacco use. The careful targeting of these risk factors--on a communitywide basis-has proven successful in preventing the onset and development of tobacco use among young people. Philip R. Lee, M.D. David Satcher, M.D., Ph.D. Assistant Secretary for Health Director Public Health Service Centers for Disease Control and Prevention i TIMN 0138848

Preveatiny Tobacco Use Anwng Young People Symptoms Prevalence (%a) by smoking status Never smoker Smoker' Phlegm _ 3 months/yr 2.4 • 26.5x Breathlessness 2.4 20.5= Wheezing (apart from colds) 7.3 31.3t Colds go to chest 4.9 31.3t General findings: Increased cough and phlegm in smokers of > i cig/week versus never smokers. Dose-response evident. Prevalence of cough and phlegm dropped among smokers who quit smoking between 1965 and 1966. Never smoker Smokert Daily cough ? 3 months 4 10 Daily phlegm ? 3 months 3 9 Dyspnea when hurrying 16 30 Chest cold for 1 week 22 30 Wheezing or asthma 12 13 Number of cigarettes smoked per day 0 < 1 1-10 11-20 > 20 Cough 2.0 5.8 18.1 27.8 64.7 Phlegm 3.3 5.8 19.4 31.9 58.8 Shortness of breath _ 5.3 13.5 13.5 36.1 58.8 Never smoker Smoker' Morning cough Boys 5.4 18.2 Girls 5.9 19.8 Cough 3 months Boys 3.8 15.4 Girls 3.5 12.1 Never smoker Ex-smoker Present smoker Cough (day ortfi M in winter) Boys Girls 5.2 6.5 7.1 10.5 13.9 16.0 Nonsmoker Ex-smoker Smoker Number of cigarettes smoked per day Cough >_ 3 months/yrt S 1-9 10-14 _ 15 Boys' 2.9 4.5 9.2 16.2 29.0 Girls 4.4 6.0 12.0 23.1 35.9 tAt least one cigarette daily for the past year. t p < 0.01. , ' 'Smoking at least one cigarette weekly. Percentages combine data reported separately in authors'•Table 4 for urban and rural children. 9For white children only. Health Consequences 19 TIMN 0138872

Surgeon General's Report Table 1. Published studies of the effects of smoking on respiratory symptoms among young people, various countries, 1965-1983 Reference* Location/year Study population Peters and Ferris 1967 Massachusetts, 1965 124 Harvard College seniors Holland and Elliott 1968 England, 1965-1966 9,786 13- and 14-year-olds in 1965; 9,433 in 1966 Addington et al. 1970 Oklahoma9 557 high school students, (grades 9-12) aged 13-19 years Seeley, Zuskin, Bouhuys 1971 ConnecticutS 195 male and 170 female high - school students aged 15-19 years ; Bewley, Halil, Snaith 1973 England, 1971 8,682 schoolchildren aged 10 and 11 years Colley, Douglas, Reid 1973 United Kingdom, 1966 3,899 persons aged 20 years sampled from 1946 birth cohort study Rush 1974 New York, 1968 12,595 high school students aged 13-18 years *Listed chronologically by publication date. . °Year not provided. 18 Health Consequences TIMN 0138871

Prerviiting Tohaceo Use Among YvunY Pevple Symptoms Prevalence (%) by smoking status Gerierrzl rinudine: Cough grade, phlegm grade, and loose cough sign significantly associated with smoking. Never smoker Smoker** RR" Morning cough Boys 8.3 16.3 5.9 Girls 8.5 28.6 6.8 Cough 3 months Boys 7.2 13.4 2.4 Girls 6.0 10.7 2.6 Never smoker Smokeru RR49 Morning cough Boys 3.1 19.2 5.9 Girls 1.8 13.5 6.8 Cough day or night Boys 20.4 46.5 2.4 Girls 18.5 47.3 2.6 Breathlessness Boys 11.8 34.9 2.9 Girls 16.5 39.2 2.3 General findings: Persistent wheezing reported for 13.8% of ever smokers and 9.7% of never smokers; difference not significant. Nonsmoker'' Ex-smokerll Smoker*** Cough all day 1 2 8 Phlegm all day 1 1 7 Wheezing 5 13 22 Frequent cough 0 Number of cigarettes smoked per day 1-6 > 6 Boys Age 11-13 23 32 42 Age->14 9 16 29 Girls Age 11-13 19 34 49 Age>-14 9 18 32 General findings: Increased risk of cough, dyspnea, and phlegm. Never smoker Low-tar smokerm Medium-tar smoker$# Morning phlegm 2.7 7.6 11.4 Morning cough 6.3 20.7 20.5 Phlegm day or night 5.2 13.8 13.2 Cough day or night 19.1 43.9 40.6 General findings: Starting smoking associated with bronchitis and pneumonia. '°RR = Relative risk for children smoking at least one cigarette weekly versus children who hatd never smoked. "Nonsmoker =:Vever smoking and smoking not more than one cigarette daily for 5 one year. 9lEx-smoker = Smoking one month or more before date of the interview. •*5moker = Smoking ? 1 g of tobacco daily; one cigarette was estimated to contain Ig of tobacco. '-Smoking daily, cigarettes < 10mg of tar. tuSmoking daily, cigarettes 10-18mg of tar. Health Consequences 21 TIMN 0138874

Surgeon General's Report Table 3. Published studies of the effects of smoking on respiratory morbidity among young people, various countries, 1963-1987 Reference* Location/year Study population Haynes, Krstulovic, Bell 1966 New Jersey' 191 male prep school students aged 14-19 years Parnell, Anderson, Kinnis 1966 Canada, 1963-1964 175 senior student nurses Finklea et al. 1971 South Carolina, 1968-1969 1,900 college students Pollard et a1.1975 Florida, 1971-1972 1,100 U.S. Navy recruits, most aged 18-22 years , Kark and Lebiush 1981 Israe1,1979 Female military recruits, mean age = 18.5 years Kark, Lebiush, Rannon 1982 Israel, 1978 Male military recruits, mean age = 18.5 years Blake, Abell, Stanley 1988 . Georgia, 1982 1,230 Army recruits, ~ ~ most aged < 22 years Charlton and Blair 1989 England, 1987 2,885 schoolchildren aged. 12 and 13 years Schwartz and Zeger 1990 Californiat 100 student nurses *Listed chronologically by publication date. tYear not provided; 26 Health Consequences TIMN 0138879

Surgeon Genera!'s Report normative, peers' and siblings' use and approval of tobacco use, and lack of parental- support and in- volvement as adolescents face the challenges of growing up. 4. Behavioral risk factors for tobacco use include low levels of academic achievement and school involve- ment, lack of skills required to resist influences to use tobacco, and experimentation with any tobacco prod- uct. 5. Personal risk factors for tobacco use include a lower self-image and lower self-esteem than peers, the be- lief that tobacco use is functional, and lack of self- efficacy in the ability to refuse offers to use tobacco. For smokeless tobacco use, insufficient knowledge of the health consequences is also a factor. Chapter 5. Tobacco Advertising and Promotional Activities 1. Young people continue to be a strategically impor- tant market for.the tobacco industry. 2. Young people are currently exposed to cigarette messages through print media (including outdoor billboards) and through promotional activities, such as sponsorship of sporting events and public enter- tainment, point-of-sale displays, and distribution of specialty items. 3. Cigarette advertising uses images rather than infor- mation to portray the attractiveness and function of smoking. Human models and cartoon characters in cigarette advertising convey independence, health- fulness, adventure-seeking, and youthful activities- themes correlated with psychosocial factors that appeal to young people. 4. Cigarette advertisements capitalize on the disparity between an ideal and actual self-image and imply that smoking may dose the gap. 5. Cigaretteadvertisingappearstoaffectyoungpeople's perceptions of the pervasiveness, image, and func- tion of smoking. Sinco misperceptions in these areas constitute psychosocial risk factors for the initiation of smoking, cigarette advertising appears to increase young people's risk of smoking. Chapter 6. Efforts to Prevent Tobacco Use Among Young People 1. Most of the American public strongly favor policies that might prevent tobacco use among young people. These policies include tobacco education in the schools, restrictions on tobacco advertising and pro- motions, a complete ban on smoking by anyone on school grounds, prohibition of the sale of tobacco products to minors, and earmarked tax increases on tobacco products. 2. School-based smoking-prevention programs that identify social influences to smoke and teach skills to resist those influences have demonstrated consistent and significant reductions in adolescent smoking prevalence, and program effects have lasted one to three years. Programs to prevent smokeless tobacco use that are based on the same model have also demonstrated modest reductions in the initiation of smokeless tobacco use. 3. The effectiveness of school-based smoking-preven- tion programs appears to be enhanced and sustained by comprehensive school health education and by communitywide programs that involve parents, mass media, community organizations, or other elements of an adolescent's social environment. 4. Smoking-cessation programs tend to have low suc- cess rates. Recruiting and retaining adolescents in formal cessation programs are difficult. 5. IIlegal sales of tobacco products are common. Active enforcement of age-at-sale policies by public officials and community members appears necessary to pre- vent minors' access to tobacco. 6. Econometric and other studies indicate that increases in the real price of cigarettes significantly reduce cigarette smoking; young people are at least as re- sponsive as adults to such price changes. Maintain- ing higher real prices of cigarettes depends on further tax increases to offset the effects of inflation. 10 Introduction TIMN 0138864

Surgeon Gexera!'s Report Marc Manley, M.D., M.P.H., Chief, Public Health Applications Research Branch, Nafional Cancer Institute, National Institutes of Health, Bethesda, Maryland. Robert K. Merritt, M.A., Behavioral Scientist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. David E. Nelson, M.D., M.P.H., Medical Epidemiologist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Donald Nutbeam, Ph. D., Professor, Department of Public Health, University of Sydney, Sydney, Australia. Mario Orlandi, Ph.D., M.P.H., Chief, Division of Health Promotion Research, American Health Foundation, New York, New York. Cheryl L. Perry, Ph.D., Professor, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota. Richard W. Pollay, Ph.D., Professor of Marketing and Curator, History of Advertising Archives, Faculty bf Commerce, University of British Columbia, Vancouver, British Columbia. Edward T. Popper, D.B.A., Professor of Business Administration and Marketing, Dean, School of Business and Professional Studies, Aurora University, Aurora, Illinois. Jonathan M. Samet, M.D., Professor of Medicine, University of New Mexico, School of Medicine, Albuquerque, New Mexico. Herbert H. Severson, Ph.D., Research Scientist, Oregon Research Institute, Eugene, Oregon. Dana M. Shelton, M.P.H., Epidemiologist, Office on Smoking and Health, NationalCenterforChronic Disease Prevention and Health Promotion; Centers for Disease Control and Prevention, Atlanta, Georgia. fra° Charles W. Warren, Ph.D., Sociologist, Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion,. Centers for Disease Control and Prevention, Atlanta, Georgia. John K. Worden, Ph.D., Research Professor, Department of Family Practice and Office of Health Promotion Research, University of Vermont, Burlington, Vermont. Reviewers were David G. Altman, Ph.D., Senior Research Scientist, Stanford Center for Research in Disease Prevention, Stanford University, Palo Alto, California. Karl E. Bauman, Ph.D., Professor, Department of Health Behavior and Health Education, School of Public Health, University of North Carolina, Chapel Hill, North Carolina. Richard F. Beltramini, Ph.D., Associate Professor, Department of Marketing, Arizona State University, Tempe, Arizona. Glen Bennett, M.P.H., Coordinator, Smoking Education Program, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland. Neal Benowitz, M.D., Professor of Medicine, University of California at San Francisco, San Francisco, California. Gilbert J. Botvin, Ph.D., Professor and Director, Institute for Prevention Research, Cornell University Medical College, New York, New York Robert G. Brubaker, Ph.D., Professor, Department of Psychology, Eastern Kentucky University, Richmond, Kentucky. David M. Burns, M.D., Professor of Medicine, University of California, San Diego School of Medicine, San Diego, California. Laurie Chassin, Ph.D., Professor, Arizona State University, Department of Psychology, Tempe, Arizona. Arden G. Christen, D.D.S., Professor of Oral Biology, Department of Oral Biology, Indiana University School of Dentistry, Indianapolis, Indiana. Robert J. Collins, D.M.D., M.P.H., Chief Dental Officer, Public Health Service, Indian Health Service, Rockville, Maryland. Gregory Connolly, D.M.D., M.P.H., Director, Massachusetts Tobacco Control Program, Massachusetts Department of Public Health, Boston, Massachusetts. K. Michael Cummings, Ph.D., M.P.H., Director, Smoking Control Program, Roswell Park Cancer Institute, New York State Department of Health, Buffalo, New York, Dorynne J. Czechowicz, M.D., Associate Director for Medical and Professional Affairs, Division of Clinical Research, National Institute on Drug Abuse, National Institutes of Health, Rockville, Maryland. Michael M. Daube, Public Service Commission, Perth, Australia. • vi TIMN 0138852

Preventing Tobacco Use Among Young People Health effect Prevalence (%) by smoking status Nonsmoker Occasional smoker= Regular smoker9 Annual illness rates'/ 10 students All respiratory Severe respiratory 11.0 1.4 16•.0 3.6 22.0 5.4 Nonsmoker Smoker Illness incidence1(per 1,000 days) All respiratory Upper respiratory Lower respiratory 6.6 5.2 1.4 0 umber of cigarettes smoked per da <_lpack 10.6 7.5 3.2 y >lpack Incidence rate** (per 100 school years) Upper respiratory Outpatient 52.5 59.9 67.0 Hospital 7.6 12.0 10.2 Lower respiratory Outpatient 2.5 3.0 6.8 Hospital 0.4 0.7 0.9 0 Number of cigarettes smoked per da <10 . 10-19 y >20 Rate of outpatient visits1t for respiratory episodes (per 1,000 recruits) Febrile 249 256 257 222 Afebrile 436 469 562 560 Occasional/regular smoker% ' Never/past smoker Attack of influenza-like morbiditytt 60% 40% Number of cigarettes smoked per d ay 0 510 11-20 > 20 Influenza morbidity°° during an outbreak Affected 47.2. 62.9 67.7 71.8 Severe cases 30.1 42.9 51.6 53.5 General Findings: Relative risk =1.46 for upper respiratory infection for smokers versus nonsmokers. Illnesses ascertained by visits to clinics. General Findings: Smoking associated with increased absence from school: odds ratio = 1.29 for sometimes smokers and 3.09 for regular smokers (compared with never smokers)." Genera! Findings: Smoking significantly associated with incidence of cough and phlegm. Current amount smoked significantly predicted duration of an episode of phlegm or chest discomfort. tSmoked at least I cigarette or pipe per week. °Smoked at least I cigarette or pipe per day. 'Illness rates based on infirmary visits during a school year. 9I11ness incidence based on records of the health service. **Incidence rates based on self-administered questionnaire. ffRespiratory-related (similar symptoms) visits to dispensary, with one week grouped. #Based on self-administered questionnaire. ^`These categories were not defined. ' 'Illness occurrence based on medical records and serology. Health Consequences 27 TIMN 0138880

Prez.,enting Tobacco Use Among Young People Figure 1. Use of alcohol, marijuana, and cocaine,* by age group, National Household Survey on Drug Abuse, 1985 26-34-year-olds 50 -1 0 Alcohol never tried current 45 -I never _ 35-year-olds 50 -1 10-I 0 M Alcohol Marijiiana Cocaine nevert triedt current I tried Smoking history current I r I• Smoking history Smoking history Source: USDHHS-(1988). *The criteria for cun:ent use are as follows: alcohol = drank five or more drinks in a row at least I day in the past 30 days; marijuana = used marijuana more than 10 times; cocaine = used cocaine more than 10 times (N = 8,814). tValues were under 1 for marijuana and cocaine use. # Values were under 1 for cocaine use: Health Consequences 37 TIMN 0138890

Surgeon Genernl'> Report Table 2. Published studies of the effects of smoking on lung function among young people, various countries,1965-1981` ~ Study Reference* Location/year population Findingst Peters and Ferris Massachusetts, 124 Harvard Significant reduction 1967 1965 College seniors in spirometric flow rates when compar- ing NS with persons smoking a pack a day for four years during college; dose response with amount smoked. Addington et al. Oklahomar 140 male and 417 1970 female high school students aged 13-19 years (grades 9-12) Seely, Zuskin, Connecticutt 195 male and 170 Bouhuys 1971 female high school students aged 15-19 years No significant differ- ence in VC and FEV, when comparing NS with smokers of ? 1 cig/day for last year. From MEFV curves, V., and V;., signifi- cantly reduced in boys smoking > 15 cigs/day and girls smoking > 10 cigs/day, when compared with NS. Lim 1973 Nebra_skat 50 male and 50 No significant differ- female high ence in FEV, and FVC school students when comparing NS aged 15-18 years with smokers of >_ 10 cigs/day for 1 year,l0 of 50 smokers abnor- mal by partial MEFV curves. Comstock and Nationwide, Rust 1973 1970-1971 Comment Age distribution not given, non- significant reduc- tion for FEV1. Age distribution not given; no adjustment for height in analysis of spirometric data. Age distribution not given, non- significant reduc- tion for FEVV None 3,409 U.S. Navy PEFR lower in No definition of recruits, median •smokers (99.5%'a smoker, nonsmoker; age = 19 years, predicted) than in tests of statistical nonsmokers (100.7% significance not predicted). provided. *Listed chronologically by publication date. tNS = never smoker; FEV, = forced expiratory volume in one second; VC = vital capacity; MEFV = maximal expiratory flow volume; V;. = flow rate at 50% of vital capacity; V„ = flow rate after exhalation of 75% of vital capacity; FVC = forced vital capacity; PEFR = peak expiratory flow rate; FEF,,, = forced expiratory flow from 25% to 75% of FVC. tYear not provided. . 22 Health Consequences TIMN 0138875

Pretlenfing Tobacco Use Among Young People Smokeless Tobacco Use as a Risk Factor for Other Drug Use Smokeless tobacco use is also predictive of other drug use. In a study of more than 3,000 male adolescents interviewed twice at nine-month intervals about their use of various psychoactive substances (Ary, Lichtenstein, Severson 1987), the main findings were that (1) smokeless tobacco users were significantly more likely to use ciga- rettes, marijuana, or alcohol than nonusers, (2) users of smokeless tobacco were significantly more likely to take up the use of these other substances by the second inter- view if they were not using them at the first, and (3) adolescents who were using any of these substances at the Conclusions 1. Cigarette smoking during childhood and adoles- cence produces significant health problems among young people, including cough and phlegm pro- duction, an increased number and severity of respi- ratory illnesses, decreased physical fitness, an unfavorable lipid profile, and potential retardation in the rate of lung growth and the level of maximum lung function. 2. Among addictive behaviors, cigarette smoking is the one most likely to become established during ado- lescence. People who begin to smoke at an early age are more likely to develop severe levels of nicotine addiction than those who start at a later age. first interview were significantly more likely to increase their use of the substance if they also used smokeless tobacco. Two other facts are important to consider when evaluating the role of smokeless tobacco products in the use of cigarettes and other substances. First, the overall impact of smokeless tobacco is currently limited prima- rily to males (the main users of these substances) (USDHHS 1986b, 1990). Second, smokeless tobacco users in the Ary, Lichtenstein, and Severson (1987) study, as well as in most other surveys, tend to initiate their tobacco use at about the same age as cigarette smokers or at a slightly earlier age (see "Grade When Use of Smoke- less Tobacco and Cigarettes Begins" in Chapter 3). 3. Tobacco use is associated with alcohol and illicit drug use and is generally the first drug used by young people who enter a sequence of drug use that can include tobacco, alcohol, marijuana, and harder drugs. 4. Smokeless tobacco use by adolescents is associated with early indicators of periodontal degeneration and with lesions in the oral soft tissue. Adolescent smokeless tobacco users are more likely than nonus- ers to become cigarette smokers. Health Consequences 41 TIMN 0138894

Smokeless Tobacco Use and Other Drug Use 102 Prevalence of Smokeless Tobacco Use and Other Drug Use 102 Grade When Use of Smokeless Tobacco and Cigarettes Begins 102 Smokeless Tobacco Use and Other Health-Related Behaviors 102 Conclusions 104 Appendix 1. Sources of Data. 105 National Teenage Tobacco Surveys and Teenage Attitudes and Practices Survey 105 National Household Surveys on Drug Abuse 105 Monitoring the Future Project Surveys 105 Youth Risk Behavior Survey 106 National Health Interview Surveys 106 Appendix 2. Measures of Cigarette Smoking 107 Ever Smoking 107 Current Smoking 107 Frequent and Heavy Smoking 109 Age or Grade When Smoking Begins 110 Number of Cigarettes Smoked Each Day 110 Lifetime Patterns of Smoking 110 Attempts to Quit Smoking 110 Validity of Measures of Smoking 110 Appendix 3. Measures of Smokeless Tobacco Use 112 Ever Use of Smokeless Tobacco 112 Current Use of Smokeless Tobacco 112 Grade When Smokeless Tobacco Use Begins 114 Attempts to Quit Using Smokeless Tobacco 114 . Validity of Measures of Smokeless Tobacco Use 114 References 115 TIMN 0138906

Preventing Tobacco Use Among Young People Introduction Previous Surgeon General's reports on tobacco use and health have largely focused on the epidemiologic, clinical, biologic, and pharmacologic aspects of adult use of tobacco products. This report on Preventing Tobacco Use Among Young People provides a more detailed look at adolescence, the time of life when most tobacco users begin, develop, and establish their behavior. Because regular use soon results in addiction to nicotine, this behavior may persist through adulthood, significantly increasing, through the extended years of use, the risk of long-term, severe health consequences. Despite three decades of explicit health warnings, large numbers of young people continue to take up tobacco; currently, over three million adolescents smoke cigarettes, and over one million adolescent males cur- rently use smokeless tobacco. Clearly, effective interven- tions are needed to prevent more young people from trying tobacco. To achieve significant long-term reduc- tions in tobacco use and tobacco-related deaths in the United States, we must examine the nature and scope of adolescent tobacco use, consider the social, psychologi- cal, and marketing factors that influence young people in their decision to use tobacco products, and evaluate cur- rent efforts to prevent young people from becoming users. This report addresses the crucial problems of adolescent tobacco use. Development of the Report This report of the Surgeon General was prepared by the Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Public Health Service, U.S. Department of Health and Human Services, as part of the department's responsibility, under Public Law 91-222 and Public Law 99-252, to report current information on the health effects of cigarette smoking and smokeless tobacco use to the United States Congress. This report is the first fo focus on the problem of tobacco use among young,peiple: Given the continuing onset of use in adolescence and the growing evidence of health consequences associated with early use, the report was seen as both needed and timely. The current report has been produced through the efforts of experts in the medical, pharmacologic, epidemiologic, developmental, economic, behavioral, legal, and public health aspects of smoking and smoke- less tobacco use among young people. Initial manu- scripts for the report were prepared by 28 scientists who were selected for their expertise in specific content areas. This material was consolidated into chapters, each of which underwent peer review. The entire document was reviewed by a number of experts in the field, as well as by institutes and agencies within the U.S. Public Health Service. The final draft of the report was reviewed by the Assistant Secretary for Health and by the Secretary, Department of Health and Human Services. Several concerns guided the development of this report. The first, which is addressed in Chapter 2, is whether tobacco use is associated with health conse- quences during the period of adolescence (broadly de- fined as ages 10 through 18, although research cited in this report varies somewhat in the ages considered ado- lescent). The long-term health consequences-that is, those that emerge in adulthood-have been the subject of extensive review and are widely acknowledged in the scientific and public literature. The chapter thus focuses on the serious health consequences, as well as the in- creased risk factors for subsequent health consequences, that are evident early in life among young smokers and smokeless tobacco users. Chapter 3 examines the epidemiologic patterns of tobacco use among the young. National data on trends in adolescent use are analyzed to determine the extent of the current problem, as well as to note changes in patterns of initiation and use. The factors that influence adolescents in their decision to use tobacco are examined in Chapter 4, which considers psychosocial risk factors, and Chapter 5, which examines the influence of tobacco advertising and promotion. The final concern, the focus of Chapter 6, was to assess what has been done-from the individual level to the legislative level- to prevent tobacco use among young people. Major Conciusions 1. Nearly all first use of tobacco occurs before high school graduation; this finding suggests that if ado- lescents can be kept tobacco-free, most will never start using tobacco. 2. Most adolescent smokers are addicted to nicotine and report that they want to quit but are unable to do so; they experience relapse rates and withdrawal symptoms similar to those reported by adults. 3. Tobacco is often the first drug used by those young people who usealcohol, marijuana, and other drugs. Introduction 5 TIMN 0138859 .

Preventing Tobacco Use Among Young People Ronald M. Davis, M.D., Chief Medical Officer, Michigan Department of Public Health, Lansing, Michigan. John Elder, Ph.D., M.P.H., Professor of Health Promotion, Graduate School of Public Health, San Diego State University, San Diego, California. Paul Fischer, M.D., Editor, Journal of Family Practice, Augusta, Georgia. Michael C. Fiore, M.D., M.P.H., Director, Center for Tobacco Research and Intervention, University of Wisconsin Medical School, Madison, Wisconsin. Brian R. Flay, D. Phil., Professor and Director, Prevention Research Center, School of Public Health, University of Illinois, Chicago, Illinois. Erica Frank, M.D., M.P.H., Assistant Professor, Department of Community Preventive Medicine/ Department of Medicine, Emory University School of Medicine, Atlanta, Georgia. Betsy Gelb, Ph.D., Director, Institute for Health Care Marketing, and Professor of Marketing, University of Houston, Houston, Texas. Samuel S. Gidding, M.D., Associate Professor of Pediatrics, Northwestern University Medical School, Division of Cardiology, Children's Memorial Hospital, Chicago, Illinois. Thomas Glynn, Ph.D., Acting Associate Director, Cancer Control Science Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland. Ellen R. Gritz, Ph.D., Professor and Chair, Department of Behavioral Science, The University of Texas M.D. Anderson Cancer Center, Houston, Texas. Sandra W. Headen, Ph.D., Assistant Professor of Research, Department of Health Behavior and Health Education, School of Public Health, Chapel Hill, North Carolina. ' Richard B. Heyman, M.D., Committee on Substance Abuse, American Academy of Pediatrics, and Suburban Pediatric Associates, Inc., Cincinnati, Ohio. _, David Hill, Ph.D:;~ Director, Anti-Cancer Council of Victoria, Victoria,~Australia. Thomas Houston, M.D., Director, Department of Preventive Medicine and Public Health, American Medical Association, Chicago, Illinois. John Hughes, M.D., Professor, Human Behavioral Pharmacology Laboratory, Departments of Psychiatry, Psychology, and Family Practice, University of Vermont, Burlington, Vermont. vu Saundra MacD. Hunter, Ph.D., Research Professor, Tulane University Medical Center, Department of Applied Health Sciences, School of Public Health and Tropical Medicine, New Orleans, Louisiana. Dushanka V. Kleinman, D.D.S., Deputy Director, National Institute of Dental Research, National Institutes of Health, Bethesda, Maryland. Norman A. Krasnegor, Ph.D., Chief, Human Learning and Behavior Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland. Edward Lichtenstein, Ph.D., Research Scientist, Oregon Research Institute, Eugene, Oregon. Douglas S. Lloyd, M.D., M.P.H., Associate Administrator for Public Health Practice, Health Resources and Services Administration, Department of Health and Human Services, Rockville, Maryland. Russell V. Luepker, M.D., M.S., Professor and Head, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota. -~ William R. Lynn, Public Health Advisor, Cancer Control Science Program, National Cancer Institute,_National Institutes of Health, Bethesda, Maryland. Willard Manning, Ph.D., Professor, Institute for Health Services Research, School of Public Health, University of Minnesota, Minneapolis, Minnesota. Stephen E. Marcus, Ph.D., Senior Epidemiologist, National Institute of Dental Research, National Institutes of Health, Bethesda, Maryland. J. Michael McGinnis, M.D., Deputy Assistant Secretary for Health, Office of Disease Prevention and Health Promotion, Department of Health and Human Services, Washington, D.C.. Ann D. McNeil, Ph.D., Manager, Smoking Program, -Health Education Authority, London, England. David Murray, Ph.D., Professor, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota. Thomas Novotny, M.D., M.P.H., Centers for Disease Control and Prevention Liaison Officer and Assistant Dean for Public Health Practice, School of Public Health, University of California, Berkeley South, Berkeley, California. Patrick O'Malley, Ph.D., Research Scientist, Institute for Social Research, Survey Research Center, University of Michigan, Ann Arbor, Michigan. TIMN 0138853

' Prevcntiug Toberccv Use t1Hwf14T Young People plausibly lead to increased frequency and severity of respiratory infections in smokers. Studies involving a wide age range. of young people indicate that smoking increases respiratory mor- bidity (Table 3). A number of these studies compared medical care by smokers and nonsmokers in settings where all medical care was obtained at a single clinic. In one of the earliest studies, Haynes, Krstulovic, and Bell (1966) examined the numbers of diagnoses for respira- tory tract illnesses among male students (aged 14-19 years) at a preparatory school. Nearly half of the stu- dents were smokers. All respiratory illnesses were more common in the smokers; the increase was greatest for the illnesses considered "severe." The findings of studies involving student nurses (Parnell, Anderson, Kinnis 1966) and military cadets (Finklea et al. 1971) were similar. A series of studies have included military recruits as subjects (Table 3); their ages ranged from 18 through 22. In the study of Pollard et al. (1975), the rates of respiratory diagnoses were not significantly different between smokers and nonsmokers. In the more recent study of military recruits by Blake, Abell, and Stanley (1988), self-report of smoking was associated with in- creased risk for diagnosis of an upper respiratory tract infection during a 13-week basic training period. Kark and Lebiush (1981) and Kark, Lebiush, and Rannon (1982) examined attack rates for influenza and influ- enza-like illnesses in Israeli military recruits and found that smoking was associated with an increased attack rate in both male and female recruits. Recently, in a study that examined adolescents and young adults who had sickle cell anemia, Young et al. (1992) found a strong relationship between cigarette smoking and acute'chest syndrome. In sickle cell ane- mia patients, acute chest syndrome is characterized by fever, cough, chest pain, leukocytosis, and pulmonary infiltrates in the chest radiograph. All smokers in this study had a history of acute chest syndrome, whereas 65 percent of the nonsmokers did. Smoking also ap- peared to increase the frequency of sequelae of sickle cell lung disease. _ A study in the United Kingdom (Chariton and Blair 1989) associated smoking with increased absen- teeism from school among 2,885 children aged 12 and 13 years. Children who on an initial questionnaire reported regular smoking were more likely than non- smokers to be absent when a follow-up questionnaire was administered four months later. The authors inter- preted these findings as showing a higher rate of minor ailments in children who smoked; however, the design could not exclude other plausible explanations (such as truancy) for the difference. In a survey of adolescents- invited for an overall evaluation in three general prac- tices in the United Kingdom, smokers reported a higher prevalence of health problems than nonsmokers (25 percent vs. 16 percent, p =.06) (Townsend et al. 1991). Epidemiologic Evidence of Nonrespiratory Effects Cardiovascular Disease In adults, cigarette smoking is a cause of coronary heart disease, arteriosclerotic peripheral vascular dis- ease, and stroke (USDHHS 1989). Although these diseases rarely occur in children and adolescents, au- topsy studies of young male victims of combat during the Korean and Vietnam conflicts and community-based autopsy studies of adolescents and young adults have shown that atherosclerosis begins in childhood and may become clinically significant in young adulthood (McNamara et a1.1971; Enos, Holmes, Beyer 1986; Strong 1986). Several autopsy-study series link cigarette smok- ing to the occurrence and extent of atherosclerosis in young adults. Strong and Richards (1976) described the association of cigarette smoking with atherosclerosis in 1,320 men from the New Orleans area. In the youngest group (aged 25 to 34 years), the development of athero- sclerosis in the coronary arteries and the abdominal aorta was consistently greater with higher levels of smoking. More recently, an eight-community study by the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group (1990) found associa- tions of smoking with atherosclerosis in 390 males aged 15 through 34 years who died of violent causes (e.g., accidents, homicides, suicides). In this study, lipids were measured in postmortem serum, and smoking was assessed by the level of serum thiocyanate. After controlling for lipid levels, age, and race, a multiple regression analysis revealed a significant association between smoking and atherosclerosis (i.e., having raised lesions greater than or equal to 5 percent of the intimal surface area) in the abdominal aorta. A multiple logistic analysis controlling for the same factors found that smoking was a significant predictor of atherosclerosis in both, the abdominal aorta and the right coronary artery. The Bogalusa Heart Study is an epidemiologic study of cardiovascular disease risk factors encountered from birth through age 26. Among deceased subjects whose average age was 18 years, cigarette smoking was not associated with aortic fatty streaks or involvement of the coronary arteries with atherosclerosis (Newman et al. 1986; Freedman et al. 1988). However, in subjects who Health Consequences 25 Z'IMN 0138878

Preventing Tobacco Use Among Young People Table 2. Continued Reference Study Location/year population Backhouse 1975 United 195 boys at a Kingdomx detention center, mean age = 18 years Walter, Nancy, Collier 1979 Indiat 102 male medical students aged 19-21 years Woolcock et al. Australia, 10,898 school 1979 1971-1980 children, mean ages = 8.9 years for . primary school and 12.6 years for high school groups Weiss et al. 1980 Kujala 1981 Massachusetts, 650 children aged 1975 5-9 years, popula- tion sample Finland, 1976 1,075 male military recruits, mean age = 20 years Spinaci et a1.198~ Italy, 1,266 male and 1,119 1980-1981 female 6th graders, mean age =11 years Findingst PEFR on arrival dropped significantly with daily smoking amount; significant improvement during 8-week stay while unable to smoke Significantly lower PEFR and spirometric flows when compar- ing NS with smokers of > 10,000 cigarettes per lifetime. No overall effect of smoking on spiromet- ric values in 1974 data; decreased lung growth in smoking boys who had had bronchitis before age 2 years. Smoking not associated with FEF 25-,5. Significantly reduced FEV, and spirometric flows when comparing NS with smokers at interview. Smoking negatively associated with FEF 25-75 and V. I Comment None Values for smokers of 510,000 ciga- rettes were be- tween those of nonsmokers and heavy smokers. See text for review of longitudinal findings. Only 58 children reported ever smoking; see text for longitudinal findings. None Definition for smoking not given; lung function data not• provided. Health Consequences 23 TIMN 0138876

Chapter 3 Epidemiology of Tobacco Use Among Young People in the United States Introduction 55 Cigarette Smoking Among Young People in the United States 58 Recent Patterns of Cigarette Smoking 58 Ever Smoking 58 Current Smoking 58 Frequent and Heavy Smoking 62 Sociodemographic Risk Factors for Smoking 62 Age or Grade When Smoking Begins 65 Other Patterns of Smoking 67 Initiation Continuum of Smoking 68 Cigarette Brand Preference 70 Trends in Cigarette Smoking 72 Ever Smoking 72 Current Smoking 72 Age or Grade When Smoking Begins 74 Number of Cigarettes Smoked Each Day 78 Attempts to Quit Smoking 78 Trends in Knowledge and Attitudes About Smoking 80 Trends in Perceived Health Risks of Smoking . 80 Trends in Perceptions About Smoking 80 Trends in Perceptions About Smokers 81 Adult Implications of Adolescent Smoking 84 Smoking and Other Drug Use 87 Prevalence of Smoking and Other Drug Use 88 Grade When Smoking and Other Drug Use Begins 88 Cigarette Smoking and Other Health-Related Behaviors 91 Cigarette Smoking and Health Status 91 Pregnancy and Smoking 91 Self-Reported Indicators of Health Status Among Smokers 93 Self-Reported Indicators of Nicotine Addiction Among Smokers 93 Smokeless;T'obacco Use Among Young People in the United States 95 Recent Pattep).% of Smokeless Tobacco Use 95 Ever Use of Smokeless Tobacco 95 Current Use of Smokeless Tobacco 95 Use of Smokeless Tobacco and Cigarettes 97 Sociodemographic Risk Factors for Smokeless Tobacco Use 101 Grade When Smokeless Tobacco Use Begins 101 Attempts to Quit Using Smokeless Tobacco 101 Smokeless Tobacco Brand Preference 101 Trends in Perceived Health Risks of Smokeless Tobacco Use' 101 TIMN 0138905

Pretlenthrg Tobacco Llse Anwikq Ymutg People Mode of survey administration Telephone Response rate 82% in 1989 Ages/ grades 12-18 years Sample size 2,553-9,965 interview, in-person interview, mailed questionnaire Household ean of 7-19 years 71-3,429. inten,iew approximately 80%; 84% in 1991 (trend data); 12-18 years 9,086 (1991 analysis); 30-39 years 6,388 Self-administered 77%-86% of (retrospective 1991 analysis) 12th grade: 1976 1992 15,091-18,448t in school sampled seniors; 10th grade: 1992 14,726# 66%-80% of 8th grade: 1992 18,4710 elf-administered selected schools; 70%-80% of seniors remained in panel 5 years later For national survey: 23-24 years old when contacted 5-6 years later 9th-12th grades 13,665 in panel 2,272 in in school Household 90% of sampled stu- dents; 75% of selected schools Approximately 8-19 years national survey 453-1,385 interview, 85%-90% (trend analyses limited for1974-1991); telephone >_ 18 years (for 148,433 interview reconstructed prevalence, using 1970,1978-1980, and 1987 surveys); >_ 18 years (foi age 115,337 of initiation of regular smoking analyses among females, 1970, 1978-1980,1987-1988) Type of tobacco use examined Smoking: all years Smokeless: 1989 Smoking: all years Smokeless: 1988-1991 . Smoking: all years Smokeless: 198lr-1989, 1992 Smoking and smokeless Smoking: all years 'The Institute for Social Research usually reports the N (weighted), which is approximately equal to the sample size. Cases are weighted to account for differential probability of selection and then normalized to average 1.0. The range for N (weighted) for questions on smokeless tobacco between 1986 and 1992 = 2,553-2,991. N (weighted) for smokeless tobacco 3 7,093. °N (weighted) for smokeless tobacco = 8,441. Epidemiology 57 TIMN 0138909

from the findings from cross-sectional studies. Beck, Doyle, and Schachter (1982) examined white residents of Lebanon, Connecticut, in 1972 and 1978. Among male and female subjects aged 15 through 24 in 1972, smoking had reduced the increment of FEV, during the six-year follow-up interval. In a 10-year study in Sydney, Australia,. Woolcock et al. (1984) periodically measured lung function in an initial cohort of 11,497 schoolchildren. Two groups of children were included: a younger cohort that was 8.9 years of age on average at enrollment and an older cohort aged 12.6 years on average at enrollment. The investigators followed up the cohort annually, measur- ing respiratory function and assessing symptoms, ill- nesses, and smoking. A small number of children were studied more intensively with the single-breath nitro- gen test. The effect of smoking was examined only in the older cohort. Cross-sectional assessment of these data showed that at 50 percent of vital capacity, smok- ers tended to have lower maximal expiratory flow than nonsmokers. For example, adolescents who smoked at least 10 cigarettes per week had about a 5 percent lower expiratory flow rate than nonsmokers. The investiga- tors concluded that abnormalities attributable to smok- ing were found in adolescents as young as age 14 and as soon as one year after beginning to smoke at least 10 cigarettes per week. They also concluded that smoking was more harmful for children and adolescents who had a history of respiratory illness, particularly asthma. A cohort study of children in East Boston, Massa- chusetts, has been informative on the effects of passive and active smoking on lung function (Tager et al. 1979, 1983,1985,1988). In 1974, the study enrolled a cohort of children aged five through nine who were sampled from schools in East Boston. The families of these children were then invited to participate in the initial survey and in periodic follow-up examinations that included a respiratory questionnaire and spirometry. Several relevant longitudinal analyses of the East Boston data have been reported (Tager et a1.1985,1987, 1988). Using data from the first seven follow-up ex- aminations, Tager et al. (1985) described the effect of smoking on the growth rates of FEVI and on forced expiratory flow (FEF) from 25 to 75 percent of forced yital capacity (FEF,,T) in a group of 669 subjects aged 5 through 19 years at enrollment. Using a Markov type autoregressive model, researchers found significant ef- fects of smoking on both measures of lung function. The model predicted that a child's smoking, beginning at age 15 and continuing through age 20, would reduce FEV, to 92 pergent of the expected value and FEF,g,s to 90 percent of the expected value. A subsequent analysis 24 Health Consequences SurXevn Getiera!'s Rqrurt . using a nonparametric curve-smoothing method on these same data showed that male smokers had a smaller increase of FEV, at the end of the growth phase (a suggestion of a lower maximum lung function) than males who had not smoked; those who continued to smoke into early adulthood also showed no evidence of the plateau observed in never smokers before lung func- tion began to decline. Similar findings were reported for females. Relevant information is also available from a com- munity population study in Tucson, Arizona (Lebowitz and Holberg 1988). The Tucson cohort was derived from a population sample of 325 non-Hispanic white residents, originally sampled in 1972 when they were an average age of 8.8 years. Like the East Boston study, the Tucson study was directed primarily at passive smoking but also gathered information on active smok- ing by measuring FEV, and FEF,g,;. The Tucson study found effects of comparable magnitude with those ob- served in the East Boston study. Although these effects did not reach statistical significance in the Tucson data, they were in the same direction as those from East Boston, and the sample population was only half the size. Sherrill et al. (1992) examined the longitudinal effects of active and passive smoking on lung function in a cohort of New Zealand children observed from ages 9 through 15. Active smoking did not have statis- tically significant effects on FEV,, vital capacity, or FEV, /vital capacity (percent), but the numbers of regu- lar smokers were small. By age 15, 43 percent reported occasional smoking (during the last year but not every day), but only 10 percent were daily smokers (smok- ing any number of cigarettes on a daily basis). Jaakkola et al. (1991) carried out an eight-year longitudinal study of lung function in a cohort of young adults aged 15 through 40 at enrollment. Of 1,044 enrolled, 391 were subsequently followed. Smoking was found to have a significant effect on change in FEV, during the study period, but the results were not re- ported by age interval. Respiratory Morbidity In adults, smoking is associated with increased morbidity, as indexed by such measures as use of out- patient medical services and absenteeism from work, and with increased respiratory morbidity, as indexed by frequency or severity of respiratory infections (USDHHS 1990). Because smoking has been shown to alter immune and inflammatory responses (U.S. De- partment of Health, Education, and Welfare [USDHEW] 1979b), these effects on an individual's defenses could ' TIMN 0138877

SurNevii (=,eueral '> Rqvrr Table 3. Percentage of high school students who use cigarettes, by gender, Youth Risk Behavior Surveys, United States and selected U.S. sites, 1991 Lifetime cigarette use* Current cigarette use* Frequent cigarette use# Site Female Male Total Female Male Total Female Male Total Weighted data National survey 70 71 70 27 28 28 12 13 13 State surveys Alabama 70 79 74 24 32 28 11 16 13 Georgia 66 72 69 22 26 24 10 12 11 Idaho 56 65 61 22 24 23 12 14 13 Nebraska 70 75 72 28 30 29 15 15 15 New Mexico 82 81 82 30 30 30 13 14 13 New York° 72 70 71 32 28 30 18 17 17 Puerto Rico' 46 54 50 13 18 16 3 5 4 South Carolina 72 76 74 25 26 26 13 13 13 South Dakota 68 71 69 32 30 31 17 16 16 Utah 43 55 49 16 18 17 8 8 8 Local surveys Chicago 72 73 72 13 20 16 4 7 6 Dallas 70 76 73 11 16 14 4 4 4 Fort Lauderdale 65 65 65 18 13 16 10 6 8 Jersey City 73 70 72 17 16 16 4 4 4 Miami 66 66 66 12 17 15 4 8 6 Philadelphia 82 70 76 22 17. 20 11 8 10 San Diego 64 71 68 18 18 18 7 7 7 Unweighted data9 State surveys Colorado' 73 74 74 28 27 27 13 14 14 District of Columbia ' 70 60 65 5 7 6 2 2 2 Hawaii 70 70 70 27 25 26 12 13 13 Montana 68 71 69 24 24 24 13 12 12 New Hampshire 71 71 71 28 27 27 16 15 15 New Jersey° 67 61 64 NA** NA NA NA NA NA Oregon 63 65 64 22 22 22 9 10 9 Pennsylvania° 69 73 71 28 28 28 16 15 15 Tennessee 72 75 74 30 30 30 16 16 16 Wisconsin 72 73 73 30 32 31 16 17 16 Wyoming 70 74 72 27 28 28 15 17 16 Local surveys Boston 68 68 68 15 16 15 6 9 7 New York City 76 68 72 26 16 21 12 6 9 San Francisco 61 63 62 14 15 14 7 6 6 Source: Centers for Disease Control (1992d). *Ever tried cigarette smoking, even one or two puffs. rSmoked cigarettes on 1 or more of the 30 days preceding the survey. tSmoked cigarettes on 20 or more of the 30 days preceding the survey. , °Surveys did not include students from the largest city. 'Categorized as a state for funding purposes. IFourteen sites had overall response rates below 60% or had unavailable documentation; weighted estimates were not reported. **NA = Not available. 60 Epidemiology 'TIMN 0138912

Preventing Tohruco Utie Amorrg Young People United States, the United Kingdom, New Zealand, and Scandinavia and at levels of smoking as low as one cigarette per week. In one of the first studies on smoking and respira- tory symptoms in children, Holland and Elliott (1968) administered a questionnaire concerning respiratory symptoms and cigarette smoking to all children in schools in four areas of southeast England. Smoking education was then provided to half of the schools, and the questionnaire was readministered one year later. Although the intervention had no effect on the preva- lence of smoking, the study documented that smoking in childhood was associated with cough and phlegm and that these symptoms were reduced in those who had stopped smoking. Many later studies continued to show that smok- ing increased the frequency of respiratory symptoms in children and adolescents. In the United States, research with high school students (Addington et a1.1970; Seely, Zuskin, Bouhuys 1971; Rush 1974) and college students (Peters and Ferris 1967) provided early evidence of ad- verse effects of smoking on young smokers. Large stud- ies of schoolchildren (including preteens) in the United Kingdom showed that symptom rates were increased by smoking. Bewley, Halil, and Snaith (1973) reported that the frequency of cough was increased in boys and girls no older than 11.5 years who reported smoking at least •one cigarette per week. Other studies in the United Kingdom and the United States found further evidence of the effects of smoking on symptom frequency in chil- dren of similar ages (Bewley arid Bland 1976; Charlton 1984; see Table 31 in Chapter 3). The health effects of smoking among adolescents may be confounded by a history of passive smoking if the parents of an adolescent smoker also smoke. How- ever, in a study of 5,835 secondary schoolchildren in Derbyshire (United Kingdom), students who smoked at least one cigarette per week persisted in having an in- creased risk for cough and dyspnea even after parental smoking was taken into account (Bland et a1.1978). Control for other potential confounding or mediat ing factors varies among the investigations. Residence location, a surrogate for exposure to ambient air pollu- tion, was considered in several of the studies (Bewley, Halil, Snaith 1973; Bewley and Bland 1976), and a study of 20-year-olds (Colley, Douglas, Reid 1973) controlled for socioeconomic status. Lung Function Numerous cross-sectional studies of adults have shown that cigarette smokers have a lower level of lung function, as assessed by tests of lung mechanics and gas exchange, than persons who have never smoked (USDHHS 1984; Bates 1989). Longitudinal studies show that smoking speeds the age-related decline of lung func- tion. The most abundant evidence describes changes in lung function as assessed by spirometry, or the measure of the volume of air entering and leaving the lungs. One measure of scientific and clinical interest obtained through spirometry is the forced expiratory volume in one se- cond (FEVd, the volume of air blown out during the first second of the forced vital capacity maneuver. FEV, increases with lung growth and development dur- ing childhood, and rises even more steeply with the growth spurt of adolescence (Tager et al. 1988; Sherrill et al. 1992). In persons who have never smoked, FEV, begins to decline from a maximum at some time during the third or fourth decades of life (Beck, Doyle, Schachter 1982; Tager et al. 1988). In smokers, the age- related decline commences at a younger age and pro- ceeds at a steeper average rate (Beck, Doyle, Schachter 1982; USDHHS 1984; Tager et al. 1988). When people stop smoking, their average decline gradually returns to the rate observed in those who never smoked (USDHHS 1990). Cross-sectional and'longitudinal data show that smoking also adversely affects lung function in'children and adolescents (Table 2). The evidence comes princi- pally from spirometry studies of high school students, although one of the first studies to show reduced lung function in young people involved college seniors (Pe- ters and Ferris 1967). In these studies, impaired lung function has been primarily indicated through reduced flow rates after 50 percent or more of the vital capacity has been exhaled. This effort-independent, latter portion of the flow-volume loop is sensitive to abnormalities of the lung's small airways and the lung parenchyma (Bates 1989). Several studies have also found that smokers have a reduced peak expiratory flow rate (PEFR) (Table 2). This effort-dependent portion of the flow-volume loop is more sensitive to abnormal function of the lung's larger airways than of its small airways (Bates 1989). Among the first researchers to study smoking among younger people were Peters and Ferris (1967), who obtained spirometric and peak flow data from 124 Harvard College seniors. Smokers had lower (although not signifi- cantly) FEV, than persons who had never smoked. Spiro- metric flow rates and PEFR were significantly lower in the smokers. In an early study involving high school students, Seely, Zuskin, and Bouhuys (1971) foiuid evidence of abnor- mal funclion of the small airways in both boys and girls who smoked. Subsequent cr+oss-sectional studies of teenagers have tended to confirm that smokers have reduced lung function, as assessed by spirometry or PEFR measiuement. More recent, longitudinal data show that smoking reduces the rate of lung growth, as would be anticipated Health Consequences 17 TIMN 0138870

Prevenfiitg Tvhneco Use Anwitg Young People Table 2. Percentage of young people who have ever smoked cigarettes, by gender, race/Hispanic origin, age/grade, and region, Teenage Attitudes and Practices Survey (TAPS), National Household Surveys on Drug Abuse (NHSDA), Monitoring the Future Project (MTFP), Youth Risk Behavior Survey (YRBS), United States,1989,1991,1992 Characteristic 1989 TAPS* 1991 NHSDAt 1992 MTFPt,§ 1991 YRBS' Overall 46.5 41.9 61.8 70.1 Gender Male 48.3 44.4 63.5 70.6 Female 44.4 39.3 60.2 69.5 Race/Hispanic origin White, non-Hispanic 49.5 46.5 65.3 70.4 Male 51.5 49.1 66.2 71.4 Female 49.3 43.7 64.6 69.3 Black, non-Hispanic 36.4 28.1 42.6 67.2 Male 38.7 31.0 45.5 64.7 Female 34.1 25.0 40.4 69.3 Hispanic 43.1 34.4 NA4 75.3 Male 42.5 36.1 := 75.7 Female 43.7 32.5 74:9 . ~ Age/grade 12-14 years 29.7 26.0 15-16 years 52.5 45.9 17-18 years 63.9 60.9 8th grade 45.2 ' 9th grade 64.8 10th grade 53.5 68.3 11 th grade 72.8 12th grade 61.8 74.5 Region Northeast 46.0 39.7 63.7 70.6 North Central 47.9 46.2 65.2 73.0 South 46.5 41.1 61.1 71.3 West 45.0 , 40.3 56.5 65.0 Sources: 1989 TAPS Centers for Disease Control and Prevention (CDC), Office on Smoking and Health (OSH) (unpublished data); 1991 NHSDA:: CDC, OSH (unpublished data);1992 MTFP: Johnston, O'Malley, Bachman (in press); Institute for Social Research, Uni+versityy of Michigan (unpublished data); 1991 YRBS: CDC (1992c); CDC, Division of Adolescent and School Health (unpublished data). *1989 TAPS, aged 12-18.years. Based on responses to the questions, "Have you ever smoked a cigarette?" and "Have you ever tried or experimented with cigarette smoking, even a few puffs?" Respondents who had smoked a cigarette, even a few puffs, were classified as ever smokers. '1991 NHDSA, aged 12-18 years. Based on response to the question, "About how old were you when you first tried a cigarette?" ("Never tried a cigarette" was a precoded response.) x1992 MTFP survey. Based on response to the question, "Have you ever smoked cigarettes?" Respondents who reported that they had tried cigarettes at least once or twice were classified as ever smokers. '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. '1991 YRBS, grades 9-12. Based on response to the question, "Have you ever tried cigarette smoking, even one or two puffs?" 9NA = Not available. Epidemiology 59 TIMN 0138911

Prerenhirg Tobacco Use Among Young People Table 5. Percentage of young people who report frequent or heavy use of cigarettes, by gender, race/ Hispanic origin, age/grade, and region, Teenage Attitudes and Practices Survey (TAPS), National Household Surveys on Drug Abuse (NHSDA), Monitoring the Future Project (MTFP), Youth Risk Behavior Survey (YRBS), United States,1989,1991,1992 Characteristic 1989 TAPS* 1991 NHSDAt 1992 MTFPx•' 1991 YRBS' Measure of use Frequent Heavy Heavy Frequent Overall 8.1 6.6 10.0 12.7 Gender Male 8.4 6.9 10.4 13.0 Female 7.7 6.2 9.2 12.4 Race/Hispanic origin White, non-Hispanic 10.1 7.9 12.0 15.4 Male 10.5 8.1 12.2 15.0 Female 9.7 7.6 11.6 15.8 Black, non-Hispanic 1.9 2.8 1.6 3.1 Male 2.8 3.7 2.4 4.5 Female 1.0 1.8 0.9 1.9 Hispanic 4.4 3.0 NAt 6.8 Male 4.0 2.4 8.0. Female 4.9 .3.6 5.7 Age/grade 12-14 years 1.8 1.2 15-16 years 8.3 6.5 17-18 years 16.7 14.4 8th grade 2.9 9th grade , 8.4 10th grade 6.0 11.3 11 th grade 15.6 12th grade 10.0 15.6 Region Northeast 8.7 7.7 11.1 12.1 North Central 9.1 7.1 10.9 18.9 South 7.3 6.2 10.2 10.5 West 7.6 5.7 6.8 9.0 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); 1991 YRBS: CDC (1992c); CDC, Division of Adolescent and School Health (unpublished data). *1989 TAPS, aged 12=18 years. Based on responses to the questions, "Have you ever smoked a cigarette?" and "Think about the last 30 days. Onhow many of these days did you smoke?" Those who had smoked on 20 or more of the previous 30 days were classiffed as frequent smokers. }1991 NHSDA, aged 12-18 years. Based on response to the question, "How many cigarettes have you smoked per day, on the average, during the past 30 days?" Respondents who reported smoking about one-half pack a day (6-15 cigarettes) or more were classified as heavy smokets. t1992 MTFP survey. Based on response to the question, "How frequently have you smoked cigarettes during the last 30 days?" Respondents who reported smoking about one-half pack per day or more were classified as heavy smokers. °With the exception of data for 8th- and 10th-grade students, all other data points for the MTFP survey reflect estimates for high school seniors. '1991 YRBS, grades 9-12. Based on response to the question, "During the past 30 days, on how many days did you smoke cigarettes?" Those who had smoked on 20 or more of the previous 30 days were classified as frequent smokers. qNA = Not available. Epidemiology 63 TIMN 0138915 1

Surgeon Gelteral'. Report (USDHHS 1988; Henningfield, Clayton, Pollin 1990) showed that 12- through 17-year-olds who had'smoked cigarette , in the past 30 days were approximately 3 times more likely to have consumed alcohol, 8 times more likely to have smoked marijuana, and 22 times more likely to have used cocaine in the past 30 days than those who had not smoked cigarettes. Data from the 1985- 1989 MTFP showed that seniors who had smoked ciga- rettes in the past 30 days were about 1.6 times more likely to have consumed alcohol, 4 times more likely to have smoked marijuana, and 5 times more likely to have used cocaine in the past 30 days than those who had not smoked cigarettes (see "Smoking and Other Drug Use" and Table 23 in Chapter 3). The 1985 NHSDA (USDHHS 1988; Henningfield, Clayton, Pollin 1990) examined heavier drug use as a function of cigarette smoking. Having 5 or more drinks in succession in the past 30 days, using marijuana on more than 10 occasions, and using cocaine on more than 10 occasions were considered heavier usage of drugs. A strong association was observed between cigarette smok- ing and other drug use among all age groups in this study, although the percentage of the increases in drug use from the never-smoker to the daily-smoker levels was strongest in the 12- through 17-year-old group (Fig- ure 1). Among these youngest smokers, those who smoked daily were approximately 14 times more likely to have binged on alcoho1,114 times more likely to have used marijuana at least 11 times, and 32 times more likely to have used cocaine at least 11 times than those who had not smoked. A similar correlation between frequency of alcohol use and level of cigarette smoking was found in a study of 7th- through 12th-grade students in New York State (Welte and Barnes 1987). In the Welte and Barnes study, as in the NHSDA, not only were smoking any cigarettes and drinking alcohol related, but daily smoking was a predictor of binge drinking. These data are consistent with those from a study of adult multiple-drug abusers, which found that severity of nicotine dependence, as measured either by a scale that assesses the strength of a given habit or by cigaret#es smoked per day, was corre- lated directly with severity of alcohol consumption prob- lems, as measured by scores on the Michigan Alcoholism Screening Test (Kozlowski et a1.1993). These data indi- cate a strong direct relationship between level of nicotine dependence and alcohol abuse but do not in themselves show the direction of the relationship or rule out the possibility that other factors commonly determine the coincidental occttrrence of high Ievels of tobacco and other drug use. Data from a longitudinal study in which 4,192 students (grades six through eight) were surveyed three times over four years extended the findings that the a mount of tobacco use is directly related to other drug use (Bailey 1992). Specifically, this study showed that students who during follow-up periods escalated from low-level use of tobacco or alcohol to heavy-level use were more likely to begin using other psychoactive substances or to increase their use of these substances than students who remained low-level users of tobacco or alcohol (Bailey 1992). Other studies suggest that the age at onset of cigarette smoking determines the probability of subse- quent use of marijuana and of heavy alcohol use. For example, Clayton and Ritter (1985) found not only that cigarette smoking, along with alcohol use, was the most powerful predictor of marijuana use, but also that the effect was strongest when smoking was initiated by age 17. Similarly, Keenan (1988) found that the age at onset of cigarette smoking was significantly younger in people with a history of alcoholism than in those who did not use alcohol. Another study estimated that the relative risk of alcoholism was increased tenfold among cigarette smok- ers and that people who heavily use alcohol represent approximately one-third of all cigarette smokers (DiFranza and Guerrera 1990). A further analysis,s of these and additional data led Kozlowski et al. (1993) to conclude that because the association between smoking and drinking is weaker among light smokers, the per- centage of heavier smokers who develop problems with alcohol might be greater. than 30 percent. Of all drug users surveyed by the NIDA, cigarette smokers were by far the most likely to report experienc- ing various features of addiction. Among 12- through 17-year-olds who had used cigarettes, 27 percent were daily users and 20 percent felt dependent; of those who had used alcohol, 6 percent were daily users and 5 per- cent felt dependent; of those who had.used marijuana, 18 percent were daily users and 10 percent felt dependent; of those who had used cocaine, 14 percent were daily users and 6 percent felt dependent (USDHHS 1988; Henningfield, Clayton, Pollin 1990). Cigarette smoking was also, by far, the drug use most commonly associated with withdrawal symptoms. Thus, cigarette smoking not only occurs early in the progression of drug use, it appears to be the first of these drugs to produce features of addiction in young people. Smoking as a Facilitator for Other Drug Use A number of inechanisms could explain how ciga- rette smoking facilitates the use of alcohol and illegal drugs. These mechanisms are not mutually exclusive. Moreover, othqrvariables may operate to nondifferentially increase the use of tobacco and a wide range of other substances. For example, children with conduct disorders are at increased risk of using tobacco, heroin, alcohol, 36 Health Consequences TIMN 0138889

Surgeorr General's Report Table 6. Prevalence (%) of cigarette smoking among high school seniors, by various sociodemographic risk factors, Monitoring the Future Project, United States, 1985-1989 Sociodemographic risk factor N (weighted) Smoked during past month Smoked _ 10 cigarettes/day Household structure Lives with both parents 58,100 28.3 10.3 Lives with father only 2,657 35.4 16.3 Lives with mother only 13,955 29.5 12.2 Lives alone 547 47.2 28.3 Other 5,783 34.4 17.8 Population density of locale in which respondent grew up Farm 4,445 32.5 12.3 Country 9,438 30.8 12.4 Small city 23,837 28.9 11.0 Medium-sized city or suburb 16,096 29.3 10.9 Large city or suburb 12,504 28.3 10.8 Very large city or suburb 7,612 . 25.9 8.9 Self-reported overall academic performance Above average 24,640 21.6 6.6 Slightly above average 18,688 28.0 9.7 Average 28,609 . .34.0 14.2 Below average 5,652 40.6 20.7 Plans to complete four years of college 50,364 23.9 6.9 Does not plan to complete four years of college 25,379 39.1 19.5 Plans to enter the armed forces Male 8,317 31.2 13.7 Female 2,644 30.4 12.3 Does not plan to enter the armed forces Male 25,621 26.1 10.0 Female 34,669 30.1 11.0 Importance of religion Very important 20,637 19.2 5.9 Important 25,166 29.5 10.5 Not/somewhat important 33,104 35.1 15.2 Source: Centers, for Disease Control and Prevention, Office on Smoking and Health (unpublished data). , 64 Epidemiology -TIMN 0138916

Preventing Tobacco Use Among Young People Acknowledgments Th,s report was prepared by the Department of Health and Human Services under the general direction of the Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. David Satcher, M.D., Ph.D., Director, Centers for Disease Control and Prevention, Atlanta, Georgia. Jeffrey P. Koplan, M.D., M.P.H., Director, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Richard B. Rothenberg, M.D., M.P.H., Associate Director for Science, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Michael P. Eriksen, Sc.D., Director, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. The editors of the report were Cheryl L. Perry, Ph.D., Senior Scientific Editor, Professor, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota. Gayle Lloyd, M.A., Managing Editor, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Frederick L. Hull, Ph.D., Technical Editor, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Contributing authors were David R. Arday, 1\!,t.D.; M.P.H., Preventive Medicine Specialist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Dennis V. Ary, Ph.D., Research Scientist, Oregon Research . Institute, and President, Oregon Center for Applied Science, Eugene, Oregon. Michael Booth, Ph.D., Lecturer, Department of Public Health, University of Sydney, Sydney, Australia. Dee Burton, Ph.D., Associate Director for Med ia Research, University of Illinois at Chicago Prevention Research Center, School of Public Health, Chicago, Illinois. Frank J. Chaloupka IV, Ph.D., Assistant Professor, Department of Economics, The University of Illinois at Chicago, Chicago, Illinois. K. Michael Cummings, Ph.D., M.P.H., Director, Smoking Control Program, Roswell Park Cancer Institute, New York State Department of Health, Buffalo, New York. Joseph R. DiFranza, M.D., Director of Research, Fitchburg Family Practice Residency Program, Fitchburg, Massachusetts. Roselyn Payne Epps, M.D., M.P.H., Expert, National Cancer Institute,National Institutes of Health, Bethesda, Maryland. Jean L. Forster, Ph.D., M.P.H., Associate Professor, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota. Gary A. Giovino, Ph.D., Chief, Epidemiology Branch, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Elbert D. Glover, Ph.D., Director, Tobacco Research Center, Mary Babb Randolph Cancer Center, West Virginia University School of Medi.cine/Robert C. Byrd Health Sciences Center, Morgantown, West Virginia. Jack E. Henningfield, Ph.D., Chief, Clinical Pharmacology Branch, Addiction Research Center, National Institute on Drug Abuse, National Institutes of Health, Baltimore, Maryland. Lloyd Johnston, Ph.D., Program Director, Institute of Social Research, University of Michigan, Ann Arbor, Michigan. Laura Kann, Ph.D., Chief, Surveillance Research Section, Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. R. Monina Klevens, D.D.S., M.P.H., Epidemiologist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Edward Lithtenstein, Ph.D., Research Scientist, Oregon Research Institute, Eugene, Oregon. V TIMN 0138851

Preventing Tobacco Use Among Young People Table 12. Percent distribution of an initiation continuum for cigarette smoking among persons aged 12-18 years, by age, gender, and race/Hispanic origin, Teenage Attitudes and Practices Survey, United States, 1989 Age (years) Uptake continuum category Overall 12-14 1. Never tried smoking, 44.3 55.5 not susceptible 2. Never tried smoking, 10.2 15.8 susceptible 3. Tried smoking, not a whole 7.9 6.6 cigarette, not susceptible 4. Tried smoking, not a whole 3.3 4.3 cigarette, susceptible 5. Smoked 1-99 cigarettes, 13.5 7.5 but none in the last 30 days, and not intending to smoke in a year 6. Smoked 1-99 cigarettes, but none 4.1 4.2 in the last 30 days, and might smoke in a year 7. Smoked _ 100 cigarettes, but 0.9 0.2 none in the last 30 days, and not intending to smoke in a year 8. Smoked ? 100 cigarettes, but 0.4 0.2 none in the last 30 days, and might smoke in a year 9. Smoked 1-99 cigarettes, at least sonie in the past 30 dayj_=~.. 10. Smoked >-1U0 cigarettes and smoked on 1-19 days during the past 30 days 5.9 3.7 2.2 0.7 11. Smoked at least 100 cigarettes 7.3 1.3 and smoked on at least 20 days during the past 30 days Gender Race/Hispanic origin 5-16 7-18 ale Female White/ non- His- panic Black/ non- His- panic ispanic 40.1 32.9 42.0 46.8 42.3 54.0 40.3 8.4 4.3 10.1 10.3 9.4 10.5 15.9 8.3 9.5 8.6 7.2 7.1 12.7 8.0 3.2 2.1 3.8 2.7 2.6. 5.2 5.4 16.6 . 18.8 13.6 13.4 14.6 9.6 12.6 4.8 3.1 4.2 3.9 4.4 1.9 5.4 1.0 1.9 1.2 0.7 1.2 0.0 0.8 0.4 0.7 0.4 0.4 0.5 0.3 0.5 7.3 7.4 5.8 5.9. 6.3 4.1 5.6 2.6 3.8 2.3 2.0 2.6 0.6 1.7 7.5 15.5 7.8 6.7 9.1 1.2 4.0 A Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data). Epidemiology 69 TIMN 0138921

"`".<:a'katr a''T Surgeori General's RepWt cocaine, and other drugs (USDHHS 1988). Similarly, a longitudinal study showed that first-grade children who were characterized by their teachers as either shy or aggressive were significantly more likely than their peers to smoke cigarettes, drink alcohol, and use illegal drugs in their teenage years (Kellam, Ensminger, Simon 1980). Evidence of other predictive factors, however, does not rule out the possibility that young people who smoke have an increased risk of using other drugs. Morphologic changes in brain structure that have been induced by nicotine exposure might predispose persons to the abuse of other drugs; this mechanism, however, has not yet been experimentally investigated. One possibility is that common pathways of drug- produced reinforcement in the brain might be altered so that the reinforcement produced by subsequent drug exposure is intensified. Central nicotinic receptors are known to be critical mediators of the reinforcing effects of nicotine (USDHHS 1988). In turn, activation of these receptors leads to activation of the dopaminergic reward system, which is critical in mediating the reinforcing effects of a wide variety of abused drugs, including co- caine and heroin. Thus, it is a plausible, but unproven, hypothesis that nicotine exposure would lead to a height- ened sensitivity to the reinforcing effects of other drugs of abuse. This hypothesis is supported by the finding that the development of tolerance to nicotine is accompanied by the development of tolerance ("cross-tolerance") to alcohol (Burch et al. 1988; Collins et al. 1988). Other research with animals also shows that-nicotine exposure, eitheralone or in combination with otherdrugs, may alter the behavioral responses to drugs of abuse, including alcohol and cocaine (Signs and Schechter 1986; Horger, Giles, Schenk 1992). These data together suggest a plau- sible biological basis for a causal role for tobacco use in the development of other substance abuse patterns, even if this role is shared by other risk factors. Nicotine produces various effects that have been shown to be produced similarly by one or more other abused drugs; all of these findings were discussed in greater detail in the 1988 Surgeon General's report (USDHHS 1988) an~elsewhere (Pomerleau and Pomerleau 1984). Nicotin~administration produces feel- ings of pleasure and euphoria that elevate the same scales on the Addiction Research Center Inventory as the effects of heroin, cocaine, alcohol, and other abused drugs (Henningfield, Miyasato, Jasinski 1985; USDHHS 1988). Human subjects report, and laboratory rats demonstrate, that nicotine produces acute effects that are more like a stimulant than a sedative (Henningfield, Miyasato, Jasinski 1985; USDHHS 1988). Nicotine administration causes cortical EEG activation (increase in alpha and beta frequency, decrease in beta power) that is associated with increased vigilance and improved cognitive func- tion (USDHHS 1988; Pickworth, Herning, Henningfield 1989). Conversely, nicotine deprivation leads to EEG deactivation and concomitant decreases in vigilance and cognitive function (USDHHS 1988; Pickworth, Herning, Henningfield 1989). Nicotine administration modulates the various levels of catecholamines, which are impor- tant in the regulation of mood and reactions to stressful stimuli (Pomerleau and Pomerleau 1984; USDHHS 1988). Partly through its effects on serotonergic systems in the brain, nicotine has some of the same effects on appetite as medications prescribed for this purpose. Nico- tine can reduce skeletal muscle tension and thereby con- tribute to the feelings of pleasurable relaxation often attributed to various abused drugs. For all of these drugs, including nicotine, the specific effect produced is related to the dose of the drug administered. Thus, depending on the dose of the drug or drugs taken, the time since the last dose, and other factors, theoretically the user may achieve certain effects with any of several drugs, achieve various maximal effects through drug combinations, or use certain drug combinations in an effort to reduce certain adverse effects (Gardner 1980). Certain trends in drug abuse that have become prominent over the past decade increase the potential role of cigarette smoking in the development of other forms of drug use. Specifically, there are increasing reports of smokable preparations of various drugs, in- cluding cocaine ("crack"), methamphetamine ("ice"), phencyclidine ("PCP"), and heroin, and marijuana con- tinues to be smoked by large numbers of people (USDHHS 1988). Drug administration via smoking re- quires the user to learn to regulate dose and to become tolerant of the rapid onset and aversive effects of smoke inhalation. These basic skills may be learned through the process of becoming dependent on tobacco, as is dis- cussed in "Developmental Stages of Smoking" in Chap- ter 4 of this report and in the 1988 report. Once learned, these skills can be transferred to other smoked drugs and can facilitate the process of experimentation with such drugs, as well as increase the potential for addiction. . 38 Health Consequences T'MN 0138891

Surgeon General 's Report 4. Adolescents with lower levels of school achieve- ment, with fewer skills to resist pervasive influences to use tobacco, with friends who use tobacco, and with lower self-images are more likely than their peers to use tobacco. 5. Cigarette advertising appears to increase young people's risk of smoking by affecting their perceptions of the pervasiveness, image, and func- tion of smoking. 6. Communitywide efforts that include tobacco tax in- creases, enforcement of minors' access laws, youth- oriented mass media campaigns, and school-based tobacco-use prevention programs are successful in reducing adolescent use of tobacco. Summary Introduction The health effects of cigarette smoking have been the subject of intensive investigation since the 1950s. Ciga- rette smoking is still considered the chief preventable cause of premature disease and death in the United States. As was documented extensively in previous Sur- geon General's reports, cigarette smoking has been caus- ally linked to lung cancer and other fatal malignancies, atherosclerosis and coronary heart disease, chronic ob- structive pulmonary disease, and other conditions that constitute a wide array of serious health consequences (USDHHS 1989). More recent studies have concluded that passive (or involuntary) smoking can cause disease, including lung cancer, in healthy nonsmokers. In 1986, an advisory committee appointed by the Surgeon Gen- eral released a special report on the health consequences of smokeless tobacco, concluding that smokeless tobacco use can cause cancer and can lead to nicotine addiction (USDHHS 1986). In the 1988 report, nicotine was desig- nated a highly addictive substance, comparable in its physiological and psychological properties to other ad- dictive substances of abuse (USDHHS 1988). Considerable evidence indicates that the health problems associated with smoking are a function of the duration (years) and the intensity (amount) of use. The younger one begins to smoke, the more likely one is to be a current smoker as art,adult: Earlier onset of cigarette smoking and smokeless tobacco use provides more life- years to use tobacco andthereby increases the potential duration of use and the risk of a range of more serious health consequences. Earlier onset is also associated with heavier use; those who begin to use tobacco as younger adolescents are among the heaviest users in adolescence and adulthood. Heavier users are more likely to experience tobacco-related health problems and are the least likely to quit smoking cigarettes or using smokeless tobacco. Preventing tobacco use among young people is therefore likely to affect both duration and intensity of total use of tobacco, potentially reducing long-term health consequences significantly. Health Consequences of Tobacco Use Among Young People Active smoking by young people is associated with significant health problems during childhood and adolescence and with increased risk factors for health problems in adulthood. Cigarette smoking during adolescence appears to reduce the rate of lung growth and the level of maximum lung function that can be achieved. Young smokers are likely to be less physically fit than young nonsmokers; fitness levels are inversely related to the duration and the intensity of smoking. Adolescent smokers report that they are significantly more likely than their nonsmoking peers to experience shortness of breath, coughing spells, phlegm production, wheezing, and overall dimin- ished physical health. Cigarette smoking during child- hood and adolescence poses a dear risk for respiratory symptoms and problems during adolescence; these health problems are risk factors for other chronic con- ditions in adulthood, including chronic obstructive pulmonary disease. Cardiovascular disease is the leading cause of death among adults in the United States. Atheroscle- rosis, however, may begin in childhood and become clinically significant by young adulthood. Cigarette smoking has been shown to be a primary risk factor, for coronary heart disease, arteriosclerotic peripheral vascular disease, and stroke. Smoking by children and adolescents is associated with an increased risk of early atherosclerotic lesions and increased risk factors foi cardiovascular diseases. These risk factors include increased levels of low-density lipoprotein cholesterol, increased very-low-density lipoprotein cholesterol, increased triglycerides, and reduced levels of 6 Introduction TIMN 0138860

Preventing Tobacco Use Among Young People Karen M. Deasy, Assistant Director (Liaison), Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Washington, D.C. Susan R. Derrick, Editorial Assistant, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Alice A. DeVierno, M.L.S., Manager, Technical Information Center, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Elizabeth D. Eckl, M.S.L.S., Information Specialist, Circle Solutions, Inc., McLean Virginia. Joseph Gfroerer, Statistician, Division of Epidemiology and Prevention Research, National Institute on Drug Abuse, National Institutes of Health, Rockville, Maryland. Donna Gloria, Secretary, HCR Consulting Group, Atlanta, Georgia. Lakshmi M. Grama, M.L.S., Database -Advisor, Circle Solutions, Inc., McLean, Virginia. Janet C. Greenblatt, Statistician, Office of Applied Studies, Substance Abuse and Mental Health Services Administration, Washington, D.C. William A. Harris, Computer Specialist, Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Lillian Hatch, M.S.L.S., Information Specialist, Circle Solutions, Inc., McLean, Virginia. Corinne G. Husten, M.D., M.P.H., Medical Officer, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Gwendolyn A. Ingraham, Writer-Editor, National Center for Injury Preventirnt and Control, Centers for Disease Control and Preveation, Atlanta, Georgia. Jeffrey C. Johnson, Computer Specialist, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota. Doreen Johnson-Kloehn, M.A., Scientist, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota. Steven C. Joseph, M.D., Dean, School of Public Health, University of Minnesota, Minneapolis, Minnesota. ix Sarah Knowlton, J.D., Attorney-Advisor, Office of the General Counsel, Centers for Disease Control and Prevention, Atlanta, Georgia. Kelli Komro, M.S. W., M.P.H., Doctoral Student, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota. Sushil Kriplani, M.A., Consultant, Minneapolis, Minnesota. Mark J. Leech, M.A., Information Specialist, Circle Solutions, Inc., McLean, Virginia. Peggy Lytton, Editor, Circle Solutions, Inc., McLean, Virginia. Karen McCloud, Editorial Assistant, HCR Consulting Group, Atlanta, Georgia. Bonnie L. Manning, Executive Secretary, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota. William L. Marx, Technical Information Specialist, Office on Smoking and Health,' National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Daniel F. McLaughlin, Editor, Circle Solutions, Inc., McLean, Virginia. Jennifer A. Michaels, M.L.S., Technical Information Specialist, Of[ico on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Nancy A. Miltenberger, M.A., Editor, Circle Solutions, Inc., McLean, Virginia. Kimberly J. Miner, Ph.D., Postdoctoral Fellow, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota: -Paul D. Mowrey, M.S., Research Scientist, Battelle Memorial Institute, Atlanta, Georgia. Suong Nguyen, Student, School of Public Health, San Diego University, San Diego, California. Gwen J. Nunnally, Secretary, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Cathie M. O'Donnell, Project Director, Circle Solutions, Inc., McLean, Virginia. TIMN 0138855

Surgewt General's Repvrt Guy S. Parcel, Ph.D., Professor and Director, Center for Health Promotion and Research Development, University of Texas Health Science Center, Houston, Texas. Joseph Patterson, Director of Government Relations and Specia l Projects, American Cancer Society, Atlan ta, Georgia. Terry F. Pechacek, Ph.D., Associate Professor, School of Medicine and Biomedical Sciences, State University of New York, Buffalo, New York. Michael Pertschuk, J.D., Co-Director, The Advocacy Institute, Washington, D.C. John P. Pierce, Ph.D., Associate Professor and Head, Cancer Prevention and Control, University of California, San Diego, Califonnia. John M. Pinney, Chief Executive Officer, Corporate Health Policies Group, Bethesda, Maryland. Patrick Remington, M.D., State Medical Officer and Epidemiologist, Chronic Disease and Health Promotion Section, Wisconsin Department of Health and Social Services, Madison, Wisconsin. John W. Richards, Jr., M.D., Associate Editor, Journal of Family Practice, Augusta, Georgia. Julius Richmond, M.D., John D. McArthur Professor of Health Policy Emeritus, Harvard Medical School, Boston, Massachusetts. Nancy A. Rigotti, M.D., Assistant Professor of Medicine and Preventive Medicine, Harvard Medical School and Associate Director, Quit Smoking Service, Massachusetts General Hospital, Boston, Massachusetts. Jonathan M. Samet, M.D., Professor of Medicine, University of New Mexico, School of Medicine, Albuquerque, New Mexico. Thomas C. Schelling, Ph.D., Distinguished Professor of Economics and Public Affairs, Departmentof Economics/ School of Public Affairs, University of Maryland, College Park, Maryland. Russell Sciandra, M.A:; I'rojectManager, American Stop Smoking InterventiongtiidyforCancer Prevention, New York State Department of Health; Albany, New York Donald R. Shopland, Coordinator, Smoking and Tobacco Control Program, National' Cancer Institute, National Institutes of Health, Bethesda, Maryland. Vivian L. Smith, M.S.W., Acting Director, Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Jesse Steinfeld, M.D., Surgeon General, U.S. Public Health Service, 1969-1973, San Diego, California. Steve Sussman, Ph.D., Associate Professor, Institute for Health Promotion and Disease Prevention Research, University of Southern California, Alhambra, California. Ira B. Tager, M.D., Professor of Epidemiology, University of California, Berkeley, School of Public Health, Berkeley, California. Larry Wallack, Dr. P.H., Professor, School of Public Health, University of California at Berkeley, Berkeley, California. Kenneth E. Warner, Ph.D., Professor and Chair, Department of Public Health Policy and Administration, School of Public Health, University of Michigan, Ann Arbor, Michigan. Jeffrey Wasserman, Ph.D., Associate Director, Health Policy Research, SysteMetrics, Santa Barbara, California. Scott T. Weiss, M.D., Associate Professor of Medicine, Harvard School of Public Health, and Channing Laboratory, Harvard Medical School, and Brigham and Women's Hospital, Boston, Massachusetts. Judith Wilkenfeld, J.D., Assistant Director, Division of Advertising Practices, Federal Trade Commission, Washington, D.C. Deborah M. Winn, Ph.D.,, Chief, Analytical Studies and Decision Systems Branch, Epidemiology and Oral Disease Prevention Program, National Institute of Dental Research, National Institutes of Health, Bethesda, Maryland. Ernst L. Wynder, M.D., President, American Health Foundation, New York, New York. Other eontributors were Deborah Anker, M.A., Graphic Artist, Circle Solutions, Inc., McLean, Virginia. Victoria Agee, M.L.S., Agee Indexing Services, Albuquerque, New Mexico. Kelly L. Byrne, Word Processing Specialist, Circle Solutions, Inc., McLean, Virginia. Michele Chang, Special Assistant to the Director, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Jeffrey H. Chrismon, Computer Programmer, The Orkand Corporation, Atlanta, Georgia. Anita Cowan,M.L.S., Director, Information Systems and Services Group, Circle Solutions, Inc., McLean, Virginia. vui TIlVIN 0138854

Preventing Tobacco Use Among Young People and smokeless tobacco use continue to be of great public health importance, since one out of three U.S. adoles- cents uses tobacco by age 18. The social environment of adolescents, including the functions, meanings, and im- ages of smoking that are conveyed through cigarette advertising, sets the stage for adolescents to begin using tobacco. As tobacco products are available and as peers begin to try them, these factors become personalized and Chapter Conclusions Following are the specific condusions for each chap- ter of this report: Chapter 2. The Health Consequences of Tobacco Use by Young People 1. Cigarette smoking during childhood and adoles- cence produces significant health problems among young people, including cough and phlegm pro- duction, an increased number and severity of respi- ratory illnesses, decreased physical fitness, an unfavorable lipid profile, and potential retardation in the rate of lung growth and the level of maximum lung function. 2. Among addictive behaviors, cigarette smoking is the one most likely to become established during ado- lescence. People who begin to smoke at an early age are more likely to develop severe levels of nicotine addiction than those who start at a later age. 3. Tobacco use is associated with alcohol and illicit drug use and is generally the first drug used by young people who enter a sequence of drug use that can include tobacco, alcohol, marijuana, and harder drugs. 4. Smokeless tobacco use by adolescents is associated with early indicators of periodontal degeneration and with lesions in the oral soft tissue. Adolescent smokeless tobaccp users are more likely than nonus- ers to become cigarette smokers. Chapter 3. Epidemiology of Tobacco Use Among Young People in the United States 1. Tobacco use primarily begins in early adolescence, typically by age 16; almost all first use occurs before the time of high school graduation. 2. Smoking prevalence among adolescents declined sharply in the 1970s, but the decline slowed relevant, and tobacco use may begin. This process most affects adolescents who, compared with their peers, have lower self-esteem and self-images, are less involved with school and academic achievement, have fewer skills to resist the offers of peers, and come from homes with lower socioeconomic status. Tobacco-use prevention programs that target the larger social environment of adolescents are both efficacious and warranted. significantly in the 1980s. At least 3.1 million adoles- cents and 25 percent of 17- and 18-year-olds are current smokers. 3. 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, 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. 4. Many adolescent smokers are addicted to cigarettes; these young smokers report withdrawal symptoms similar to those reported by adults. 5. 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. Chapter 4. Psychosocial Risk Factors for Initiating Tobacco Use 1. The initiation and development of tobacco use among children and adolescents progresses in five stages: from fonning attitudes and beliefs about tobacco, to trying, experimenting with, and regularly using to- bacco, to being addicted. This process generally takes about three years. 2. Sociodemographic factors associated with the onset of tobacco use include being an adolescent from a family with low socioeconomic status. 3. Environmental risk factors for tobacco use include acce!Esibility and availability of tobacco products, perceptions by adolescents that tobacco use is Introduction 9 TIMN 0138863

Surgeon General's Repurt . The chronic phase of the addictive process is highly resistant to substantial modification. For example, ef- forts to reduce tobacco smoke and nicotine exposure by smoking cigarettes with lower ratings of nicotine deliv- ery or to smoke fewer cigarettes are usually partially or completely thwarted by compensatory changes in how the cigarettes are smoked; smokers may compensate for "cutting back" by inhaling more deeply or smoking the cigarette farther down to its more potent and more toxic end (Kozlowski 1981,1982; Benowitz et al. 1983; Benowitz and Jacob 1984; USDHHS 1988). Abstinence from smok- ing is generally short-lived; the majority of persons who quit on their own or in minimally supportive interven- tions appear to relapse within one week of their last cigarette (Kottke et al. 1989). In fact, in testament to the persistence of addiction, nearly one-third of those who have abstained for one year after quitting relapse later (USDHHS 1990; Giovino 1991). These patterns of relapse are similar to those observed with other drug addictions. Several potential predictive measures of the sever- ity of addiction in a person may forecast the severity of withdrawal and the outcome of an attempt to quit. These measures, which have been discussed in detail in the 1988 report of the Surgeon General (USDHHS 1988), include cotinine level in biological fluid such as saliva, blood, or urine; number of cigarettes smoked per day; score on the Fagerstrom Tolerance Questionnaire; and number of symptoms attributed from the Diagnostic and Statistical Manual of Mental Disorders (APA 198y). These measures tend to predict, although not perfectly, the difficulty of achieving abstinence, the severity of with- drawal svmptoms, the rapidity of relapse, and the effi- cacy of replacement therapy (USDHHS 1988). One final source of vulnerability to nicotine depen- dence appears to be genetic predisposition. Research with animals has shown that the amount of up-regulation (increased binding in the brain) of nicotine receptors after nicotine exposure is related to genetic constitution, as are certain behavioral and physiologic effects (Marks et al. -1989; Collins 1990). Data from studies with human twins have yielded indices of heritability for cigarette smoking similar to those for drinking alcohol (Hughes 1986; Kozlowski 1991; Carmelli et a1.1992). Nondrug Factors in Nicotine Dependence Nondrug factors can affect the prevalence of drug addiction in society as well as its severity in individuals. Some of the factors are the same as those that determine the prevalence and severity of other medical disorders resulting from exposure to toxins. Among the most important factors in determining the prevalence of drug addiction is the exposure to the addicting substance (USDHHS 1988). This factor is no less important in the spread of drug addiction than it is in the spread of disorders such as acquired immunodeficiency syndrome, malaria, and influenza infections. Moreover, social fac- tors can determine the type and frequency of exposure to the etiologic agent, as well as the time frame over which exposure continues. Many nondrug factors associated with both abstinence and relapse appear to operate simi- larly across addictions. These factors include illness induced by drug dependence (which will at least tempo- rarily interrupt drug use), ability to learn to manage cravings, social reinforcements for abstinence, availabil- ity of the substance, cost of the substance, and perception of the risk oPusing the substance (USDHHS 1988). Persons vary in their vulnerability to nicotine and other drug addiction, just as they vary in their vulnerabil- ity to other medical disorders; some people show a high degree of resistance to the disorder despite multiple exposures to the agent, and others very quickly become addicted (USDHHS 1988). Psychosocial factors affecting the vulnerability of the young and the onset of tobacco use are discussed in Chapter 4. Smoking as a Risk Factor for Other Drug Use Introduction The 1988 Surgeon General's report (USDHHS 1988) showed that among adolescents, cigarette smoking is a risk factor in the development of alcohol use and illegal drug use. The nature of the interrelationship be- tween tobacco and other drug use is complex; in several possible ways, tobacco use may heighten the probability that a young person will use other drugs (Slade 1993; see "Smoking and Other Drug Use" in Chapter 3 and "Behav- ioral Factors in the Initiation of Smoking" in Chapter 4). Progression of Drug Use Kandel (1975) found that studies of the progression of drugg use iit the 1970s showed that cigarette smoking and alcohol use generally preceded marijuana smoking and other illegal drug use. In fact, Kandel's study 34 Health Consequences TIMN 0138887

Premnting Tobacco Use Among Young People were less likely to have smoked than male dropouts (33 vs. 52 percent). White high school students and graduates were more likely than their black counterparts to have smoked in the past week (19 vs. 6 percent). White dropouts were also more likely to have smoked than were black dropouts (46 vs. 17 percent). Data on past- month smoking for 16- through 18-year-old high school seniors and similar-aged youth who reported that they had dropped out of school are available from the NHSDA (Kopstein and Roth 1993). About 28 percent of white students and 72 percent of white dropouts were past- month smokers, and 7 percent of black students and 30 percent of black dropouts were past-month smokers. Among Hispanic 16- through 18-year-olds, however, past- month smoking prevalence was less divergent between students (25 percent) and dropouts (27 percent). Pirie, Murray, and Luepker (1988), using surveys conducted in Minnesota, also reported a higher prevalence of smoking among dropouts. Age or Grade When Smoking Begins Smoking initiation at a young age increases the subsequent risk of heavy smoking (Escobedo et al. 1993; Taioli and Wynder 1991) and of smoking-attributable mortality (USDHHS 1989b). As is discussed in detail in Chapter 4 (see "Developmental Stages of Smoking"), smoking initiation is a complex process that can occur over a number of years. The present analysis examined two points in this process: the age a person first tries a cigarette, and the age a person begins smoking daily. Because some initiation occurs after the adolescent years, the analysis began with self-reported data re- called by adults in the 1991 NHSDA (Table 7). The analysis was further restricted to adults aged 30 through 39 because virtually all initiation occurs before the age of 30 (CDC 1991b; SAMHSA, unpublished data) and be- cause virtually all of the increased mortality that results from cigarette smoking occurs after the age of 40 (Na- tional Center for Health Statistics [NCHS] 1992a; Table 7. Cumulative percentages of recalled age at which a respondent first tried a cigarette and began smoking daily, among persons aged 30-39, National Household Surveys on Drug Abuse, United States, 1991 All persons* Persons who had ever tried a cigarette Persons who had ever smoked daily Age (years) First tried a cigarette Began smoking daily First tried a cigarette First tried a cigarette Began smoking daily < 12 14.1 0.9 18.0 15.6 1.9 < 14 29.7 3.9 38.0 36.7 8.0 < 16 48.2 12.2 61.9 62.2 24.9 < 18 63.7 26.0 81.6 81.9 53.0 <_ 18 68.8 34.9 88.2 89.0 71.2 < 20 71.0 37.8 91:0 91.3 77.0 < 25 Y-76.6 46.5 98.2 98.4 94.8 < 30 77.4 48:1 99.3 99.4 98.1 <_ 39 78.0 49.0 100.0 100.0 100.0 Never smoked 100.0 100.0 NAt NA NA Mean age NA NA 14.5 14.6 17.7 Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data). *All persons (N = 6,388). 'NA = Not applicable. Epidemiology 65 'I'I1VIN 0138917

Surgevtt Gettgra1's Report died after age 20, smoking appears to have been related to atherosclerosis (Berenson et al. 1992). Smoking among young people has been associated with serum lipid profiles in a pattern predictive of in- creased risk for cardiovascular diseases. In a published meta-analysis of studies on children who smoke, Craig et al. (1990) found that among 8- through 19-year-olds, smoking increased levels of low-density lipoprotein cho- lesterol by 4 percent, triglycerides by 12 percent, and very-low-density lipoprotein cholesterol by 12 percent. Levels of high-density lipoprotein (HDL) cholesterol were reduced by 9 percent. These changes were comparable to-and of larger magnitude than-those observed in smoking adults. Physical Fitness Even among young people trained as endurance runners, smoking appears to compromise physical fitness in levels of both performance and endurance. Cigarette smoking reduces the oxygen-carrying capacity of the blood and increases both heart rate and basal metabolic rate-changes that counter the benefits of physi- cal activity in a direct relation to the duration of smoking and the number of cigarettes regularly smoked (Royal College of Physicians of London 1992). In a study of 19- year-old army conscripts (N = 6,500), those who smoked ran a' significantly shorter distance in 12 minutes and took significantly longer to sprint 80 meters than their nonsmoking counterparts (Marti et a1.1988). In the same study, the smokers among 4,100 joggers in a 16-kilometer race were consistently slower than the nonsmokers. Young adult smokers also have chronic, mild ad- verse cardiovascular physiologic changes, including di- minished exercise performance on standard treadmill testing and blunted heart rate response to exercise (Sidney et al. 1993). The left ventricular mass is increased in young adult smokers, and their resting heart rates are two to three beats per minute more rapid than nonsmok- ers' (Gidding et al. 1992). Health Outcomes in PtWtancy Cigarettesmokingduringpregnancyhasbeenlinked with a variety of adverseoutcomes (USDHHS 1989,1990). Early reports of the Surgeon General (USDHEW 1971, 1973,1979a) concluded that smoking by a mother during pregnancy retards fetal growth and maycause fetal death late in pregnancy as well as infant mortality. The 1977- 1978 report (USDHEW 1979a) further concluded that smoking during pregnancy has dose-response relation- ships with abruptio placenta, placenta previa, bleeding during pregnancy, premature and prolonged rupture of placental membranes, and preterm delivery. The comprehensive reviews of the 1979 and 1980 reports (USDHEW 1979a; USDHHS 1980) concluded that the risk of spontaneous abortion increases with the amount of smokingand thatthe riskofsudden infantdeathsyndrome (SIDS) is increased by maternal smoking. A more recent study confirms the increased risk of SIDS with matemal smoking (Schoendorf and Kiely 1992). Impaired fertility was linked to smoking in the 1980 report (USDHHS 1980). These adverse health effects of smoking on reproduction have not been specifically investigated in young women in the 10- through 20-year age range. Epidemiologic Evidence of the Health Effects of Passive Smoking The health effects of passive smoking were com- prehensively addressed in the 1986 report of the Surgeon General (USDHHS 1986a) and in a report of the National Research Council (1986). These reviews and subsequent reports (Samet, Cain, Leaderer 1991; USEPA 1992) have demonstrated that exposure to parental smoking during childhood significantly increases the occurrence of lower respiratory illnesses during the first years of life, in- creases the frequency of chronic respiratory symptoms, and reduces the rate of lung growth during childhood and adolescence. Evidence is accumulating to suggest that smoking by parents increases the severity of child- hood asthma (USDHHS 1991b; Samet, Cain, Leaderer 1991), as indicated by the need for medication and hospi- tal treatment. SIDS, the most common cause of death in the first year of life, has been linked to parental smoking in several epidemiologic studies. Children of parents who smoke have a twofold increased risk of dying of SIDS; this relationship appears to be dose-related (Schoendorf and Kiely 1992; Malloy et al. 1988). The evidence on passive smoking and respiratory health was recently reviewed by the USEPA (1992). This review confirmed that ETS is causally linked to lung cancer. Janerich et al. (1990) noted that approximately 17 percent of lung cancers among nonsmokers can be attrib- uted to high levels of ETS during childhood and adoles- cence. The USEPA report also concluded that exposure to ETS causes lower respiratory illness in infants and young children; this finding is stronger than that of the 1986 Surgeon General's report, which did not character- ize this association as causal. The agency's report also inferred from its data that childhood exposure to ETS reduced lung function, increased respiratory symptoms, caused middle ear effusion, and exacerbated asthma. For example, the report estimated that ETS exposure exacerbates symptoms of asthma in about 20 percent of the two million to five million asthmatic children in the United States. The report also hypothesized that ETS may be associated with the onset of asthma. 28 Health Consequences TIMN 0138881

Preventing Tobacco Use Among Young People Figure 2. Cumulative percentage of females becoming regular cigarette smokers by age 18, by age at time of survey, United States,1970,1978-1980, and 1987-1988 c v ` d ~ 40 35 30 25 20 5-I Age at time of survey: 18-24 years 0 3 5 7 9 11 13 15 17 Age when respondent began smoking regularly (years) 30 Age at time of survey: 25 35-44 years 20-I 5 0 3 5 7 9 11 13 15 17 Age when respondent began smoking regularly (years) Age at time of survey: 55-64 years 0 - 3 5 7 9 11 13 15 17 Age when respondent began smoking regularly (years) 30 Age at time of survey: 25 45-54 years 20 ~ 0 - 3 5 7 9 11 13 15 17 Age when respondent began smoking regularly (years) 12n Age at time of survey: ? 65 years 8 2-I 0 - 3 5 7 9 11 13 15 17 01 -- 3 5 7 9 11 13 15 17 Age when respondent began smoking regularly (years) Age when respondent began smoking regularly (years) Source: National Health Interview Surveys 1970,1978,1979,1980,1987;1988, 1987-1988 Surveys Centers for Disease Control and Prevention, Office on Smoking and Health' (unpublished data). 1978-1980 Surveys 1970 Survey Epidemiology 77 TIMN 0138929

Preventing Tobncco Use Among Young People Table 14. Trends in the prevalence (%) of ever smoking among young people, National Teenage Tobacco Surveys (NTTS), National Household Surveys on Drug Abuse (NHSDA), Monitoring the Future Project (MTFP), National Health Interview Surveys (NHIS), United States, 1968-1992 Year NTTS* NHSDAt MTFPx NHISS 1968 36.1 1970 40.8 1972 39.2 1974 41.3 69.5 41.1 1976 64.1 75.4 1977 67.8 75.8 1978 75.3 36.7 1979 34.0 78.1 74.0 39.3 1980 71.0 34.1 1981 71.0 1982 72.6 70.1 1983 70.6 34.5 ~ 1984 69.7 1985 63.2 68.8 29.8 1986 67.6 1987 67.2 26.2 1988 66.2 66.4 27.7 1989 ' 65.7 1990 61.4 64.4 27.6 1991 63.6 63.1 25.3 1992 61.8 ' Sources: NTTS: U.S. Department of Health, Education, and Welfare (USDHEW) (1972,1976,1979b); NHSDA: Centers for Disease Control and Prevention (CDC), Office on Smoking and Health (OSH) (unpublished data on 1974-1991 surveys); MTFP: Johnston, O'Malley, Bachman (in press); NHIS: CDC, OSI-i (unpublished data on 1974-1991 surveys). *NTTS, aged 17-18 years. Published reports (USDHEW 1972,1976,1979b) merge never smokers and experimenters (those who tried or experimented with smoking, but who had not yet smoked 100 cigarettes) into one category. By definition, therefore, the NT'I9 will underestimate the percentage of ever smokers. The trends, however, use the same definition. 'NHSDA, aged 17-19;years. Those who reported in 1974,1976, and 1977 that they were current smokers and those who were not current smokers but who responded "yes" to the question, "Have you ever smoked cigarettes?" were classified as ever smokers for those years. For the years 1979 through 1991, ever smoking status was determined by response to the question, "About how old were you when you first tried a cigarette?" The prevalence of ever smoking is the complement of the response "Never tried a cigarette." xMTFP high school seniors, aged 17-18 years. Based on response to the question, "Have you ever smoked cigarettes?" §NHIS, aged 18-19 years. Based on response to the question, "Have you smoked at least 100 cigarettes in your entire life?" Those who had smoked at least 100 cigarettes by the time of the survey were classified as ever smokers. °Available information from published sources (USDHEW 1972,1976,1979b) do not permit exact comparisons with the 1989 TAPS data. Epidemiology 73 TIMN 0138925

Preventtng Tobacco Use Anrvng Young People maintaining drug abstinence, and the symptoms can be so unpleasant as to precipitate relapse (Jaffe 1985; USDHHS 1988). In surveys by the National Institute on Drug Abuse (NIDA), withdrawal and inability to main- tain abstinence are commonly attributed to cigarette smok- ing and heroin use (USDHHS 1988). The majority of people monitored who regularly use other addictive drugs (including cocaine and marijuana)-report that they have not experienced withdrawal, even though many of these people feel dependent and have been unable to maintain abstinence (USDHHS 1988). Severity of Nicotine Addiction Tobacco-delivered nicotine can be highly addic- tive. Each year, nearly 20 million people try to quit smoking in the United States (USDHHS 1990), but only about 3 percent have long-term success (Pierce et al. 1989; Centers for Disease Control and Prevention [CDC], Office on Smoking and Health, unpublished data). Even among addicted persons who have lost a lung because of cancer or have undergone major cardiovascular sur- gery, only about 50 percent maintain abstinence for more than a few weeks (West and Evans 1986; USDHHS 1988). In a 1991 Gallup Poll, 70 percent of current smokers reported that they considered themselves to be "addicted" to cigarettes (Gallup Organization 1991). These findings are consistent with data from NIDA's 1985 National Household Survey on Drug Abuse (NHSDA), which showed that 84 percent of 12- through 17-year-olds who smoked one pack or moreof cigarettes per day felt that they "needed" or were "dependent" on cigarettes (Henningfield, Clayton, Pollin 1990). The NHSDA data show that young smokers develop toler- ance and dependence, increase the amount they smoke, and are unable to abstain from nicotine. These findings suggest that the addictive processes in adolescents are fun- damentally the same as those studied in adults (USDHHS 1988; Henningfield, Clayton, Pollin 1990). Several studies have found nicotine to be as addic- tive as heroin, cocaine, or alcohol (Henningfield,.Clayton, Pollin 1990; Henningfield, Cohen, Slade 1991; Kozlowski et al. 1993). Moreover, because the typical pattern of tobacco use entails.:daily and repeated doses of nicotine, addiction is more common among all users than is true of other drug use, which tends to occur on a far less frequent basis (USDHHS 1988). For example, only about 10 to 15 percent of current alcohol drinkers are consid- ered problem drinkers, but approximately 85 to 90 per- cent of cigarette smokers smoke at least five cigarettes every day (Henningfield, Cohen, Slade 1991; Evans et al. 1992; Henningfield 1992b; Kozlowski et al. 1993). Only 2 to 3 percent of smokers (or about 7 to 10 percent of those who try quitting) stop smoking for one year (CDC 1993a), and most daily smokers report that they feel dependent on smoking and have experienced with- drawal symptoms (USDHHS 1988; Henningfield, Clayton, Pollin 1990). Chemistry and Addiction Potential Many behaviors that become regular, habitual, and hard to give upp involve the ingestion of a substance. What sets drug addictions apart from less harmful habits is that the ingested substance releases a psychoactive drug with the demonstrated potential to addict. Several thousand chemicals are present in cigarette smoke. Some may conceivably modulate nicotine's addictive effects, but the fact that different forms of nicotine delivery can be substituted for one another (e.g., nicotine gum or transdermal patch in place of cigarettes) suggests that nicotine is critical in the addiction process (Henningfield 1984; Benowitz 1988; USDHHS 1988; Russell 1990). Nicotine is a naturally occurring alkaloid present in varying concentrations in different strains of tobacco. Most cigarettes sold in the United States contain about 8 to 9 milligrams of nicotine, of which the smoker typically in- gests 1 to 2 milligrams per cigarette (Benowitz eta1.1983; USDHHS 1988). Nicotine is both a lipid- and water- soluble molecule that can be rapidly absorbed in°a mildly alkaline environment through the skin or the lining of the mouth and nose. Because of the massive area for absorp- tion in the alveoli of the lungs, nicotine inhaled deeply is almost immediately extracted from the smoke into the pulmonar,v veins; this sudden spike or bolus of nicotine is delivered to the brain, via arterial circulation, in approxi- mately 10. seconds (USDHHS 1988). In contrast, although smokeless tobacco has much higher levels of nicotine than cigarettes, the delivery of the drug is much more gradual; the effect peaks within approximately 20 minutes of use (Benowitz et al. 1988). The peak for nicotine replacement medications is even slower-30 minutes or longer for nicotine gum (Benowitz et a1.1988), several hours for the four commercially available transdermal patch systems (Palmer, Bucklet, Faulds 1992). In fact, because of the efficiency of the pulmonary route in extracting nicotine from inhaled tobacco smoke, nicotine may be 10 times more concentrated in arterial blood than in simultaneously sampled venous blood; these levels are much higher than those produced by nicotine replacement medications (Henningfield, London, Benowitz 1990). As vehicles for nicotine delivery, tobacco products are convenient to use, and they provide the experienced user with a means of regulating dose level. Such control does not, however, protect the user against drug depen- dency, since tobacco products appear to deliver the opti- mal addittion potential (or abuse. liability) of nicotine. Chemicals can be tested for their addiction potential to Health Consequences 31 TIMN 0138884

Preventing Tobncco Use Among Young People Table 15. Trends in the prevalence (%) of current smoking* among young people, by gender, National Teenage Tobacco Surveys (NTTS), National Household Surveys on Drug Abuse (NHSDA), Monitoring the Future Project (MTFP), National Health Interview Surveys (NHIS), United States, 1968-1992 NTTS NHSDA MTFP NHIS Year Males Females (aged 17-18 years) Males Females (aged 17-19 years) Males Females (aged 17-18 years) Males Females (aged 18 -19 years) 1968 34.0 21.0 1970 37.8 24.1 1972 31.2 26.0 1974 32.6 26.4 47.8 38.7 36.9 30.8 1976 35.1 52.0 37.7 39.1 1977 39.0 47.2 36.7 39.7 1978 34.5 38.1 30.6 33.5 1979 19.6 27.0 41.7t 41.7t 31.2 37.1 29.5 34.2 1980 26.8 33.4 24.9 27.8 1981 26.5 31.6 1982 35.6 37.3 26.8 32.6 1983 . 28.0 31.6 23.3 31.4 1984 25.9 31.9 1985 27.8 26.7 28.2 31.4 20.1 24.5 1986 27.9 30.6 1987 27.0 31.4 21.6 20.9 1988 28.3 32.9 28.0 28.9 19.6 23.1 1989 $ 27.7 29.0 1990 28.9 20.2 29.1 29.2 21.7 18.0 1991 27.0 27.0 29.0 27.5 22.0 20.6 1992 29.2 26.1 Sources: NTTS: U.S. Department of Health, Education, and Welfare (USDHEW) (1972,1976,1979b); NHSDA: Centers for Disease Control and Prevention (CDC), Office on Smoking and Health (OSH) (unpublished data on 1974-1991 surveys); MTFP: Bachman, Johnston, O'Malley (1980a, b,1981,1984,1985,1987,1991); Johnston, Bachman, O'Malley (1980a, b, 1982, 1984,1986,1991,1992); Johnston, O'Malley, Bachman (1991a, in pfess); Institute for Social Research, University of Michigan (unpublished data); NHIS: CDC, OSH (unpublished data in 1974-1991 surveys). *For the NTTS, current smokers are those who state that they smoke less than one cigarette per week, one or more cigarettes per week, or one oi more cigarettes a day (USDHEW 1979b). For the NHSDA and the MTFP, current smoking is defined as any cigarette smoking during the 30 days preceding the survey. For the NHIS, current smokers are those who report that they have smoked at least 100 cigarettes and who respond "yes" to the question, "Do you smoke now?" 'The 1979 NHSDA determined current smoking status only for those respondents who had smoked at least 100 cigarettes (lifetime). The National Institute on Drug Abuse later published adjusted 1979 estimates- using data from the 1982 NHSDA (Miller et al. 1983). The adjusted 1979 estimates used the ratio of the 1982 prevalence estimate, based on the 1979 definition, to the prevalence estimate based on the definition used in other years (i.e., any smoking in the last 30 days, regardless of whether the respondent had ever smoked 100 lifetime cigarettes). This table reports estimates based on the same adjust- ment procedure. #Available information from published sources (USDHEW 1972,1976,1979b) does not permit exact comparisons with the 1989 TAPS data. it Epidemiology 75 TIMN 0138927

Surgeon General's Report 14-year-old students could directly affect the gingival tissues, causing gingivitis, or gum inflammation. In a study of 565 adolescent male students with gingivitis in Georgia, Offenbacher and Weathers (1985) found that gingival recession was significantly more prevalent, and the odds of developing this condition were nine times greater, among smokeless tobacco users than among nonusers. Navy recruits from 45 states were examined to determine if smokeless tobacco use was associated with gingival recession (Weintraub et al. 1990). Results of the study showed that 31 percent of heavy users and 19 percent of nonusers or low users had gingival recession. Users' age and the intensity of smokeless tobacco use were significant factors in ex- plaining variations in the degree of gingival recession. Two additional studies of adolescents failed to show an association between the use of smokeless tobacco and gingival recession (Wolfe and Carlos 1987; Creath et al. 1988), possibly because most of the users had been using the product for a short time. Nicotine Addiction The addictive qualities of smokeless tobacco are also a matter of major concern (Christen and Glover 1981; Glover, Christen, Henderson 1981; Glover et al. 1989; Hatsukami, Nelson, Jensen 1991). Smokeless tobacco users develop a nicotine dependency similar to that of cigarette smokers (Benowitz et a1.1988). This is not surprising, since smokeless tobacco users absorb at least as much nicotine as smokers do (Russell, Jarvis, Feyerabend 1980)-perhaps as much as twice the amount (Benowitz et al. 1988). The high pH of saliva favors absorption of nicotine through oral mucosa, and the degree of absorption increases with the increasing pH of the tobacco product. The rate of absorp- tion of nicotine from snuff is particularly rapid (Russell, Jarvis, Feyerabend 1980; Edwards, Glover, Schroeder 1987). With continued use of smokeless tobacco, blood nicotine levels remain relatively high; these levels fall more slowly after smokeless tobacco is removed from the mouth than after a cigarette has been smoked (Benowitz e t aL 1988). Adolescents develop physical dependence from smokeless tobacco use, as is evidenced by their experi- ence of withdrawal syntptoms when they try to quit (see "Smokeless Tobacco Cessation" in Chapter 6). Smokeless tobacco cessation produces withdrawal symptoms that are similar to those for smoking cessa- tion (Hatsukami, Gust, Keenan 1987), including cravings, irritability, distractibility, and hunger. Adolescents who are most addicted to nicotine appear to be less able to quit (Eakin, Severson, Glasgow 1989). Thus, as is seen with cigarette u,se (see "Adult Implications of Adoles- cent Smoking" in Chapter 3 and "Adolescent Smoking Behavior as a Risk Factor for Subsequent Smoking" in Chapter 4), adolescents who are heavy smokeless to- bacco users are likely to become adult users. The addictive potential of smokeless tobacco use is aggravated by the fact that some smokeless products are highly effective in the initiation process and are even termed "starter products" by one smokeless tobacco com- pany (Marsee v. United States Tobacco Company 1989; Henningfield and 1Vemeth-Coslett 1988). These prod- ucts tend to be low in nicotine concentration and low in pH (thus reducing absorption); some are in a unit dosage form ("tobacco pouch"), which helps first-time users avoid placing too much of the substance in their mouths. These products may have contributed to the reversal of the demographics of smokeless tobacco users from 1970 to 1986. In 1970, the majority of smokeless tobacco users were 50 years old and older; by 1986, the majority were 35 years old and younger (USDHHS 1987,1988). As is discussed in Chapter 5 (see "Smokeless Tobacco Adver- tising and Promotional Expenditures"), marketing and advertising factors have been identified as having in- stilled the general perception that smokeless tobacco products are safe and socially acceptable (Connolly et-al. 1986; USDHI-IS 1987; Glover et al. 1989). Marketing strategies included a heavy reliance on distributing free samples of product types designed to introduce new users to what one company termed the "graduation process" (Marsee v. United States Tobacco Company 1989). Advertising strategies then encouraged new users to experience greater "satisfaction" and "pleasure" by switching to maintenance products higher in nicotine concentration and pH (Marsee v. United States Tobacco Company 1989; Henningfield and Nemeth-Coslett 1988). Smokeless Tobacco Use as a Risk Factor for Cigarette Smoking Young people who use smokeless tobacco appear to be at greater risk to smoke cigarettes than are nonus- ers. Among smokeless tobacco users, 12 to 43 percent also smoke cigarettes (Eakin, Severson, Glasgow 1989; Williams 1992; CDC 1993b; Stevens et al., in press; see Table 23 in Chapter 3). In the 1986-1989 MTFP, 44 percent of high school seniors had tried both smokeless tobacco and cigarettes; of those, 63 percent had tried smokeless tobacco either before or at about thesame time as cigarettes (see Table 38 in Chapter 3). In a prospective study, Ary, Lichtenstein, and Severson (1987) found that smokeless tobacco users were significantly more likely than nonusers to initiate cigarette smoking. Smokeless tobacco users were also more likely to increase their use of cigarettes over a one-year period. For adolescents who use both smokeless tobacco and cigarettes, cessation of one substance may lead to a direct increase in the other (Biglan, La Chance, Benowitz, unpublished data). 40 Health Consequences , TIMN 0138893

Sttrgeon Getternl's Report Table 8. Age or grade when respondents first tried a cigarette, Teenage Attitudes and Practices Survey (TAPS), National Household Surveys on Drug Abuse (NHSDA), Monitoring the Future Project (MTFP), Youth Risk Behavior Su -rvey (YRBS), United States,1989,1991 Age/grade* TAPSt % NHSDA= % MTFPS % YRBS' % < 12 years/< grade 6 10.1 25.2 18.5 19,2 13-14 years/grades 7-8 11.4 14.5 21.6 17.7 15-16 years/grades 9-10 22.0 16.6 14.9 15.9 > 16 years/> grade 10 8.2 3.9 5.3 5.7 Never smoked 48.3 39.9 39.8 41.4 Sources: 1989 TAPS: Centers for Disease Control and Prevention (CDC), Office on Smoking and Health (OSH) (unpublished data); 1991 NHSDA: CDC, OSH (unpublished data); 1991 MTFP: Institute for Social Research, University of Michigan (unpublished data); 1991 YRBS: CDC, Division of Adolescent and School Health (unpublished data). *In TAPS, the NHSDA, and the YRBS, respondents reported the age at which they had first smoked; in the MTFP, respon- dents reported the grade in which they first smoked. tincludes 17- and 18-year-old respondents to the 1989 TAPS who had completed the 11th grade and who still attended school. Response categories were constructed using the questions, "Have you ever smoked a cigarette?" and "How old were you when you smoked your first whole cigarette?"(N = 687). tIncludes respondents to the 1991 NHSDA between the ages of 17 and 18 years who had completed the 11th grade and responded to the question, "About how old were you when you first tried a cigarette?" (N = 979). °Includes high school senior respondents to the 1991 MTFP survey who responded to the question, "When if ever did you first do each of the following things ... Smoke your first cigarette?" (N [weighted] = 2,012). 'Includes 12th-grade respondents to the 1991 YRBS who responded to the question, "How old were you when you smoked a whole cigarette for the first time?" (N = 3,127). Table 9. Age or grade when respondents began smoking daily, National Household Surveys on Drug Abuse (NHSDA), Monitoring the Future Project (MTFP), Youth Risk Behavior Survey (YRBS), United States, 1991 Age/grade* NHSDAt % MTFPx % YRBS§ % < 12 years/< grade 6 3.3 2.3 3.3 13-14 years/grades 7-8 4.0 8.5 6.1 15-16 years/grades 9-10 10.4 • 11.9 10.2 > 16 years/> grade 10 4.6 6.0 4.5 Never smoked daily ... 77.5 71.2 76.0 Sources: 1991 NHSDA: Centers for Disease Control and Prevention (CDC), Office on Smoking and Health (unpublished data); 1991 MTFP: Institute for Social Research, University of Michigan (unpublished data);1991 YRBS: CDC, Division of Adolescent and School Health (unpublished data). *In the NHSDA and the YRBS, respondents reported the age at which they had begun smoking daily; in the MTFP, respon- dents reported the grade in which they had begun smoking daily. +Includes 17- and 18-year-old respondents to the 1991 NHSDA who had completed the 11th grade who responded to the question, "About how old were you when you first started smoking daily?" (N = 959). tIncludes high school senior respondents to the 1991 MTFP survey who responded to the question, "When, if ever, did you first do each of the following things ... Smoke cigarettes on a daily basis?" (N [Evtd.] = 2,074). 0Includes 12th-grade respondents to the 1991 YRBS who responded to the question, "How old were you when you first started smoking cigarettes regularly? (at least one cigarette every day for 30 days)" (N = 3,074). 66 Epidemiology `TIMN 0138918

Preventhrg Tobacco Use Among Young People US DEPARTMENT OF HEALTH, EDUCATION, AND ' WELFARE. The health consequences of smoking. A report of the Surgeon General: 1971. US Department of Health, Education, and Welfare, Public Health Service, Health Services and Men- tal Health Administration. DHEW Publication No. (HSM) 71-7513,1971. US DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE. The health consequences of smoking. US Department of Health, Education, and Welfare, Public Health Service, Health Services and Mental Health Administration. DHEW Publica- tion No. (HSM) 73-8704,1973. US DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE. The health consequences of smoking, 1977-1978. US Department of Health, Education, and Welfare, Public Health Service, Office of the Assistant Secretary for Health, Office on Smoking and Health. DHEW Publication No. (PHS) 79-50065,1979a. US DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE. Smoking and health. A report of the Surgeon General. US Department of Health, Education, and Welfare, Public Health Service, Office of the Assistant Secretary of Health, Office on Smoking and Health. DHEW Publication No. (PHS) 79-50066,1979b. US ENVIRONMENTAL PROTECTION AGENCY. Respira- tory health effects of passive smoking: lung cancer and other disorders. US Environmental Protection Agency, Office of Research and Development, Office of Air and Radiation. EPA/ 600/6-90,1992. WALTER S, NANCY NR, COLLIER CR. Changes in forced expiratory spirogram in young male smokers. American Review of Respiratory Disease 1979;119(5):717-24. WEINTRAUB JA, ARTHUR JS, KUEHNE J, STINNETT S, CHAMBLESS M. Association between smokeless tobacco use and gingival recession. Abstract #46, American Association of Public Health Dentists 53rd Annual Meeting, Boston, MA, October 12,1990. WEISS ST, TAGER 1B, SPEIZER FE, ROSNER B. Persistent wheeze: its relation to respiratory illness, cigarette smoking, and level of pulmonary function in a population sample of children. American Review of Respiratory Disease 1980; 122(5):697-707. - WELTE JW, BARNES GM. Youthful smoking: patterns and relationships to alcohol and other drug use. Journal of Adoles- cence 1987;10(4):327-40. WEST RR, EVANS DA. Lifestyle changes in long term survi- vors of acute myocardial infarction. Journal of EpidemioloQy and Community Health 1986;40(2):103-9. WILLIAMS NJ. A smokeless tobacco cessation program for postsecondary students [dissertation]• Memphis (TN): Mem- phis State University, 1992. WINN DM. Smokeless tabacco and cancer: the epidemi- ological evidence. CA: A Cancer Journal for Clinicians 1988; 38(4):236-43. WOLFE MD, CARLOS JP. Oral health effects of smokeless tobacco use in Navajo Indian adolescents. Community Den- tistry and Oral Epidemiology 1987;15(4):230-5. WOOLCOCK AJ, LEEDER SR, PEAT JK, BLACKBURN CRB. The influence of lower respiratory illness in infancy and child- hood and subsequent cigarette smoking on lung function in Sydney schoolchildren. American Review of Respiratory Disease 1979;120(1):5-14. WOOLCOCK AJ, PEAT JK, LEEDER SR, BLACKBURN CRB. The development of lung function in Sydney children: effects of respiratory illness and smoking. A ten year study. European Journal of Respiratory Diseases 1984;65(1325uppl):1-97. WORLD HEALTH ORGANIZATION. Smokeless tobacco con- trol. Report of a WHO study group. WHO Technical Report Series 773. Geneva: World Health Organization, 1988. YAMAGUCHI K, KANDEL DB. Patterns of drug use from adolescence to young adulthood: II. Sequences of progression. American Journal of Public Health 1984;74(7):668-72. YOUNG RC JR, RACHAL RE, HACKNEY RL JR, UY CG, SCOTT RB. Smoking is a factor in causing acute chest syn- drome in sickle cell anemia. Journal of the National Medical Association 1992;84(3):267-71. , Health Consequences 51 ,FIIVIN 0138904

Preventing Tobacco Use Anwng Young People Table 4. Percentage of young people who currently smoke cigarettes (within the past 30 days), by gender, race/Hispanic origin, age/grade, and region, Teenage Attitudes and Practices Survey (TAPS), National Household Surveys on Drug Abuse (NHSDA), Monitoring the Future Project (MTFP), Youth Risk Behavior Survey (YRBS), United States, 1989, 1991, 1992 Characteristic 1989 TAPS* 1991 NHSDAt 1992 MTFPt-S 1991 YRBS' Overall 15.7 13.1 27.8 27.5 Gender Male 16.0 13.5 29.2 27.6 Female 15.3 12.8 26.1 27.3 Race/Hispanic origin White, non-Hispanic 18.5 15.4 31.8 30.9 Male 18.7 15.5 32.1 30.2 Female 18.2 15.3 31.5 31.7 Black, non-Hispanic 6.1 5.3 8.2 12.6 Male 7.8 6.0 10.8 14.1 Female 4.9 4.6 5.8 11.3 Hispanic 11.8 10.1 NAq 25.3 Male 11.8 9.5 27.8 Female 11.7 10.8 22.9 Age/grade 12-14 years 5.9 3.9 15-16 years 17.5 14.0 17-18 years 27.5 25.5 8th grade 15.5 9th grade 23.2 10th grade ' 21.5 , 25.2 11 th grade 31.6 12th grade 27.8 30.6 Region Northeast 17.6 14.7 29.6 23.7 North Central 16.6 14.9 31.7 36.5 South 14.0 11.7 26.4 24.8 West 15.5 12.3 22.8 23.1 Sources: 1989 TAPS: Centers-for Disease Control and Prevention (CDC), Office on Smoking and Health (OSH) (unpublished data); 1991 NHSDA: CDC, OSH (unpublished data);1992 MTFP: Johnston, O'Malley, Bachman (in press); Institute for Social Research, University of Michigan (unpublished data); 1991 YRBS: CDC (1992c); CDC, Division of Adolescent and School Health (unpublished data). *1989 TAPS, aged 1,Z.18'years. Based on responses to the questions, "Have you ever smoked a cigarette?" and "Think about the last 30 days. Ok- how, many of these days did you smoke?" }1991 NHSDA, ag~ 12-18 years. Based on response to the question, "When was the most recent time you smoked a cigarette?" 4992 MTFP survey. Based on response to the question, "How frequently have you smoked cigarettes during the last 30 days?" 6With the exception of data for 8th- and 10th-grade students, all other data points for the MTFP survey reflect estimates for high school seniors. '1991 YRBS, grades 9-12. Based on response to the question, "During the past 30 days, on how many days did you smoke cigarettes?" 9NA = Not available. Epidemiology 61 TIMN 0138913

Preventing Tobacco Use Among Young People Introduction Understanding national trends and patterns of to- bacco use among adolescents is crucial to the public health effort to reduce tobacco-related morbidity and mortality. Along with information on young people s knowledge, attitudes, and perceptions concerning to- bacco use, these data can help elucidate historical pat- terns, suggest target groups for programs to prevent tobacco use, determine the need for future interventions, assess the effect of national campaigns against tobacco use, and contribute to predictions of the future burden of tobacco-related disease. Previous reports from the Surgeon General have described tobacco use among the nation's youth (U.S. Department of Health, Education, and Welfare [USDHEW] 1979a; U.S. Department of Health and Hu- man Services [USDHHS] 1989b). The following analysis both updates and expands these discussions. In particu- lar, the analysis incorporates cross-sectional data from four national surveillance systems that track health be- haviors (including tobacco use) among adolescents and from one adult survey with information on older adoles- cents (Table 1). Data are also used from a national longitudinal survey of adolescents and young adults. The National Teenage Tobacco Surveys (NTfS) cited in this chapter were conducted by the U.S. Public Health Service and the U.S. Department of Education in 1968, 1970, 1972, 1974, and 1979; a modified version of the survey was conducted in 1989 as the Teenage Atti- tudes and Practices Survey (TAPS). The National House- hold Surveys on Drug Abuse (NHSDA) cited were conducted nine times from 1974 through 1991 by the National Institute on Drug Abuse (NIDA); the survey is now sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA). The Moni- toring the Future Project (MTFP) surveys included were conducted yearly from 1976 through 1992 for NIDA by the University of Michigan's Institute for Social Research (ISR). The Youth Risk Behavior Survey (YRBS), cited extensively throughout this chapter, was conducted in 1991 by the Centeeis for Disease Control (CDC) as a component of the Youth Risk Behavior Surveillance System. The National Health Interview Surveys WHIS) cited in this report included yearly data on cigarette smoking during 11 years from 1970 through 1991. Sur- vey methodology varied across these surveillance sys- tems (see Appendix 1, "Sources of Data," for more detail on methodologic characteristics), and the different sur- veys offered several measures of tobacco use (see Ap- pendix 2, "Measures of Cigarette Smoking," and Appendix 3, "Measures of Smokeless Tobacco Use"). The most comparable of these data sources are TAPS, the NHSDA, the MTFP, and the YRBS. Because the questions used, the ages sampled, and the sites and modes of administration (school-based self-administered questionnaires vs. household-based telephone and in- person interviews) differ, however, even these data are not directly comparable. The MTFP, for example, consis- tently reports higher prevalence estimates than the two household surveys, mainly because the study popula- tion is limited to high school seniors; these respondents, who are usually 17 or 18 years old, are considerably older than the 12- through 18-year-old population included in TAPS and the NHSDA. When possible, most of the comparisons presented in this chapter in- clude age- or grade-specific estimates. However, even after controlling for age differences, the estimates on some measures of tobacco use from the household sur- veys are lower than the estimates from the school sur- veys (see Appendix 2). The purpose of this chapter is to document re- ported trends and patterns of tobacco use in one source. Differences in the age of the target populations employed, in the setting of the survey, in the wording of questions, and in other factors may cause apparent differences in the actual values of some of the estimates reported here. However, these differences are frequently resolved when inethodological issues are taken into consideration. In- corporating data from several types of data collection systems has revealed a number of consistencies in pat- terns and trends of tobacco-use behaviors that apply to both school-based and household-based sample frames (and thus to school attenders, infrequent school attenders, and dropouts). f Epidemiology 55 TIMN 0138907

Prcventh~Er Tvhaeco UseAincurg Ycuurg !?eople Many chronic changes in cardiovascular physiol- ogy have been observed in children exposed to ETS. These changes indude lower HDL cholesterol, increased carboxyhemoglobin concentration, and increased red-cell 2.3-diphosphoglycerate, as well as physiologic response suggesting mild, chronic hypoxemia (Moskowitz et al. 1990). ETS is also known to increase platelet aggregation (Glantz and Parmley 1991). The effect of peer smoking-as a source of ETS- on nonsmoking children has not been studied but may also be a health risk. Adult Health Implications of Smoking Among Young People Respiratory Diseases As was discussed previously, sustained smoking during adulthood is associated with the development of COPD and the progressive loss of lung function (USDHHS 1984,1990). Evidence suggests that smoking during childhood may increase the risk for developing COPD in adulthood as well as at an earlier age. The adult who smoked during childhood may have experi- enced early inflammatory changes-childhood smoking is known to reduce lung growth-and thereby not at- tained the level of function achieved during the normal growth and development of the lungs. Any age-related decline in lung function during adulthood would thus start from a lower level-and might begin at a younger age-than declines observed in adults who have never smoked. In fact, the proportionate impeding effect of childhood smoking on lung growth greatly exceeds the loss of lung function associated with smoking during adulthood (Tager et a1.1985,1988). If one or both parents of an adolescent smoke, the effects of parental smoking on early childhood respira- tory illnesses and on the growth of lung function may increase the risk of COPD. Illnesses in the lower respira- tory region during childhood are a suspected risk factor for COPD (Samet, Tager, Speizer 1983), and passive smoking reduces the rate at which lung function grows (USDHHS 1986a). Cardiovascular Disease In adults, cigarette smoking has been causally associated with coronary heart disease, arteriosclerotic peripheral vascular disease, and stroke (USDHHS 1983, 1989). Smoking contributes to increased risk for coro- nary heart disease probably through at least five in- terrelated processes, including the development of atherosclerosis (USDHHS 1990). It is likely that the earlier the age at which one starts to smoke, the earlier the onset of coronary heart disease. The recent evidence from the PDAY Research Group shows more athero- sclerosis in young smokers than in young nonsmokers. The unfavorable effects of smoking on lipid levels in children may contribute to the development of athero- : sclerosis in young adulthood. Cancer The multistage coneept of carcinogenesis implies that the risk of smoking-related cancers is strongly de- pendent on the duration and intensity of smoking (Armitage and Doll 1954; Doll 1971; Taioli and Wynder 1991). The relevant epidemiologic data and mathemati- cal analyses are most abundant for lung cancer. Both epidemiologic and experimental evidence suggest that the risk for lung cancer varies more strongly with the duration of cigarette smoking than with the number of cigarettes smoked (Peto 1977; Doll and Peto 1978). Analy- sis of data from a cohort study of British doctors showed that lung cancer incidence increased with the fourth or fifth power of duration of smoking but with the second power of number of cigarettes smoked daily (Doll and Peto 1978). Although these data can be adequately de- scribed by alternative mathematical models that give lesser weight to duration (Moolgavkar, Dewanji, Luebeck 1989), the dependence of lung cancer risk on duration of smoking implies that starting smoking at an earlier age increases the potential number of life-years of smoking and therefore increases lung cancer risk. If one assumes, for example, that lung cancer risk rises exponentially as a function of the duration of smoking, then the risk at age 50 for a person who began smoking regularly at age 13 is 350 percent greater than that for a 50-year-old who started smoking at age 23. Similar analyses have not been done for other smoking-related sites of cancer. Nevertheless, for most smoking-related cancers, the risk rises with the durationpf smoking (USDHHS 1982,1989,1990; Interna- tional Agency for Research on Cancer 1985). One could Health Consequences 29 TIMN 0138882

Surgeori Gerrernl's Repvrt Table 18. Trends in high school seniors' beliefs and attitudes about smoking and smokers, Monitoring the Future Project, United States, 1976, 1981, 1986, 1991 Beliefs and attitudes ' About smoking How much do you think people risk harming themselves if they smoke one or more packs of cigarettes per day?* (percentage who say great risk) The harmful effects of cigarettes have been exaggerated.} (percentage who agree) Smoking is a dirty habit. (percentage who agree) How do you think your close friends feel (or would feel) about your smoking one or more packs of cigarettes per day?t (percentage who disapprove) Do you think that people (who are 18 or older) should be prohibited by law from smoking tobacco in certain specified public places? (percentage who say yes) About smokers 1976 1981 1986 1991 56.4 63.3 66.0 69.4 15.5 16.2 13.8 65.5 68.6 71.6 600 73.9 76.2 74.3 42.05 43.0 45:1 44.9 In my opinion, when a guy my age is smoking a cigarette, it makes him look (percentage who agree) ... like he's trying to appear mature and sophisticated 61.4 62.7 60.8 ... insecure 42.0 43.6 47.9 ... conforming 25.4 21.3 16.5 ... rugged, tough, independent 8.6 9.9 9.8 ... mature, sophisticated • 5.3 4.6 5.0 ... cool, calm, in cont"rol 6.2 5.5 5.3 Sources: Bachman, Johnaton, O'Malley (1980a, 1987); Johnston, Bachman, O'Malley (1980a, 1982); Institute for Social Research, University of Michigan (unpublished data). *Possible responses included "no risk," "slight risk," "moderate risk," "great risk," "can't say-drug unfamiliar." Percentages include those who say "great risk." +Possible responses included "disagree," "mostly disagree," "neither," "mostly agree," "agree." Percentages include those who "agree" or "mostly agree." xPossible responses included "not disapprove," "disapprove," "strongly disapprove." Percentages include those who "disapprove" or "strongly disapprove." °1977 data. 82 Epidemiology -- TIMN 0138934

Surgevn Getteral'> Rel;urt Cigarette Smoking Among Young People in the United States Recent Patterns of Cigarette Smoking Ever Smoking The proportion of adolescents classified as ever smokers (i.e., those who had tried a cigarette [see Appen- dix 2 for variations in this measureD varied across sur- vey systems (Table 2). In the 1989 TAPS, 47 percent of students aged 12 through 18 had tried smoking. In the 1991 NHSDA, the prevalence for this same age range was 42 percent. The different estimates between these two household surveys may reflect actual decreased prevalence during the intervening two years or may result from sampling error, from slight differences in response to different survey questions, or from the dif- ferent way these home-based surveys were adminis- tered (by telephone in TAPS and in person in the NHSDA). Of the two self-administered school surveys, the 1991 YRBS reported a higher prevalence of ever smoking (70 percent) than the 1992 MTFP (62 percent), even though the YRBS included students in grades 9 through 12 (age range generally 14 through 18 years), whereas the MTFP was limited to high school seniors. This difference may partly result from the questions each survey used to elicit information on ever smoking. The MTFP survey asked, "Have you ever smoked cigarettes?", and the YRBS asked a question that might have drawn additional affirmative responses: "Have you ever tried or experimented with cigarette smoking, even one or two puffs?" What stands out from all four surveys is that by age 18, about two-thirds of adolescents in the United States have tried smoking. Also evident across the sur- veys is that the prevalence of ever smoking is greater (if only slightly so in one survey) among males than fe- males. Findings by racial/ethnic groups were generally in accord across the surveys: whites had the highest prevalence of ever smoking and blacks the lowest in TAPS, the NHSDA, and the MTFP; Hispanics had the highest prevalence of the three groups in the YRBS. Ever smoking increased as a function of increasing age or grade in all four surveys. Adolescents living in the north-central region of the United States were the most likely to report having smoked (Table 2). Prevalence for individual states were available from the Youth Risk Behavior Surveillance System, which besides its yearly national YRBS also conducts individual surveys in se- lected states and cities. In 1991, the percentage of stu- dents who had tried smoking ranged from 49 to 82 percent (median, 71 percent) (Table 3). Current Smoking The overall national prevalence of current smoking (i.e., having smoked within the last 30 days) for persons 12 through 18 years old was estimated to be 16 percent in the 1989 TAPS and 13 percent in the 1991 NHSDA (Table 4). These estimates suggest that at least 3.1 million U.S. adolescents are current smokers. Among high school seniors, the prevalence of past-month smoking was 28 percent in the 1992 MTFP; 28 percent of high school students were past-month smokers in the 1991 YRBS. In all the surveys, current prevalence among males was equal to or slightly higher than current prevalence for females. This pattern differs from that reported for the late 1970s and mid-1980s, when the prevalence for adolescent females was generally higher than that for adolescent males (USDHEW 1979b; USDHHS 1989b). The national prevalence of past-month smoking among adolescents was higher for whites than for His- panics and was lowest for blacks (Table 4). Pooled data from the 1985-1989 MTFP provided information on smok- ing among Asian American and Native American ado- lescents (Bachman et al. 1991). Past-month smoking prevalence was higher for Native American male (37 percent) and female (44 percent) seniors than for white male (30 percent) and female (34 percent) seniors. Cur- rent smoking was about as common for Asian American male (17 percent) and female (14 percent) seniors as it was for black male (16 percent) and female (13 percent) seniors. Data on Hispanic smoking prevalence, pre- sented in the same report, indicate that smoking preva- lence among Hispanic high school seniors from 1985 through 1989 ranked between that of white and black high school seniors, as it did in TAPS, the NHSDA, and the YRBS. Current prevalence increased with increasing age or grade (Table 4). TAPS and the NHSDA reported smoking prevalences for persons 17 and 18 years old that were slightly lower than those of 12th-grade students surveyed by the MTFP and the YRBS. Prevalence esti- mates from TAPS and the NHSDA for persons 15 and 16 years old were considerably lower than for 9th- and 10th-grade high school students in the MTFP and the YRBS. These estimates are consistent with the argument that estimates of cigarette smoking from household sur- veys may underreport actual use, especially for younger adolescents. • 58 Epidemiology TIMN 0138910

Preventing Tobacco llse Among Young People high-density lipoprotein cholesterol. If sustained into adulthood, these patterns significantly increase the risk for early development of cardiovascular disease. Smokeless tobacco use is associated with health consequences that range from halitosis to severe health problems such as various forms of oral cancer. Use of smokeless tobacco by young people is associated with early indicators of adult health consequences, including periodontal degeneration, soft tissue lesions, and general systemic alterations. Previous reports have documented that smokeless tobacco use is as addictive for young people as it is for adults. Another concern is that smoke- less tobacco users are more likely than nonusers to be- come cigarette smokers. Among addictive behaviors such as the use of alco- hol and other drugs, cigarette smoking is most likely to become established during adolescence. Young people who begin to smoke at an earlier age are more likely than later starters to develop long-term nicotine addiction. Most young people who smoke regularly are already addicted to nicotine, and they experience this addiction in a manner and severity similar to what adult smokers experience. Most adolescent smokers report that they would like to quit smoking and that they have made numerous, usually unsuccessful attempts to quit: Many adolescents say that they intend to quit in the future and yet prove unable to do so. Those who try to quit smoking report withdrawal symptoms similar to those reported by adults. Adolescents are difficult to recruit for formal cessation programs, and when enrolled, are difficult to retain in the programs. Success rates in adolescent cessa- tion programs tend to be quite low, both in absolute terms and relative to control conditions. Tobacco use is associated with a range of problem behaviors during adolescence. Smokeless tobacco or cigarettes are generally the first drug used by young people in a sequence that can include tobacco, alcohol, marijuana, and hard drugs. This pattern does not imply that tobacco use causes other drug use, but rather that other drug use rarely occurs before the use of tobacco. Still, there are a number of biological, behavioral, and social mechanisnms by which the use of one drug may facilitate the use of other drugs, and adolescent tobacco users are substantially more likely to use alcohol and illegal drugs than are nonusers. Cigarette smokers are also more likely to get into fights, carryweapons, attempt suicide, and engage in high-risk sexual behaviors. These problem behaviors can be considered a syndrome, since involvement in one behavior increases the risk for in- volvement in others. Delaying or preventing the use of tobacco may have implications for delaying or prevent ing these other behaviors as well. The Epidemiology of Tobacco Use Among Young People Overall, about one-third of high-school-aged ado- lescents in the United States smoke or use smokeless tobacco. Smoking prevalence among U.S. adolescents declined sharply in the 1970s, but this decline slowed significantly in the 1980s, particularly among white males. Although female adolescents during the 1980s were more likely than male adolescents to smoke, female and male adolescents are now equally likely to smoke. Male ado- lescents are substantially more likely than females to use smokeless tobacco products; about 20 percent of high school males report current use, whereas only about I percent of females do. White adolescents are more likely to smoke and to use smokeless tobacco than are black and Hispanic adolescents. Sociodemographic, environmental, behavioral, and personal factors can encourage the onset of tobacco use among adolescents. Young people from families with lower socioeconomic status, including those adolescents living in single-parent homes, are at increased risk of initiating smoking. Among environmental factors, peer influence seems to be particularly potent in-~ the early stages of tobacco use; the first tries of ciga=ettes~ and smokeless tobacco occur most often with peers, and the peer group may subsequently provide expectations, re- inforcement, and cues for experimentation. Parental tobacco use does not appear to be as compelling a risk factor as peer use; on the other hand, parents may exert a positive influence by'disapproving of smoking, being involved in children's free time, discussing health mat- ters with children,.and encouraging children's academic achievement and school involvement. How adolescents perceive their social environment may be a stronger influence on behavior than the actual environment. For example, adolescents consistently over- estimate the number of young people and adults who smoke. Those with the highest overestimates are more likely to become smokers than are those with more accu- rate perceptions. Similarly, those who perceive that ciga- rettes are easily accessible and generally available are more likely to begin smoking than are those who per- ceive more difficulty in obtaining cigarettes. Behavioral factors figure heavily during adoles- cence, a period of multiple transitions to physical matu- ration, to a coherent sense of self, and to emotional independence. Adolescents are thus particularly vulner- able to a range of hazardous behaviors and activities, including tobacco use, that may seem to assist in these transitions. Young people who report that smoking serves positive functions oris potentially useful are at increased risk for smoking. These functions are assaciated with Introduction 7 TIMN 0138861

Surgeon General's Report prevalence of daily cigarette smoking at all grade levels increased among the classes of 1989,1990, and 1991. Number of Cigarettes Smoked Each Day Trends in the intensity of smoking among MTFP high school seniors indicate that since 1976, the propor- tion of heavy smokers (_ one-half pack per day) has decreased and the proportion of never smokers has in- creased (Figure 3). For example, in 1976, 25 percent of high school seniors had never smoked, and 19 percent were heavy smokers; by 1992, 38 percent had never smoked, and 10 percent were heavy smokers (Bachman, Johnston, CYMalley 1980a; ISR, University of Michigan, unpublished data). Attempts to Quit Smoking Cessation attempts are common among young smokers. In the 1989 TAPS, 74 percent of 12- through 18-year-old smokers reported that they had seriously thought about quitting, 64 percent reported that they had tried to quit smoking, and 49 percent reported that they had tried to quit during the previous six months (Allen et a1.1993). Nearly half of all smokers among high school se- niors surveyed by the MTFP between 1976 and 1984 reported that they wanted to stop smoking (Table 17). Interest in quitting declined slightly thereafter. About 30 percent of current smokers reported that at one time in their lives they had tried but failed to stop smoking. About 40 percent of daily smokers reported that they had tried at least once to stop smoking but had failed. The percentage of seniors who at some time had smoked regularly but had not smoked during the 30 days pre- ceding the survey (former smokers) increased sharply for males from 1977 through 1980 and for females from 1977 through 1981 (Figure 4). This measure declined sharply after 1980 for males and after 1981 for females. Table 17. Trends in high school senior smokers' interest in quitting smoking and attempts to quit smoking, by frequency of smoking during the past 30 days, Monitoring the Future Project, United States, 1976-1989 Respondents answering "Yes" Survey Question 1976 -1979 N (weighted) % 1980-1984 N (weighted) % 1985-1989 N (weighted) % Do you want to stop smoking now? Among those who smoked 3,872 46.1 3,805 47.1 3,418 42.5 at all during the last 30 days Among those who smoked 3,396 46.1 . 3,262 47.6 2,761 43.9 > I cigarette/day during the last 30 days 7 Have you ever tried to stop smoking and found that you could not? Among those who smoked ,740 1.5 ,942 31.4 ,534 27.8 at,all during the last 30 days Among those who smoked 3,604 38.5 3,464 41.6 2,953 -39.4 > 1 cigarette/day during the last 30 days Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data). 78 Epidemiology 711ViN 0138930

Preventing Tobacco Use Among Young People Figure 3. Trends in the intensity of smoking among high school seniors, Monitoring the Future Project, United States, 1976-1992 Never smoked ~ ~ M Have smoked but not in the past 30 days < 1 cigarette/day in the past 30 days 1-5 cigarettes/day in the past 30 days mmm ? one-half pack/day in the past 30 days Sources: Bachman, Johnston, O'Malley (1980a, b, 1981, 1984,1985,1987,1991); Johnston, Bachman, O'Malley (1980a, b, 1982, 1984,1986,1991,1992); Institute for Social Research, University of Michigan (unpublished data). Figure 4. Trends in the percentage of former smokers among ever smokers,* by gender, high school seniors, Monitoring the Future Project, United States, 1976-1989 . Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data). *Percentage of those who had ever smoked regularly who had not smoked during the previous 30 days. Epidemiology 79 TIMN 0138931

PrerenEing Tobacco Use Among Young People Introduction The health consequences of tobacco use among adults have been reviewed extensively in previous Surgeon General's reports (Public Health Service [PHS] 1964; U.S. Department of Health and Human Services [USDHHS] 1986b, 1989). Among young people, the short-term health consequences of smoking include respiratory and nonrespiratory effects, addiction to a toxic substance (nicotine), and the associated risk of other drug use. Long-term health consequences of adolescent smoking may be seen in the association between early onset of tobacco use and future (adult) smoking, with concomitant health consequences. Passive (also called "involuntary") smoking during adolescence is also asso- ciated with harmful respiratory and nonrespiratory effects. Lastly, the use of smokeless tobacco poses seri- ous health consequences to young people. Health Consequences of Smoking Among Young People Introduction The health effects of cigarette smoking have been the subject of intensive investigation since the 1950s. Extensive evidence, documented in numerous reports of the Surgeon General, has causally linked ci&arette smoking to a wide array of health outcomes that extend from annoying symptoms to fatal malignancies (USDHHS 1989). Until recently, this research was largely directed at the effects of smoking on adults. As is discussed in Chapter 3 (see "Age or Grade When Smok- ing Begins"), the onset and development of cigarette use occur primarily during adolescence (USDHHS 1989); the health consequences of smoking among young people thus have great public health significance. In recent years, investigations of the health effects in school- age youth have reported sufficient data to support conclusions about adverse effects of smoking during childhood and adolescence. Most of the evidence reviewed here is gathered from epidemiologic studies of young people ranging from 10 through 20 years old. Selected studies that relate to older age groups, yet are relevant to young people, are also included. - Emphasis is placed on the res- ,~ piratory effects of:_:SYita., king, for which the evidence is abundant. Data-,on smoking and cardiovascular risk factors and atherogenesis are also addressed, as are the adult health implications of starting to smoke during childhood. Overview of'the Toxicology of Tobacco Smoke Cigarette smoke is a complex mixture of organic and inorganic compounds generated by the combustion of tobacco and additives. Current knowledge about the physicochemical nature of tobacco smoke is well de- scribed in earlier Surgeon General's reports (PHS 1964; USDHHS 1981, 1989). Thousands of individual com- pounds have been isolated in cigarette smoke, including pharmacologically active agents (e.g., nicotine), toxic agents (e.g., carbon monoxide, hydrogen cyanide, and acrolein), and mutagens and carcinogens (e.g., polycy- clic aromatic hydrocarbons). Cigarette smoke is further classified as mainstream smoke (MS), the smoke drawn through the mouthpiece of the cigarette, and sidestream smoke (SS), the smoke given off by smoldering tobacco between puffs and the smoke diffusing through the cigarette paper and escap- ing from the burning cone during puffing. Because of the differing combustion conditions under which MS and SS are generated, their chemical compositions differ; in par- ticular, undiluted SS tends to have higher concentrations of many toxic and tumorigenic agents (USDHHS 1986a, 1989). The quantitative yields of tar (the material depos- ited in a filter as MS is being drawn), nicotine, and carbon monoxide from cigarettes can be assessed by using a smoking machine standardized to a particular pattern of puffing (USDHHS 1989). Passive smoking refers to nonsmokers' inhalation of tobacco smoke. The term "environmental tobacco smoke" (ET51 is now widely used to refer to the mixture of predominantly SS and exhaled MS that is inhaled by the passive smoker. Passive smoking was the subject of the 1986 Surgeon General's report (USDHHS 1986a); that report reviews in detail the components of ETS, as did a contemporaneously-prepared report of the National Re- search Cop.ncil (1986). In 1991, the National Institute for Occupational Safety and Health recommended that ETS be regarded as a potential occupational carcinogen and Healfh Consequences 15 TIMN 0138868

l're.vriturs Tohak-co Lhe -ltruaig 1'vtnig t'ruhlr Figure 7. Trends in the percentage of high school seniors who do not mind' being around people who are smoking, by race, Monitoring the Future Project, United States, 1981-1991 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 Year Sources: Bachman, Johnston, O'Malley (1981, 1984, 1985, 1987,1991); Johnston, Bachman, O'Malley (1982, 1984, 1986, 1988, 1991,1992); Institute for Social Research, University of Michigan (unpublished data). Table 20. Intensity of smoking (%) in senior year of high school, by intensity of smoking 5- 6 years later, Monitoring the Future Project, United States, 1976-1986 Smoking intensity (past 30 days) 5-6 years later (%)* Senior-year smoking inten5ity: (use in past 30 days) : < None 1 ciga- rette /day 1-5 ciga- rettes /day '/2 pack >_ 1 pack Number Column (weighted) percentage None 85.6 4.9 2.6 2.7 4.1 9,238 67.6 < 1 cigarette/day 57.8 14.4 9.6 7.8 10.4 1,268 9.3 1- 5 cigaretes per day 29.6 8.8 17.2 20.5 23.9 1,058 7.7 About'! pack/day 18.8. 4.9 8.7 21.7 46.0 1,000 7.3 _ 1 pack/day 13.4 2.7 4.1 10.1 69.T 1,100 ' 8.1 Total 68.0 5.9 5.0 6.6 14.6 13,665 100.0 Source: Institute for Social Research, University of Michigan (unpublished data). *Entries are row percentages. Epidetnivlvgy 85 r~'IrIlaT 0138937

Prevcnfing Tobacco Use Among Young People BEWLEY BR, BLAND JM. Smoking and respiratory symp- toms in two groups of schoolchildren. Preventive Medicine 1976;5(1):63-9. BEWLEY BR, HALIL T, SNAITH AH. Smoking by primary schoolchildren prevalence and associated respiratory symp- toms. British Journal of Preventive and Social Medicine 1973;27(3):150-3. BIGLAN A, LA CHANCE PA, BENOWITZ NL. Experi- mental analyses of the effects of smokeless tobacco depriva- tion. Unpublished data. BLAKE GH, ABELL TD, STANLEY WG. Cigarette smoking and upper respiratory infection among recruits in basic com- bat training. Annals of Internal Medicine 1988;109(3):198-202. BLAND M, BEWLEY BR, POLLARD V, BANKS MH. Effect of children's and parents' smoking on respiratory symptoms. Archive of Disease in Childhood 1978;53(2):100-5. BLUM A. Smokeless tobacco. Journal of the American Medical Association 1980;244(2):192. BOCK G, MARSH J, editors. The biology of nicotine dependence. Proceedings of Ciba Foundation Symposium 152, 7-9 November 1989, London. West Sussex (England): John Wiley & Sons, Inc., 1990. BOUQUOT JE. Epidemiology. In: Gnepp DR, editor. Pathol- ogy of the head and neck. New York: Churchill Livingstone, 1987. BOUQUOT JE. Reviewing oral leukoplakia: clinical concepts for the 1990s. Journal of the American Dental Association 1991;122(7):80-2. BOYD GM, GLOVER ED. Smokeless tobacco use by youth in the U.S. Journal of School Health 1989;59(5):189-93. BRADY JV, LUKAS SE, editors. Testing drugs for physical dependence potential and abuse liability. Monograph No. 52. US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administra- tion, National Institute on Drug Abuse._ Bethesda (MD): DHHS Publication No. (ADM) 84-1332,1984. BRESLAU N, FENN N; PETERSON E. Early smoking initia- tion and nicotine dependence in a cohort of young adults. Drug and Alcohol Dependence. 1993;33(2):129-37. BURCH JB, DE FIEBRE CM, MARKS MJ, COLLINS AC. Chronic ethanol or nicotine treatment results in partial cross- tolerance between these agents. Psychopharmacology 1988;95(4)452-8. CARMELLI D, SWAN GE, ROBINETTE D, FABSITZ R. Genetic influence on smoking-a study of male twins. New England Journal of Medicine 1992;327(12):829-33. CASEY K. If only I could quit: becoming a nonsmoker. Center City (MN): Hazelden Foundation, 1987. CENTERS FOR DISEASE CONTROL AND PREVENTION. Smoking cessation during previous year among adults-United States, 1990 and 1991. Morbidity and Mortality Weekly Report 1993a;42(26):504-7. CENTERS FOR DISEASE CONTROL AND PREVENTION. Use of smokeless tobacco among adults-United States, 1991. Morbidity and Mortality Weekly Report 1993b;42(14):263-6. CENTERS FOR. DISEASE CONTROL AND PREVENTION, OFFICE ON SMOKING AND HEALTH. Unpublished data. CHARLTON A. Children's coughs related to parental smoking. British Medical Journal 1984;288(6431):1647-9. CHARLTON A, BLAIR V. Absence from school related to children's and parental smoking habits. British Medical Journal 1989;298(6666):90-2. CHRISTEN AG, GLOVER ED. Smokeless tobacco: seduction of youth. World Smoking and Health 1981;6(2):20-4. CHRISTEN AG, MCDONALD JL, CHRISTEN JA. The impact of tobacco. use and cessation on nonmalignant and pre-cancerous oral and dental diseases and conditions. Indiana University School of Dentistry teaching monograph. Indianapolis: Indiana Univer- sity, 1991. CLAYTON RR, RfITER C. The epidemiology of alcohol and drug abuse among adolescents. Advances in Alcoholism and Substance Abuse 1985;4(3-4):69-97. COLLEY JRT, DOUGLAS JWB, REID DD. Respiratory dis- ease in young adults: influence of early childhood lower respiratory tract illness, social class, air pollution, and smok- ing. British Medical Journal 1973;3(5873):195-8. COLLINS AC. Interactions of ethanol and nicotine at the receptor level. In: Galantar M, editor. Recent Developments in Alcoholism. Volume 8. Combined Alcohol and Other Drug Dependence. New York: Plenum Press, 1990. COLLINS AC, BURCH JB, DE FIEBRE CM, MARKS MJ. Tol- erance to and cross tolerance between ethanol and nicotine. Pharmacology, Biochemistry and Behavior 1988;29(2):365-73. COMSTOCK GW, RUST PF. Residence and peak expiratory flow rates among Navy recruits. American Journal o f Epidemiol- ogy 1973;98(5):348-54. Health Consequences 43 N 0138896 ~IM

S«rgeon General's RepvrP Table 16. Trends in the prevalence (%'o) of current smoking* among white and black young people, National Household Surveys on Drug Abuse (NHSDA), Monitoring the Future Project (MTFP), National Health Interview Surveys (NHIS), United States, 1974-1992 NHSDA+ MTFP NHIS Year White Black (aged 17-19 years) White Black (aged 17-18 years) White Black (aged 18-19 years) 1974 41.9 47.4 33.6 33.7 1976 43.0 47.2 38.3 39.7 1977 42.9 44.3 38.4 34.4 1978 37.0 31.5 33.3 26.3 1979 44.4# 37.7t 34.9 28.7 32.6 30.8 1980 31.0 25.2 26.1 29.0 1981 30.1 22.3 1982 39.2 20.9 31.3 21.2 1983 31.3 21.2 28.6 18.5 1984 31.0 17.6 1985 28.6 20.8 31.7 18.7 23.4 18.4 1986 32.0 14.6 1987 32.2 13.9 23.4 15.3 1988 33.0 17.6 32.3 12.8 23.7 9.4 1989 32.1 12.4 1990 28.3 7.2 32.5 12.0 22.2 10.3 1991 30.5 11.4, 31.8 9.4 24.9 7.6 1992 ' 31.8 8.2 Sources: NTTS: U.S. Department of Health, Education, and Welfare (1972,1976,1979b); NHSDA: Centers for Disease Control and Prevention (CDC), Office on Smoking and Health (OSH) (unpublished data on *1974-1991 surveys); MTFP: Bachman, Johnston, O'Malley (1980a, b,1981,1984,1985,1987,1991); Johnston, Bachman, O'Malley (1980a, b,1982,1984, 1986, 1991, 1992); Johnston, O'Malley, Bachman (1992a); Institute for Social Research, University of Michigan (unpublished data); NHIS: CDC, OSH (unpublished data on 1974-1991 surveys). *For the NHSDA and the MTFP, current smoking is defined as any cigarette smoking during the 30 days preceding the survey. For the NHIS, current smokers are those who report that they have smoked at least 100 cigarettes and who respond "yes" to the question, "Do you smoke now?" 'In the NHSDA, "white" and "black" include respondents of Hispanic origin, except for 1985. xThe 1979 NHSDA determined current smoking status only for those respondents who had smoked at least 100 cigarettes (lifetime). The National Institute on Drug Abuse later published adjusted 1979 estimates using data from the 1982 NHSDA (Miller et a1.1983). The adjusted 1979 estimates used the ratio of the 1982 prevalence estimate, based on the 1979 definition, to the prevalence estimate based on the definition used in other years (i.e., any smoking in the last 30 days, regardless of whether the respondent had ever smoked 1001ifetime cigarettes). This table reports estimates based on the same adjust- ment procedure. 1987-1988 NHIS (Figure 2). The data confirm that women in the United States have started to smoke at increasingly younger ages. The largest differences exist for women who were at least 45 years old at the time of the survey. The initiation curve for 18- through 24-year-old females surveyed in 1987 and 1988 is, by age 18, lower than that for 18- through 24-year-old females surveyed in 1978 through 1980, which is consistent with the notion that the prevalence of cigarette smoking has declined recently among young females (Table 15). Johnston, O'Malley, and Bachman (1992a) used retrospective reports from MTFP high school seniors to describe trends in the initiation of daily smoking among seniors. Theirdata show that the likelihood of becoming a daily smoker at an earlier grade level increased sharply during the early to middle 1970s for the 1976 through 1978 senior dasses. From 1975 through 1977, this likeli hood decreased, and the grade of initiation declined or leveled for the 1979-1986 and 1988 classes. The lifetime 76 Epidemiology TIMN 0138928

Surgeon General's Report The trend of cessation is similar to the trend for current smoking prevalence. Substantial progress occurred in the late 1970s, but this progress slowed considerably in the 1980s. Trends in Knowledge and Attitudes About Smoking Trends in Perceived Health Risks of Smoking Data from the MTFP allow comparisons of trends in beliefs about the risks associated with cigarette smok- ing and in actual smoking behavior. The decline in the prevalence of ever smoking has been associated with an increase in the percentage of high school seniors who believe that smoking one or more packs of cigarettes each day is a serious health risk (Figure 5). This associa- tion has been observed for both genders and for whites and blacks (Bachman, Johnston, O'Malley 1980a, b, 1981, 1984, 1985, 1987, 1991; Johnston, Bachman, O'Malley 1980a, b, 1982,1984,1986,1991; ISR, University of Michi- gan, unpublished data). For example, during the early 1980s, the percentage of black high school seniors who felt that there is great risk associated with smoking a pack or more per day increased substantially. At the same time, the percentage of black youth who had smoked at all and who had smoked daily declined rapidly. In 1989, over 50 percent of smokers and 74 percent of non- smokers reported that they believed that smoking a pack or more per day is a serious health risk (1989 MTFP, CDC, OSH, unpublished data). The percentage of seniors who believed that smok- ing entails a great risk to health increased from 56 per- cent in 1976 to 69 percent in 1991, and the percentage who believed that the health effects of smoking had been exaggerated decreased from 16 percent in 1981 to 14 percent in 1991 (Table 18). Nonetheless, 3 out of 10 seniors in 1991 still did not believe that heavy smoking poses a serious threat to health. Among 12- through 18-year-olds in the 1989 TAPS, 32 percent believed that there is no harm in having an occasional cigarette; 57 percent of smokers in the survey endorsed that statement (Allen et a1.1993). Twenty-one percent of smokers and 3 percent of never smokers be- lieved that it is safe to smoke for only a year or two. Trends in Perceptions About Smoking - The percentage of high school seniors surveyed by the MTFP who considered smoking a "dirty habit" in- creased between 1981 (66 percent) and 1991 (72 percent) (Table 18). About 73 percent of white and 74 percent of black adolescents now feel this way, compared with only Figure 5. Trends in the percentage of high school seniors who believe that smoking is a serious health risk and in the percentage who have ever smoked, Monitoring the Future Project, United States, 1976-1991 Sources: Bachman, Johnston, O'Malley (1980a, b, 1981, 1984,1985,1987,1991); Johnston, Bachman, O'Malley (1980a, b, 1982, 1984, 1986,1991, 1992); Institute for Social Research, University of Michigan (unpublished data). 80 Epidemiology TIMN 0138932

Pre-enting Tobacco Use Amoxg Young People USDHHS 1989b). Since the recalled age at initiation is often 10 or more years younger than the age of the respondent at the time of the survey, recall bias may affect the reliability of these estimates. In the 1991 NHSDA, 69 percent of respondents aged 30 through 39 years reported trying a cigarette by age 18. Of all persons who had ever tried a cigarette, 88 percent had tried their first cigarette by age 18. The mean age of first trying a cigarette was 14.5 years. Thirty-five percent of the respondents had become daily smokers by age 18. Of those who had ever smoked daily, 71 percent had smoked daily by age 18. The mean age of becoming a daily smoker was 17.7 years. Surveys conducted in 1991 among school-aged stu- dents, while lacking information on postadolescent ini- tiation, provide information of more recent initiation patterns (i.e., during the 1980s and early 1990s). Among 12th-grade students surveyed in 1991,22 percent of TAPS respondents, 40 percent of NHSDA respondents, 40 per- cent of MTFP respondents, and 37 percent of YRBS re- spondents first tried a cigarette by age 14 (Table 8). About 60 percent of the respondents in the NHSDA, the MTFP, and the YRBS and about 50 percent of the TAPS respondents had smoked by their senior year. Daily cigarette use began by age 16 (or the 10th grade) for 18 to 23 percent of respondents to the NHSDA, the MTFP, and the YRBS (Table 9). By their senior year, 22 to 29 percent of these respondents had become daily smokers. Other Patterns of Smoking Two of the surveys gathered further information about smoking patterns-the number of days per month an adolescent smoked and the number of cigarettes the adolescent smoked per day. In the 1991 YRBS, responses indicated that in general, the greater number of days students reported smoking during the 30 days preceding the survey, the greater the number of cigarettes they smoked per day (Table 10). For example, 49 percent of students who smoked cigarettes on only one or two days during the preceding 30 days smoked fewer than one cigarette per day; among students who smoked ciga- rettes on all 30 days, 47 percent smoked 11 or more per day. Smoking patterns were also reported recently by Moss et al. (1992), using 1989 TAPS data (Table 11). About 41 percent of teenage smokers-whether male or female-smoked every day, and about one in four smoked on fewer than five of the preceding 30 days. The percentage of smokers who smoked every day increased with increasing age; 48 percent of 16- through 18-year- old smokers smoked every day. About twice as many white as black teenagers smoked every day (42 vs. 22 percent), and blacks were more likely than whites to have smoked on fewer than five days. Non-Hispanics were more likely than Hispanics to smoke every day. Sixteen percent of 12- through 18-year-old TAPS respondents who smoked during the week preceding the survey smoked 20 or more cigarettes daily.` Males smoked more cigarettes daily than females. Older stu- dents smoked more cigarettes daily than younger stu- dents; 47 percent of 16- through 18-year-old smokers and 11 percent of 12- and 13-year-old smokers reported smoking 10 or more cigarettes daily. Whites smoked more cigarettes daily than blacks, and non-Hispanics Table 10. Percent distribution of the number of cigarettes smoked per day, by the number of days on which cigarettes were smoked during the 30 days preceding the survey, Youth Risk Behavior Survey, United States, 1991 Cigarettes smoked per day Number of days cigarettes were sn[oked-. < 1 1 2-5 6-10 11-20 > 20 Total N 1-2 49.2 29.2 18.0 1.7 1.0 0.2 100 756 3-5 25.3 29.2 41.5 3.6 - 0.4 0.0 100 452 6-9 7.0 32.5 54.4 5.8 0.4 0.0 100 273 10-19 7.4 13.0 66.5 10.8 1.8 0.4 100 326 20-29 0.7 4.6 61.4 27.9 5.4 0.0 100 294 30 0.1 0.3 26.5 26.0 36.6 10.8 100 803 Average 14.8 15.0 37.2 14.$- 14.1 4.0 100 -2,904 Source: Centers for Disease Control and Prevention, Division of Adolescent and School Health (unpublished data). F_H;''_ - •7gy 67 TI~~ 0138919

SurYeon Genrrcr!'S Rcport Past-month smoking was generally most common in the north-central region of the United States and least prevalent in the West and the South (Table 4). Among the available state and local surveys of high school stu- dents (Table 3), the percentage of students who were current smokers ranged from 6 to 31 percent (median 27 percent). From the weighted surveys, current smoking prevalence was lowest in Puerto Rico and Utah and highest in South Dakota, New Mexico, and New York (excluding New York City). Frequent and Heavy Smoking In the 1989 TAPS, 8 percent of U.S. adolescents 12 through 18 years old were frequent smokers (i.e., had smoked on 20 or more of the 30 days preceding the survey) (Table 5). In 1991, 13 percent of high school students surveyed in the YRBS were frequent smokers. In the 1991 NHSDA, 7 percent of persons 12 through 18 years old were heavy smokers (i.e., had smoked at least one-half pack per day); 10 percent of high school seniors in the 1992 MTFP survey were heavy smokers. Males were slightly more likely than females to report frequent or heavy smoking (Table 5). To a greater extent than was found for current smoking, white adolescents were more likely than black or Hispanic adolescents to be frequent or heavy smokers. Among white adolescents in the different surveys, fre- quent and heavy smoking were 2.8 to 7.5 times more common than among black adolescents and 2.3 to 2.6 times more common than among Hispanic adolescents. As was noted for both ever smoking and current smoking, frequent and heavy smoking increased with increasing age or grade. Frequent and heavy smoking were more prevalent in the north-central and northeast regions and less prevalent in the South and the West. Sociodemographic Risk Factors for Smoking_ In its surveys of high school seniors from 1985 through 1989, the MTFP elicited data on several possible sociodemographic risk factors for adolescent smoking (Table 6). The surveys found, for example, that students who lived alone had the. highest prevalences of past- month smoking (47 percent) and heavy smoking (28 percent). Living in a single-parent household increased the risk of past month or heavy smoking only when the mother was the absent parent. Data from the 1968,1970, 1972, 1974, and 1979 NTTS indicate higher smoking prevalences among youth living in households with fewer than two parents or parent surrogates (USDHEW 1972, 1976,1979b). The available published reports, however, did not provide more detail on the exact structure of the household. The 1989 TAPS examined other aspects of family structure for possible associations with adolescent smok- ing status (Allen et al. 1993). The survey findings showed that youths 12 through 16 years old who were current smokers were almost twice as likely to be home without a parent or other adult for 10 or more hours a week than were teens who had never smoked. Furthermore, TAPS teens who said that they discussed serious problems with friends rather than with a parent, other relative, or another adult were two times more likely to be current smokers than were teens who reported discussing seri- ous problems with their parents (Moss et al. 1992). The 1985-1989 MTFP reported an inverse relation- ship between both past-month and heavy smoking and the population density of the locales in which the seniors grew up (Table 6); those seniors who grew up on a farm or in the country were more likely to smoke than those who grew up in large cities. The MTFP also found that as school performance among high school seniors declined from above average to below average, past-month smok- ing prevalence increased from 22 to 41 percent, and heavy smoking prevalence increased from 7 to 21 per- cent. A similar relationship was observed in the 1989 TAPS (Moss et a1.1992). Postgraduation plans were another predictor° of smoking behavior among MTFP seniors. Students who said they planned to complete four years of college were less likely to be past-month smokers (24 percent) or heavy smokers (7 percent) than were those who did not plan to get a college degree (39 percent were past-month smokers, 20 percent were heavy smokers). Males who planned to enter the armed forces after high school were more likely to be past-month smokers (31 percent) or heavy smokers (14 percent) than males who did not have such plans (26 percent were past-month smokers, 10 percent were heavy smokers). This association was neg- ligible among females. Among MTFP seniors, past-month and heavy smoking were least prevalent among those who felt that religion was very important in their lives and increased uniformly as the self-reported importance of religion lessened. Similarly, adolescent smokers in the 1989 TAPS were more likely to report that they rarely or never attended religious services (54 percent) than were never smokers (29 percent) (Allen et a1.1993). TAPS also analyzed smoking by dropout status. Respondents who had left school before graduating were more than twice as likely to report smoking in the past week as were those who currently attended or had gradu- ated from high school (43 vs. 17 percent) (CDC 1991a). Female high school students and graduates were about as likely as their male counterparts to have smoked in the past week (17 vs. 18 percent). Female dropouts, however, 62 Epidemiology TIMN 0138914

bonding with peers, being independent and mature, and having a positive social image. Since reports from adolescents who begin to smoke indicate that they have lower self-esteem and lower self-images than their non- smoking peers, smoking can become a self-enhancement mechanism. Similarly, not having the confidence to be able to resist peer offers of tobacco seems to be an impor- tant risk factor for initiation. Intentions to use tobacco and actual experimentation also strongly predict subse- quent regular use. The positive functions that many young people attribute to smoking are the same functions advanced in most cigarette advertising. Young people are a strategi- cally important market for the tobacco industry. Since most smokers try their first cigarette before age 18, young people are the chief source of new consumers for the tobacco industry, which each year must replace the many consumers who quit smoking and the many who die from smoking-related diseases. Despite restrictions on tobacco marketing, children and adolescents continue to be exposed to cigarette advertising and promotional ac- tivities, and young people report considerable familiar- ity with many cigarette advertisements. In the past, this exposure was accomplished by radio and television pro- grams sponsored by the cigarette industry. Barred since 1971 from using broadcast media, the tobacco industry increasingly relies on promotional activities, including sponsorship of sports events and public entertainment, outdoor billboards, point-of-purchase displays, and the distribution of specialty items that appeal to the young. Cigarette advertisements in the print media persist; these messages have become increasingly less informational, replacing words with images to portray the attractive- ness and function of smoking. Cigarette advertising fre- quently uses human models or human-like cartoon characters to display images of youthful activities, inde- pendence, healthfulness, and adventure-seeking. In pre- senting attractive images of smokers, cigarette advertisements appear to stimulate some adolescents who have relatively low self-images to adopt smoking as a way to improve their.Wm self-image. Cigarette adver- tising also appears to affect adolescents' perceptions of the pervasiveness of saoking, images of smokers, and ~-, the function of smoking: Since these perceptions are psychosocial risk factors for the initiation of smoking, cigarette advertising appears to increase young people's risk of smoking. Efforts to Prevent the Onset of Tobacco Use Most of the U.S. public strongly favors policies that might prevent tobacco use among young people. These policies include mandated tobacco education in schools, a complete ban on smoking by anyone on school grounds, 8 Introduction Surgeon General's Repvrt further restrictions on tobacco advertising and promo- tional activities, stronger prohibitions on the sale of to- bacco products to minors, and increases in earmarked taxes on tobacco products. Interventions to prevent ini- tiation among young people-even actions that involve restrictions on adult smoking or increased taxes-have received strong support among smoking and nonsmok- ing adults. Numerous research studies over the past 15 years suggest that organized interventions can help prevent the onset of smoking and smokeless tobacco use. School- based smoking-prevention programs, based on a model of identifying social influences on smoking and provid- ing skills to resist those influences, have demonstrated consistent and significant reductions in adolescent smok- ing prevalence; these program effects have lasted one to three years. Programs to prevent smokeless tobacco use have used a similar model to achieve modest reductions in initiation of use. The effectiveness of these school- based programs appears to be enhanced and sustained, at least until high school graduation, by adding coordi- nated communitywide programs that involve parents, youth-oriented mass media and counteradvertising, com- munity organizations, or other elements of adolescents' social environments. A crucial element of prevention is access: adoles- cents should not be able to purchase tobacco products in their communities. Active enforcement of age-at-sale policies by public officials and community members ap- pears necessary to prevent minors' access to tobacco: Communities that have adopted tighter restrictions have achieved reductions in purchases by minors. At the state and national levels, price increases have significantly reduced cigarette smoking; the young have been at least as responsive as adults to these price changes. Maintain- ing higher real prices of cigarettes provides a barrier to adolescent tobacco use but depends on further tax in- creases to offset the effects of inflation. The results of this review thus suggest that a coordinated, multicomponent campaign involving policy changes, taxation, mass me- dia, and behavioral education can effectively reduce the onset of tobacco use among adolescents. Summary Smoking and smokeless tobacco use are almost always initiated and established in adolescence. Besides its long-term, effects on adults, tobacco use produces specific health problems for adolescents. Since nicotine addiction also occurs during adolescence, adolescent to- bacco users are likely to become adult tobacco users. Smoking and smokeless tobacco use are associated with other problem behaviors and occur early in the sequence of these behaviors. The outcomes of adolescent smoking TIMN 0138862

SurReori Geiiernl's Report Table 1. Sources of national data on tobacco use among young people, 1968-1992 Survey title Abbreviated title Sponsoring agency or organization Type of survey Years National Teenage NTTS, TAPS National Clearinghouse Cross-sectional 1968,1970, 1972, Tobacco Surveys; for Smoking and Health, 1974,1979,1989 1989 Teenage Attitudes and Practices Survey ational Household SDA National Cancer Institute, National Institutes of Health; National Institute of Education; Office on Smoking and Health (OSH), Centers for Disease Con- trol and Prevention (CDC)* National Institute oss-sectional 74,1976,1977, Surveys on Drug on Drug Abuse/ 1979,1982,1985, Abuse Substance Abuse and 1988,1990,1991 Monitoring the MTFP Mental Health Services Administration National Institute Cross-sectional 1976-1992 Future Project on Drug Abuse; and annual surveys; - University of Michigan, Institute for Social longitudinal 1976-1986 respondents contacted 5-6 years Research later Youth Risk Behavior YRBS Division of Adolescent Cross-sectional 1991 Survey and School Health, (national, as National Health NHIS CDC National Center for well as state and local) Cross-sectional 1970,1974, Interview Surveys Health Statistics 1978-1980,1983, (NCHS), CDC 1985,1987-88, 1990,1991 t Sources: NTTS: U.S. Department of Health, Education, and Welfare (1972,1976,1979b); TAPS: CDC (1991a); Allen et al. (1991,1993); Moss et al. (1992 ); NHSDA: Abelson and Atkinson (1975); Abelson and Fishburne (1976); Fishburne, Ableson, Cisin (1980); Gfroerer (1993); Miller et al. (1983); U.S. Department of Health and Human Services [USDHHS] (1988a, 1990a, 1991a, 1992a, 1993); 1991 NHSDA: CDC, OSH (unpublished data); MTFP: Bachman, Johnston, O'Malley (1980a, b,1981,1984, 1985,1987,1991); Johnston, Bachman, O'Malley (1980a, b,1982,1984,1986,1991,1992); Johnston, O'Malley, Bachman (1991a, b, 1992a, b, in press);1990-1992 MTFP surveys: Institute for Social Research, University of Michigan (unpublished data); YRBS: Kolbe (1990); CDC (1992c, d); Kolbe, Kann, Collins 1993; CDC, Division of Adolescent and School Health (unpublished data); NHIS: NCHS (1958,1975,1985,1988a, b, 1989); USDHHS (1992a); 1970,1978-1980,1987-1988 NHIS: CDC, OSH (unpub- lished data). *The 1989 TAPS was partially sponsored by the American Cancer Society. 56 Epidemiology TIMN 0138908

Gt'ilt'nd• Rt'(tlt/'i Table 29. Percentage of high school students who used tobacco, by participation on sports teams and steroid use, Youth Risk Behavior Survey, United States, 1991 Category Number Any cigarette use* Current cigarette uset Current frequent cigarette user Current smokeless tobacco use; Participation on sports teams' Total 0 teams 5,738 , 73.6 31.3 17.2 6.6 _ 1 team 6,429 67.2 24.3 8.9 13.5 Female 0 teams 3,608 72.0 29.0 14.3 '0.7 >_ 1 team 2,635 66.3 24.8 9.6 2.1 Male 0 teams 2,125 76.1 34.8 21.6 15.5 >_ 1 team 3,794 67.8 23.9 8.4 21.0 Steroid use9 Total 0 times 11,868 69.7 26.8 12.1 9.7 >_ I time 382 87.2 54.8 35.7 38.7 Female 0 times 6,164 69.3 26.9 12.2 1.1 ? 1 time 116 88.5 61.8 29.9 16.5 Male 0 times 5,700 70.0 26.6 12.0 18.1 >_ I 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. ' Cigarette use on > I day during the 30 days preceding the survey. t Cigarette use on _ 20 days during the 30 days preceding the survey. ' During the 30 days preceding the survey; includes chewing tobacco or snuff. ' During the 12 months preceding the survey; includes sports teams sponsored by school and other organizations. 9 During the respondent's lifetime, without a doctor's prescription. 92 Epidemiology TIMN 0138944

Scergeon General's Report Trends in Cigarette Smoking Ever Smoking Data from the NTTS, the NHSDA, and the MTFP suggest that the prevalence of ever smoking among ado- lescents has declined since the 1970s (Table 14). In the NHSDA, the prevalence of smoking among youths 17 through 19 years old declined from 78 percent in 1979 to 64 percent in 1991, an average decline of 1.2 percentage points per year. In the NTI'FP, the prevalence among 17- and 18-year-olds decreased from 76 percent in 1977 to 62 percent in 1992, an average decline of 0.9 percentage points per year. In the NHIS, the percentage of 18- and 19-year-olds who had smoked at least 100 cigarettes dropped from 41 percent in 1974 to 25 percent in 1991, an average decline of 1.0 percentage points each year. Current Smoking NHIS data have been used to examine historical trends in smoking by reconstructing the prevalence of cigarette smoking for the decades in this century before systematic surveillance of cigarette smoking was con- ducted (USDHHS 1980, 1985, 1991b; Harris 1983). Us- ing information on a respondent's date of birth, age at initiation of fairly regular smoking, and duration of abstinence (for former smokers), the smoking status of the respondent can be assessed for any given year. For this report, the reconstructed prevalence of smoking among those aged 10 through 19 years is reported for the years 1920 through 1980. Except for 1980, smoking during this 60-year pe- riod was more common among white and black ado- lescent males than among white and black adolescent females (Figure 1). The prevalence of cigarette smoking Figure 1. Trends in the reconstructed prevalence* of cigarette smoking among 10-19-year-olds, by gender and race, United States, 1920 -1980 ~ White males 1920 1930 1940 1950 Year 1980 1960 1970 1111111 - Black males White females Black females Source: U.S. Department of Health and Human Services (1991b). Data sources are the 1970,1978,1979,1980, and 1987 National Health Interview Surveys. *The smoking prevalence for each of the years indicated was calculated for people who would have been 10-19 years old in each of those years by using the survey respondents' date of birth, age when fty first began smoking regularly, and age when they quit smoking (see Appendix 2). 72 Epidemiology ,rIMN 0138924

>u, ~c( nt Q& rtt•r,tl'- R",,,yt Table 21. Direction of change in smoking behavior (9'~) between senior year of high school and 5-6 years later, Monitoring the Future Project,United States, 1976-1986 senior classes Smoking status 5-6 years later* Senior-year smoking status (use in past 30 days) Quit Less use Same level More use Number (weighted) None , 85.6 14.4 9,238 < 1 cigarette/day 57.8 14.4 27.8 1,268 1-5 cigarettes/day 29.6 8.8 17.2 44.4 1,058 About'/~ pack/da,v 18.8 13.6 21.7 46.0 1,000 > 1 pack/day 13.2 17.7 40.2 29.0 869 Source: Institute for Social Research, University of Michigan (unpublished data). *Entries are row percentages. Table 22. Smoking intensity 5-6 years after high school, by senior-year smoking status and expectation to smoke in 5 years, Monitoring the Future Project, United States, 1976-1986 senior classes Senior-year Smoking intensity smoking intensity (past 30 days) (use in past 30 5-6 years later* days) and predicted likelihood of < 1 cigarette 1=5 cigarettes > 1 pack Number smoking in 5 years None , /day /day 1/2 pack/day /day (weighted) None Will smoke 55.3 10.6 19.8 8.3 5.9 30 Will not smoke 84.7 5.6 2.9 2.5 4.3 1,829 Total 84.2 5.7 3.2 2.6 4.3 1,859 < 1 cigarette/day Will smoke 41.7 18.4 19.5 14.0 6.4 36 Will not smoke 58.4 14.7 9.7 9.7 7.5 208 Total 55.9 15.2 11.1 10.4 7.3 244 1-5 cigarettes/day Will smoke 32.3 3.0 15.5 23.0 26.2 83 Will not smoke 31.8 5.8 15.9 23.0 23.5 125 Total 32 0 4 7 7 15 23 0 24 6 208 .~ . . . . . About 1/2 pack/day Will smoke 15.5 4.9 6.5 21.0 52.1 115 Will not smoke 17.6 2.5 6.5 21.1 52.3 81 Total 16.4 3.9 6.5 21.1 52.2 196 >_ I pack/day Will smoke 13.3 2.2 3.2 9.6 71.8 153 Will not smoke 13.2 1.6 5.3 6.3 73.6 72 Total 13.3 2.0 3.8 8.5 72.4 225 Grand Total 67.0 6.0 5.2 6.6 15.2 2,731 Source: Institute for Social Research, University of Michigan (unpublished data). *Entries are row percentages. 86 Epidemiology TIh/1N 0138938

tilfl••\t'tUl c,i'Nt'tt7l'• Rt':ht/7 Table 26. Percent distribution of high school seniors (N [weightedJ = 21,007), by grade in which they first (if ever) used cigarettes and cocaine; Monitoring the Future Project, United States, 1986-1989 Grade when respondent first tried cocaine Grade when respondent first tried cigarettes <_ 6 7-8 9 0 1 2 Never used Row total <_ 6 0.1 0.4 0.9 1.2 1.4 0.9 15.-1 20.3 7-8 * 0.2 0.6 1.1 1.3 0.9 15.6 19.7 9 * * 0.2 0.5 0.6 0.3 9.0 10.7 10 * * * 0.2 0.4 0.2 6.1 7.0 11 * * * * 0.2 0.2 4.8 5.2 12 * * * * * 0.1 2.5 2.6 Never used * * 0.1 0.2 0.2 0.3 33.8 34.5 Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data). * < 0.05. Note: Totals may not equal the sum of individual percentages because of rounding. Table 27. Percentage of high school students who used tobacco, by behaviors that contribute to unintentional and intentional injuries, Youth Risk Behavior Survey, United States, 1991 Risk behavior Number Any cigarette use* Current cigarette uset Current frequent . cigarette uset Current smokeless tobacco use9 Seat belt use' Ahvavs 2,908 60.2 17.8 6.8 13.5 [Vtost the time/sometimes 5,651 70.1 26.3 11.4 17.6 Rarelv/never 3,548 80.6 40.3 21.8 26.5 Physical fighting1 0 times 6,864 63.9 20.3 8.1 13.9 1-5 times 4,358 77.8 35.4 17.3 23.2 _ 6, times 789 82.6 49.3 30.5 32.1 Weapon carrying** 0 davs 8,703 65.5 22.6 9.4 13.3 > 1 dav 3,171 82.8 41.1 22.2 27.5 Attempted suicidet 0 times 10,060 68.2 24.8 10.6 17.8 >-1 time 824 85.0 52.5 33.8 33.6 Sources: Centers for Disease Control and Prevention (CDC), Division of Adolescent and School Health (unpublished data); CDC, Office on Smoking and Health (unpublished data). * During the respondent's lifetime. Cigarette use on >_ I day during the 30 days preceding the survey. tCigarette use on ? 20 days during the 30 days preceding the survey. ' During the 30 days preceding the surve,v; includes chewing tobacco or snuff; males only. ' When riding in a car driven by someone else. 9During the 12 months preceding the survey. '*During the 30 days preceding the survey; includes any weapon such as a gun, knife, or club. 90 Epidem,oro3y TIIVIN 0138942

Sttryevn Gertern!': Ref,vrt that exposures to ETS be reduced to the lowest feasible concentration (USDHHS 1991b): - A recent monograph by Gue:in, Jenkins, and Tomkins (1992) updates and extends these earlier reviews. The U.S. Environmental Protection Agency (USEPA) also recently reviewed the evidence on involuntary smoking and respiratory health (USEPA 1992). These and other health consequences of passive smoking are discussed later in this chapter. Many of the components of SS and MS have been identified in ETS. On the other hand, ETS is an inherently dynamic mixture that changes in physical and chemical characteristics as it ages and reacts with other pollutants in indoor air and with surfaces (USDHHS 1986a; Guerin, Jenkins, Tomkins 1992). The 1986 Surgeon General's report concluded, however, that ETS was sufficiently close to MS and SS to permit generalization of the evi- dence on the health consequences of active smoking to passive smoking (USDHHS 1986a). The human body is most susceptible to these health consequences along cigarette smoke's path of ingress through the respiratory tract. The respiratory tract in- cludes the upper airway (nose, oropharynx, and larynx) and the lung (airways and the parenchyma). The air- ways are lined by an epithelium that varies in form and function at different levels of the respiratory tract. The parenchyma indudes the alveoli pulmonis (the delicate gas-ezchanging surface of the lung) and the interstitium (the location of the blood and lymphatic vessels and of the lung's supporting connective tissue). The effects of active' cigarette smoking on these structures of the lung and on many physiological func- tions of the lung have been extensively studied (USDHHS 1984, 1990; Bates 1989). Changes in lung physiology attributable to smoking include the weakening of an individual's defenses against infectious organisms and inhaled particles and gases, changes in the numbers and types of cells present within the lung, and the activation of potentially damaging proteolytic enzymes and the inactivation of the proteins that inhibit them. Many of these effects of smoking have been demonstrated in young adult smokers who have served as volunteer research subjects (USDHHS 1984): The effects of smoking on lung structure and func- tion have been demonstrated repeatedly in young adult smokers (USDHHS 1984; Bates 1989). Studies using spirometry, tests of small airway function, and lungg vol- ume measurements have shown a higher frequency of abnormalities in smokers than nonsmokers (USDHHS 1984; Bates 1989). Effects of smoking on lung structure, particularly the small airways, have been found in smok- ers in their mid-twenties. Niewoehner, IQeinerman, and 'Unless otherwise indicated, "smoking" will hence refer to active smoking. Rice (1974) examined peripheral airways of 20 nonsmok- ers and 19 smokers who had died from nonrespiratory causes at an average age of 25. A characteristic lesion, termed "respiratory bronchiolitis; " was found in all 19 of the smokers but in only 5 of the nonsmokers. The affected small airways of the smokers demonstrated an inflammatory process consisting of aggregates of pigment-containing macrophages with edema, fibrosis, and epithelial hyperplasia in adjacent bronchioles and alveoli. These observations on the effects of smoking in young people are consistent with current concepts of pathogenesis and natural history in adult smokers (USDHHS 1984, 1990). Severe chronic airflow obstruc- tion, sufficient to result in a clinical diagnosis of chronic obstructive pulmonary disease (COPD), follows sustained smoking and lung injury with progressive loss of respi- ratory function through adulthood. In smokers who develop COPD, decline of lung function at a rate well beyond that associated with aging alone eventually leads to impairment. Changes in lung function can be demon- strated in young adult smokers; these losses are consis= tent with the histopathologic evidence that the small airways of young smokers are damaged (USDHHS 1984). Epidemiologic Evidence of Respiratory Effects Respiratory Symptoms The cardinal symptoms of respiratory tract injury and disease are cough, sputum production, wheezing, and dyspnea (or shortness of breath). In epidemiologic studies of respiratory diseases, symptoms are usually discovered through responses to a standardized ques- tionnaire (Samet 1978). In adults, the occurrence of cough and phlegm is causally associated with cigarette smok- ing; the frequency of the symptoms rises with the num- ber of cigarettes smoked per day (USDHHS 1984). In some studies, wheezing is also more frequent in adult smokers than in adults who have never smoked (Schenker, Samet, Speizer 1982). The frequency of dyspnea rises as the extent of smoking-related impair- ment of lung function increases (Samet 1978). Questionnaire-based epidemiologic studies of chil dren and adolescents document that smoking is also a cause of respiratory symptoms in preteen and teenage regular smokers (those who smoke at least weekly). Studies conducted from the 1960s through the 1980s involving thousands of children provide consistent evi dence that smoking is associated with the occurrence of cough and phlegm (Table 1; see Table 31 in Chapter 3 for additional data). In several studies, smoking also in- creased the frequency of wheezing and dyspnea. These associations have been found in studies conducted in the 16 Health Consequences T1.N1N 0138869

Preveuting Tobacco Use Arnvng Young People Table 13. Percent distribution of cigarette brands that 12-18-year-old current smokers* reported usually buying, by gender, race/Hispanic origin,t age, and region, Teenage Attitudes and Practices Survey, United States, 1989 Category Number Marlboro Newport Camel Winston Benson & Hedges Salem Kool Merit Vantage Other Overall# 865 68.7 8.2 8.1 3.2 1.5 1.4 1.0 0.5 0.1 7.3 Gender Male 477 68.9 7.3 10.9 3.6 0.5 0.2 1.9 0.7 0.2 6.0 Female 388 68.4 9.4 4.6 2.6 2.9 2.9 0.0 0.3 0.0 8.9 Race White 807 71.4 5.6 8.4 3.4 1.0 ` 1.3 0.6 0.5 0.1 7.6 Black 41 8.7 61.3 3.1 0.0 9.7 3.3 10.9 0.0 0.0 2.9 Hispanic origin Hispanic 46 60.9 12.8 7.6 0.0 2.8 3.7 5.8 0.0 0.0 6.5 Non-Hispanic 817 69.1 8.0 8.1 3.3 1.5 1.3 0.8 0.5 0.1 7.3 Age (years) 12-15 195 74.8 6.1 8.7 2.5 0.9 0.4 1.1 0.0 0.0 6.5 16-18 670 67.0 8.8 7.9 3.3 1.7 1.6 1.0 0.6 0.1 7.8 Region Northeast 184 68.4 16.2 4.1 0.0 2.3 0.0 0.0 0.6, 0.5 7.9 Midwest 247 70.2 1.0.0 7.3 3.4 2.2 0.0 1.1 0.5 0.0 5.3 South 281 67.2 5.0 6.1 6.2 1.1 2.9 2.1 0.4 0.0 9.1 West 153 69.6 2.0 18.1 0.7 0.6 2.3 0.0 0.6 0.0 6.2 Overall market share, 1989 26.3 4.7 3.9 9.1 6.2 3.9 5.9 3.8 2.5 33.7 Sources: Centers for Disease Control (1992b); Maxwell (1992). *Persons who reported smoking on one or more of the 30 days preceding the survey. +Excludes the racial category "other" (N = 17). Ethnicity for two persons was unknown. tData were weighted to provide national estimates_ United States showed°more preference for Camel ciga- rettes than did smokers from other regions of the nation. Other studies conducted after TAPS report rates of Camel preference among adolescent smokers that are consis- tent with the COMMIT survey results (DiFranza et al. 1991; Pierce, Gilpin, et a1.1991). In June and July 1992, the George H. Gallup Inter- national Institute (1992) conducted a telephone survey of a nationwide sample of 1,125 youths 12 through 17 years old. Smokers (those who reported having smoked at least one cigarette during the 30 days preceding the interview) were disproportionately oversampled, and the data were weighted to represent the adolescent population. Smokers were asked, "Thinking now about the last time you bought cigarettes for yourself, what brand did you happen to buy on that occasion?" Marlboro was the brand bought by 53 percent of these teenage smokers, Camel by 16 percent, and Newport by 8 percent. The most popular brand among blacks in this survey was Newport (54 percent preference). Epidemiology 71 TIMN 0138923

Surgeon Gotcml': Report smoke a cigarette if one of their best friends were to offer them one ("definitely yes," "probably yes," "probably not; "definitely not; " and "don't know"), and (3) whether they thought they would be smoking cigarettes in one year ("definitely yes;' "probably yes," "probably not," "definitely not," and "don't know"). Never smokers who answered "no" to the first question, "definitely not" to the second question, and "definitely not" to the third question were categorized as "not susceptible" to smoking. Those who answered these three questions in any other way were considered susceptible to smoking in the future (Pierce et al. 1993). According to these criteria, 44 percent of all TAPS respondents had never tried a cigarette and were not considered susceptible to smoking, and 10 percent had never tried smoking but were con- sidered susceptible. Adolescents who had tried smoking but had not smoked a whole cigarette accounted for 11 percent of TAPS respondents; 8 percent were judged to be not susceptible to smoking in the future, and 3 percent were judged susceptible. Those who had smoked at least one cigarette were only asked question 3, above, concerning whether or not they thought they would be smoking in a year. A large category (14 percent of all respondents) was composed of those who had smoked at least 1 but fewer than 100 cigarettes, who had not smoked in the preceding 30 days, and who definitely did not intend to smoke in a year. Another 4 percent had smoked from I to 99 cigarettes, had not smoked in the preceding 30 days, and were not definite in their resolve to not be smoking in a year. Slightly more than 1 percent of TAPS respondents had smoked at least 100 cigarettes but had not smoked in the preceding 30 days; these respondents are considered to be former smokers (USDHHS 1989b, 1990b). * Finally, among the 15 percent of respondents who smoked in the preceding 30 days, about 45 percent (6 percent of all respondents) had smoked fewer than 100 cigarettes in their lifetime. Although current smok- ers, these persons were still at a relatively early stage in the process of smoking initiation. Among those who had smoked at least 100, cigarettes and had smoked in the preceding month, more than three-fourths (7 percent of all respondents) had smoked on 20 or more of those 30 days. The distribution of this continuum was similar for males and females. White adolescents were more likely to be further along the continuum than were Hispanic and black adolescents. Cigarette Brand Preference Knowing what brands of cigarettes are preferred by young smokers'may aid the development of 70 Epidemiology smoking prevention programs and may provide insight into the influence that cigarette advertising may have on young people. In 1978-1980, the NHIS assessed the brands of ciga- rettes most often used by current smokers (CDC, OSH, unpublished data). Among 707 respondents who were 18 or 19 years old, the most commonly used brands were Marlboro (37 percent), Kool (14 percent), Salem (10 per- cent), Winston (9 percent), Newport (8 percent), Virginia Slims (5 percent), Merit (4 percent), Benson & Hedges (3 percent), and Camel (2 percent). Ten percent of females and no males used Virginia Slims. Among whites, Marlboro (42 percent), Kool (10 percent), Winston (10 percent), Salem (8 percent), Virginia Slims (6 percent), and Newport (6 percent) were the most commonly used brands. Among blacks, Kool (46 percent), Newport (25 percent), Salem (20 percent), and Benson & Hedges (6 percent) were the most commonly smoked brands. In the 1989 TAPS, adolescent respondents who generally bought their own cigarettes were asked what brand they usually purchased. More than two-thirds of these smokers usually purchased Marlboro (Table.13). Preference for Marlboro did not differ appreciably by gender, Hispanic origin, age, or region of the country. White adolescent smokers were much more likely to smoke Marlboro cigarettes than were black adolescent smokers (71. vs. 9 percent). The next most popular brands, Newport and Camel, each accounted for only 8 percent of the overall population's preference. Black smokers, however, were much more likely to smoke Newport cigarettes than were white smokers (61 vs. 6 percent), although sample sizes of blacks were small. Smokers who resided in the Northeast and the Midwest were more likely to smoke Newport cigarettes than were smokers in the South and the West. Among white adolescents, Newport was more popular in the Northeast (14 percent) and the Midwest (7 percent) than in the South (1 percent) and the West (1 percent) (CDC 1992b). The Camel brand was more popular among male (11 percent) than female smokers (5 percent), among white (8 percent) than black smokers (3 percent), and among smokers residing in the West (18 percent) than among those residing in the other three regions (from 4 to 7 percent). Several nonnational studies conducted since the 1989 TAPS suggest that Camel cigarettes may be gaining in popularity among young smokers. In a 1990 survey of ninth-grade students in 10 U.S. communities included in the Community Intervention Trial for Smoking Cessa- tion (COMMTf) evaluation, 43 percent of smokers who usually bou$ht their own cigarettes bought Marlboro, 30 percent bought Camel, and 20 percent bought New- port (CDC 1992b). As TAPS data also indicated, adoles- cent smokers residing in communities in the western ' TIMN 0138922

other drug use was from 1.6 to 5.2 times more preva- lent among cigarette smokers than nonsmokers. Grade When Smoking and Other Drug Use Begins MTFP data from 1986 through 1989 were merged to observe the grade at which seniors reported trying cigarettes, smokeless tobacco, alcohol, marijuana, and cocaine (Figure 8). Among ever smokers, 31 percent tried their first cigarette by the sixth grade, and 61 per- cent first smoked by the eighth grade. Among those who had used smokeless tobacco, 23 percent had first done so by the sixth grade, and 53 percent by the eighth grade. Proportionately fewer users of alcohol, marijuana, and cocaine initiated use as early as respondents initiated use of cigarettes and smokeless tobacco. Thirty-four percent of alcohol users, 26 percent of marijuana users, and 6 percent of cocaine users first tried these drugs by the eighth grade. By the 12th grade, only 8 percent of MTFP respon- dents had not tried cigarettes or alcohol; 68 percent had tried both, and 24 percent had tried alcohol but no; cigarettes (Table 24). Of those students who had tried both cigarettes and alcohol by 12th grade, almost half (49 percent) had tried cigarettes before trying alcohol; 33 percent had tried both at about the same time. About 30 percent of all students had not tried ciga- rettes or marijuana by the 12th grade (Table 25); ~ percent had tried both, and 22 percent had tried cigarettes but not marijuana. Of those who had tried both by 12th grade, most students (65 percent) had tried cigarettes before mari- juana; 23 percent had tried both at about the same time. About one-third of seniors (34 percent) had not tried cigarettes or cocaine; 12 percent had tried both, and over half (53 percent) had tried cigarettes but not cocaine (Table 26). Of those who had tried both by 12th grade, 90 percent had tried cigarettes before trying cocaine, and 9 percent had tried both at about the same time. These data support the contention that tobacco use falls early in the sequence of drug use for young adoles- cents and therefore may be considered a "gateway" drug. Figure 8. Grade when respondents (high school seniors) first tried cigarettes, smokeless tobacco, alcohol; marijuana, and cocaine, among respondents who had ever used these substances by grade 12, Monitoring the Future Project, United States, 1986-1989 Grade 12 Grade 11 ~ Grade 10 ~ Grade 9 ~ Grades 7-8 "' Grade 5 6 Cigarettes Smokeless tobacco Alcohol Marijuana Cocaine Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data). 88 Epidemiology TIMN 0138940

PreveiiFinY Tobacco Use AmoteY Yomng People . Health Consequences of Smokeless Tobacco Use Among Young People Introduction Smokeless tobacco includes two main types: chew- ing tobacco and snuff. These products are made from the same type of dark- or burley-leaved tobacco. Most smoke- less tobacco is grown in Kentucky, Pennsylvania, Ten- nessee, Virginia, West Virginia, and Wisconsin. Leaves are generally aged one to three years, but snuff tobacco leaves are aged longer than chewing tobacco leaves (Shapiro 1981). People who use chewing tobacco place a wad of loose-leaf tobacco or a plug of compressed tobacco in their cheek; snuff users place a small amount of powdered or finely cut tobacco (loose or wrapped in a paper pouch) between their gum and cheek (USDHHS 1992b). Smokeless tobacco users then suck on the to- bacco and spit out the tobacco juices with accompanying saliva. As a consequence of the way in which smokeless products are used, smokeless tobacco is sometimes re- ferred to as spit or spitting tobacco (USDHHS 1992b). The most notable health consequences associated with smokeless tobacco use include halitosis (bad breath), discoloration of teeth and fillings, abrasion of teeth, den- tal caries, gum recession, leukoplakia, nicotine depen- dence, and various forms of oral cancer (USDHHS 1986b, 1992a; WHO 1988). Specifically, smokeless tobacco use has been implicated in cancers of the gum, mouth, phar- ynx, larynx, and esophagus (USDHHS 1986b; Winn 1988) and has also been indicated in early reports of the devel- opment of verrucous carcinoma (Winn 1988). Smokeless tobacco use may also play a role in cardiovascular dis- ease and stroke, through increases in blood pressure, vasoconstriction, and irregular heartbeat (Hsu et al. 1980; Gritz et al. 1981; Schroeder and Chen 1985). Since nearly 25 percent of adult smokeless tobacco users also smoke cigarettes (CDC 1993b), the effects on the oral cavity may be synergistic, and the risks of developing cancer of the oral cavity and pharynx noticeably increase (Blum 1980). Epidemiologic Evidence The 1986 Surgeon General's report on smokeless tobacco use concluded that there is no safe use of tobacco. Despite that report and subsequent legislation, restric- tions, and follow-up reports (USDHHS 1992a, b; see "Warning Labels on Tobacco Products" in Chapter 6 and "Smokeless Tobacco Advertising and Promotional Ex- penditures" in Chapter 5), smokeless tobacco use in the United States remains a serious concern. The use of smokeless tobacco by adults has remained relatively con- stant at about 5 percent for males and 1 percent for females. However, smokeless tobacco use among high school males has become markedly more prevalent in the past two decades; about 20 percent report using smoke- less tobacco in the past month (see "Current Use of Smokeless Tobacco" in Chapter 3 for documentation and further discussion of the prevalence of smokeless tobacco use). In some states, nearly one out of three high school males uses smokeless tobacco. There is little indication that use among young people is significantly declining (Glover et al. 1988; Boyd and Glover 1989; USDHHS 1992b; see "Current Use of Smokeless Tobacco" in Chapter 3). Smokeless tobacco use primarily begins in early ado- lescence; some research indicates an average age of onset of 10 years (USDHHS 1992b). Among high school seniors who had regularly used smokeless tobacco, 23 percent reported that they had first tried the product by the sixth grade, and 53 percent by the eighth grade (see "Grade When Smokeless Tobacco Use Begins" in Chapter 3). Health Consequences A recent report of the Office of Inspector General (USDHHS 1992b) concluded that smokeless tobacco use causes serious, but generally not fatal, short-term health consequences among young people. The primary health consequences during adolescence include leukoplakia, gum recession, nicotine addiction, and increased risk of becoming a cigarette smoker. Leukoplakia and/or gum recession occur in 40 to 60 percent of smokeless tobacco users (USDHHS 1992b). Leukoplakia has been defined by the World Health Organization as a lesion of the soft tissue that consists of a white patch (mucosal macule) or plaque that cannot be scraped off (Kramer et a1.1978; Axell et a1.1984). Greer and Poulson (1983) examined 117 high school students who were smokeless tobacco users; oral soft-tissue le- sions were found in 49 percent of these students. Oral leukoplakias carry a five-year malignant transformation potential of about 5 percent (Pindborg 1980,1985; Bouquot 1987, 1991). If smokeless tobacco use ceases, the leukoplakia appears to regress or resolve entirely (Chris- ten, McDonald, Christen 1991). Gingival tissue recession (or gum recession) com- monly occurs in the area of the oral cavity immediately adjacent to where smokeless tobacco is held. When smokeless tobacco remains exclusively in a specific intraoral location, gingival recession occurs among 30 percent (Weintraub et al. 1990) to over 90 percent (Schroeder et al. 1988) of users. Modeer, Lavstedt, and Ahlund (1980) found that snuff use among 13- and Health Catsequences 39 TIMN 0138892

Preaenting Tobacco Use Among Young People Table 18. Continued Beliefs and attitudes 1976 1981 1986 1991 About smokers In my opinion, when a girl my age is smoking a cigarette, it makes her look (percentage who agree) ... like she's trying to appear mature and 64.6 65.0 64.1 sophisticated ...insecure 47.4 49.5 52.0 ... conforming 26.5 21.7 19.5 ... independent and liberated 11.2. 9.5 9.6 ... mature, sophisticated 6.9 5.4 4.5 ... cool, calm, in control 5.5 4.5 4.1 I prefer to date people who don't 66.5 71.0 74.0 smoke. (percentage who agree) Smokers know how to enjoy life more 2.8 2.4 3.6 than nonsmokers. (percentage who agree) I think that becoming a smoker reflects 57.0 59.3 61.0 poor judgment. (percentage who agree) I strongly dislike being near people who 45.4 48.9 are smoking. (percentage who agree) I personally don't mind being around 38.2 36.9 33.1 people who are smoking. (percentage who agree) Do you disapprove of people (~~ age 18) 65.9 70.0 75.4 71.4 who smoke one or more packs of cigarettes per day? (percentage who disapprove) . about one-third of smokers preferred to date nonsmok- ers in 1989 (1989 MTFP; CDC, OSH, unpublished data). Findings from the 1989 TAPS also suggest that few adolescents consider smoking a norm for their age group. Two-thirds of 12- through 18-year-old respondents agreed with the statement, "Seeing someone smoking turns me off," and 86 percent (94 percent of never smokers and 51 percent of cuirent smokers) preferred to date nonsmok ers (Allen et a1.1993). ' Adolescents seem to be more concerned about people smoking around them. In the MTFP, the percent- age of high school seniors who strongly disliked being near smokers increased between 1986 (45 percent) and 1991(49 percent), and the percentage who reported that they did not mind being around smokers declined (from 38 percent in 1981 to 33 percent in 1991) (Table 18). Males were consistently more likely than females to mind being around smokers (Johnston, Bachman, O'Malley 1982, Epidemiology 83. TIMN 0138935

Prezenting Tobacco Use Among Young People 69 percent of whites and 54 percent of blacks surveyed in 1981 (Johnston, Bachman, UMalley 1982; ISR, Univer- sity of Michigan, unpublished data). The perception that smoking is a dirty habit has increased among males, females, smokers, and nonsmokers. Fifty percent of smokers and 81 percent of nonsmokers classified smok- ing as a dirty habit in 1989 (Johnston, Bachman, O'Malley 1982,1984,1986,1991,1992; Bachman, Johnston, O'Malley 1984,1985, 1991; 1981-1989 MTFP, CDC, OSH, unpub- lished data). Between 1977 and 1981, the percentage of seniors who felt that their close friends would not, or did not, approve of their smoking increased substantially (Table 18). The percentages reported for 1981 and 1991, however, were essentially identical. The percentage of seniors who believed that adults should be prohibited by law from smoking in certain public places increased from 42 percent in 1977 to 45 percent in 1986 and remained about the same in 1991. TAPS data on 12- through 18-year-olds provide further information on beliefs about smoking. In 1989, smokers were from two to five times more likely than never smokers to report that they believed that cigarette smoking helps people relax, reduce stress, feel more comfortable in social situations, reduce boredom, and keep their weight down (Allen et a1.1993). Smokers may also deny the addictive properties of cigarettes (USDHHS 1988b). TAPS data indicated that 39 percent of smok- ers-but only 11 percent of never smokers-believed that they would be able to quit smoking anytime they wanted. Trends in Perceptions About Smokers The overwhelming majority of high school seniors surveyed by the MTFP did not believe that cigarette smoking makes smokers their age look mature, in con- trol, or independent (Table 18). About half believed that smoking makes smokers look insecure, and more than 60 percent perceived cigarette smoking as something smokers use to try to look mature. Between 1981 and 1991, smoking among seniors became less of the behav- ioral norm; fewer than 20 percent of seniors in 1991 reported feeling that smoking is an attempt to conform to such a norm. Responses to the MTFP indicate that the majority of high school seniors prefer to date nonsmokers and that this is becoming a trend. Since 1981, the propor- tion of respondents who prefer to date nonsmokers has increased by over 10 percent, to about 74 percent. The most substantial change occurred among black high school seniors (Figure 6). The percentage of-white seniors who preferred to date nonsmokers increased only slightly. Over 85 percent of nonsmokers and Figure 6. Trends in the percentage of high school seniors who prefer to date nonsmokers, by race, Monitoring the Future Project, United States,1981-1991 Sources: Bachman, Johnston, O'Malley (1981,1984,1985,1987,1991); Johnston, Bachman, O'Malley (1982,1984,1986,1991, 1992); Institute for Social Research, University of Michigan (unpublished data). Epidemiology 81 T11VIN 0138933

tittr~:GtIrt l;0l0,d '. KrE1( mf 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* NHSDAr MTFPI§ 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 Ma le 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 vears 9.6 6.5 15-16 years 20.8 15.0 17-18 vears 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?" 11991 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.) r1992 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. 'With the exception of data for 8th- and 10th-grade students, all other data points for the MTFP surveys reflect estimates for high school seniors. 'NA = Not available. 96 Epidemiology TIMN 0138948

5N1xoII L,oNt'!',7l'- Ri'po'" Table 31. Adjusted odds ratios* (and 95~'o 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 Have smoked Smoke regularly Self-reported occasionally, Smoked regularly at now, began daily Smoke regularly now, symptom/ but not one time, but not in smoking in began daily smoking indicator* regularly the past 30 days grades 10-12 by grade 9 Shortness of 1.38 (1.24, 1.52) 1.90 (1.56, 2.31) 2.32 (2.03, 2.64) 2.72 (2.40, 3.08) breath when not exercising Chest cold 1.34 (1.23,1.46) 1.34 (1.13,1.60) 1.53 (1.35,1.73) 1.72 (1.52,1.93) Sinus conges- 1.31 (1.20, 1.44) 0.99 (0.83, 1.19) 1.17 (1.02, 1.34) 1.19 (1.05, 1.35) tion, runny nose, sneezing Coughing spells 1.33 (1.24, 1.43) 1.28 (1.11, 1.48) 2.04 (1.83, 2.27) 2.20 ( 1.98, 2.45) Cough with phlegm or blood Wheezing or gasping Sore throat or hoarse voice Stayed home most or all of day because not feeling well= 1.42 (1.28, 1.56) 1.73 ( 1.44, 2.09) 2.31 (2.02, 2.63) 2.32 (2.04. 2.64) 1.41 (1.26, 1.48) 1.36 (1.26, 1.48) 1.43 (1.31, 1.55) 1.. 2.45 (1.99, 3.01) ' 2.36 (2.06, 2.70) 1.07 (0.92, 1.26) 1.34 ( 1.19, 1.52) 1.38 (1.17,1.62) 1.53 (1.35,1.73) 2.57 (2.25, 2.95) 1.17 (1.04,1.32) 1.56 (1.39,1.76) Overall physical 1.47 (1.32, 1.63) 2.39 (1.98, 2.90) 1.98 (1.72, 2.28) 2.08 (1.81, 2.38) healtht' Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data). *Adjusted for past-month marijuana use, lifetime cocaine use, parental education, and time. Odds ratios are relative to those for seniors who had either never smoked cigarettes or had smoked cigarettes once or twice only. 'Occurrence during the previous 30 days, with the exeption of overall physical health. =Also adjusted for past-month alcohol use. 'Odds ratios based on the percentage who reported that their health was poorer than average during the preceding year. 94 Epidenciotogy TIMN 0138946

PYtz't'NkU!\' Tobt7CiV Ust' ANIU71g ) tt!!Nti `~t'tt~t~<' Table 24. Percent distribution of high school seniors (N [weighted]= 19,831), by grade in which they first (if ever) used cigarettes and alcohol, Monitoring the Future Project, United States, 1986-1989 Grade when respondent first tried alcohol Grade when respondent first tried cigarettes _ 6 -8 9 0 1' 2 Never used Row total <_ 6 4.2 7.2 4.9 2.5 1.5 0.6 0.3 21.2 7-8 1.3 8.0 6.4 3.1 1-.3 0.5 0.2 20.8 9 0.4 2.0 4.9 2.4 1.0 0.4 0.1 11.1 10 0.3 1.1 1.9 2.8 1.0 0.3 * 7.-1 11 0.2 0.5 1.2 1.6 1.6 0.3 0.1 5.3 12 0.1 0.3 0.5 0.6 0.6 0.6 0.1 2.7 Never used 2.0 3.8 5.3 5.3 4.7 2.8 7.5 31.4 Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data). * < 0.05. Note: Totals may not equal the sum of individual percentages because of rounding. Table 25. Percent distribution of high school seniors (N [weighted] = 20,657), by grade in which they first (if ever) tried cigarettes and marijuana, Monitoring the Future Project, United States, 1986-1989 Grade when respondent first tried marijuana Grade when respondent first tried cigarettes _ 6 -8 9 0 1 2 Never used Row total <_ 6 2.0 4.5 3.3 2.2 1.4 0.8 6.2 20.3 7-8 0.3 4.1 4.4 2.9 1.5 0.8 5.8 19.8 9 0.1 0.5 2.5 2.3 1.2 0.6 3.5 10.7 10 0:2, = 0.2 0.5 1.7 1.4 0.5 . 2.6 6.9 11 * 0.1 0.3 0.4 1.3 0.6 2.5 5.2 12 * * 0.1, . 0.2 0.2 0.5 1.5 2.6 Never used 0.2 0.5 0.9 0.9 0.9 0.6 30.5 34.5 Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data). .~ 0.05. Note: Totals may not equal the sum of individual percentages because of rounding. EpidemiulogU 89 TIMN 0138941.

J'A•,•O rtitl~ 1-AWL iv LLL. .l,11rrr~: 1('COl)lL• . one-half pack-ur even as little as one to five cigarettes- per day in high school. Expectations were predictive only for those smokers who smoked less than one ciga- rette per day; 58 percent of those who thought they probably or definitely would be smoking in the future did, in fact, continue to smoke, whereas only 42 percent of those who did not expect to smoke in the future did smoke. Among seniors who had never smoked, less than 2 percent thought they would be smoking in five years (Table 19). This small group did, in fact, have a higher rate of subsequent smoking (45 percent) than never smokers who did not expect to be smoking in five years (15 percent) (Table 22). Thus, the expectation to avoid smoking seemed to make some difference among nonsmokers and very light smokers in high school, although very few seniors in these groups reported an expectation to smoke. On the other hand, among light, moderate, and heavy daily smokers, the expectation to abstain from smoking in the future seemed overwhelmed by the strong forces that tend to maintain or advance smoking behavior once it is established. One implication of these results is that young people should be made aware of the strongly addictive nature of nicotine and its ability to overwhelm future good expectations. Clearly, prevention is the major goal, but immediate cessation is of critical importance for adolescents, even for those who smoke very little in high school. Smoking and Other Drug Use In Chapter 2, tobacco use is d iscussed as a pussible predictor of other drug use (see "Smoking as a Ri~k Factor for Other Drug Use" and "Smokeless Tobacco Use as a Risk Factor for Other Drug Use"). The present chapter presents detailed information on high school seniors' usage patterns for cigarettes, alcohol, marijuana, cocaine, inhalants, and smokeless tobacco. Both preva- lence of past-month use and comparisons of the self- reported age at first use of each will be presented. Prevalence of Smoking and Other Drug Use Among high school seniors in the MTFP studies, the majority of alcohol users (60 percent) and smokeless tobacco users (57 percent) did not smoke (Table 23). The majority of marijuana (62 percent), cocaine (68 percent), and inhalant (56 percent) users smoked cigarettes. Ciga- rette smoking prevalence was from 1.9 to 3.9 times higher among users of these drugs than among nonusers. Although most drinkers (60 percent) did not smoke, almost all smokers (88 percent) were drink- ers. Almost one-half (45 percent) of cigarette smok- ers were also marijuana smokers, 11 percent were cocaine users, 5 percent used inhalants, anc:33 per- cent used smokeless tobacco (which will be discussed separately' later in-this chapter). The prevalence of Table 23. Prevalence (%) of cigarette smoking among users of other drugs and prevalence of other drug use among smokers,* high school seniors, Monitoring the Future Project, United States, 1985-1989 ther substances Prevalence of smoking among users of other drugs Prevalence of smoking among nonusers of other drugs Prevalence of drug use among smokers Prevalence of drug use among nonsmokers Alcohol 40.0 10.3 87.6 54.8 Marijuana 62.1 20.3 44.9 11.2 Cocainet 68.1 27.2 10.9 2.1 Inhalantsi 56.1 28.5 4.8 1.5 Smokeless tobacco' 43.0 22.4 32.5 15.6 Source: Centers for Disease Control and Prevention, Office on Smoking and Health (unpublished data). *Any use of cigarettes or other drugs during the. past month. 'Includes "coke," "crack," and "rock." tGlue, aerosols, laughing gas, etc. '.'vtales only, 1986-1989 senior classes only. Epidemioiogy 87 ' TTpdIN 0138939

Surgeon Gerteral's Report Table 11. Percentage of current smokers by the number of days smoked during the past month and the average number of cigarettes smoked daily, by gender, age, and race/Hispanic origin, Teenage Attitudes and Practices Survey, United States, 1989 Number of days Number of cigarettes smoked during past month* smoked daily* Category < 5 5-9 10-29 Every day < 5 5-9 10-19 ? 20 Overall 24.1 8.7 26.4 40.8 37.9 20.4 25.7 16.0 Gender Male 23.9 8.5 26.6 41.0 33.9 19.3 27.6 19.2 Female 24.3 8.9 26.2 40.6 42.7 21.6 23.5 12.1 Age (years) 12-13 51.9 8.3$ 23.3 16.5# 64.3 24.6t 11.0t 0.0 14-15 28.4 9.8 34.5 27.3 55.5 17.2 23.0 4.3# 16-18 20.0 8.4 24.1 47.5 31.6 21.1 27.2 20.1 Race White 23.4 8.4 26.2 42.0 36.6 20.1 26.5 16.8: Black 37.0 15.0* 26.5 21.6 60.3 20.5t 16.3x 2.9* Hispanic origin Hispanic 30.7 11.2t 31.9 26.3 59.2 22.5 11.6t 6.6t Non-Hispanic 23.5 8.5 26.0 42.0 36.3 20.2 26.9 16.7 Source: Moss et al. (1992). *Excludes unknown number of days smoked. 'Excludes unknown number of cigarettes smoked daily and none smoked during the past week. #Estimate does not meet standards of reliability or precision (< 30 percent relative standard error). were heavier smokers than Hispanics. Thus, not only were black and Hispanic adolescents less likely to smoke than whites, but those who did smoke, smoked fewer cigarettes each day than their white adolescent counter- parts. On average, persons 12 through 18 years old who smoked the week befor-~the survey (N = 1,099) smoked 9 cigarettes each day. Males smoked 10 cigarettes daily and females smoked 8. Whites averaged 9 cigarettes per day and blacks averaged 6(1989 TAPS, CDC, Office on Smoking and Health [OSHI, unpublished data). The overall average for adult smokers is 19 cigarettes a day (CDC 1992a). Initiation Continuum of Smoking The 1989 Surgeon General's report on smoking and health described the continuum of smoking be- havior as one that occurs in four stages: initiation, experimentation, regular smoking, and dependence or addiction (USDHHS 1989b). The report also ac- knowledged a preparatory stage that occurred before any initial smoking (Flay et a1.1983). These five stages are examined in detail in Chapter 4 (see "Develop- mental Stages of Smoking"). Data from the 1989 TAPS were used to create an initiation continuum similar to the smoking continuum for adults that was described in the 1989 Surgeon General's report (Pierceand Hatziandreu 1990; USDHHS 1989b). This initiation continuum incorporates mea- sures of smoking behavior and measures of the possibil- ity that a respondent will smoke in the future. In 1989, 54.5 percent of persons 12 through 18 years old reported that they had never smoked a cigarette, not even a few puffs (Table 12). Theserespondents were asked to report (1) whether they thought they would try a cigarettesoon ("yes," "no;" and "don't know"), (2) whether they would 68 Epidemiology TIMN 0138920

PYl i t'/dtfl(1' TllhdClO U?t' } 0ull'~ Pt'0Ej1t' Cigarette use is most likely to precede use of other sub- stances and to be prevalent among users of other drugs. Cigarette Smoking and Other Health-Related Behaviors Available data on the relationships between ciga- rette smoking and other health-related behaviors are derived from cross-sectional studies and thus suggest that other behaviors may covary with adolescent smok- ing. Even if the direction of influence is not established, information on the extent of these relationships is useful for intervention, since such data may suggest a syn- drome of health-compromising behaviors that need to be considered together. Data from the 1991 YRBS indicate that high school students who reported practicing other selected health- risk behaviors were more likely to be past-month or frequent smokers than were those who reported fewer selected health-risk behaviors. For example, students in the survey were more likely to be past-month or fre- quent smokers if they rarely or never wore seat belts, had participated in a physical fight six or more times during the preceding year, had carried weapons one or more days during the preceding month, or had made une or more suicide attempts during the preceding year (Table 27). Students were also more likely to be past-month or frequent smokers if they had ever had sexual intercourse, had had sexual intercourse with four or more partners during their lifetime, or had not used a condom during their most recent sexual intercourse (Table 28). These relationships for sexual risk behaviors held for males and females, regardless of age (CDC, OSH, unpublished data). Lastly, students were more likely to be past- month or frequent smokers if they had not participated on any sponsored sports teams during the preceding year or if they had used steroids without a doctor's prescription (Table 29). Cigarette Smoking and Health Status Pregnancy and Smoking Data on maternal smoking status during pregnancy are recorded on birth certificates in 43 states and the District of Columbia (NCHS 1992b). In these states, the overall maternal smoking prevalence was 20 percent in 1989. Maternal smoking among adolescent women Table 28. Percentage of high school students who used tobacco, by sexual risk behaviors, Youth Risk Behavior Survey, United States, 1991 Any cigarette Current cigarette Current frequent Current smokeless Risk behavior Number use* user cigarette use= tobacco use9 Sexual intercourse' No 5,011 55.1 13.8 3.1 12.9 Yes 6,508 82.6 38.8 20.7 23.9 Number of sexual partners' 1-3 4,048 81.0 33.8 15.4 23.2 >- 4 2,443 85.4 47.9 30.3 24.9 Condom use9 No 2,494 86.4 46.2 27.5 23.8 _ Yes 2,091 79.3 36.0 18.5 26.6 Sources: Centers for Disease Control and Prevention (CDC), Division of Adolescent.and School Health (unpublished data); CDC, Office on Smoking and Health (unpublished data). * During the respondent's lifetime. ' Cigarette use on _ 1 day during the 30 days,preceding the survey. t Cigarette use on _> 20 days during the 30 days preceding the survey. ° Any smokeless tobacco use, including chewing tobacco or snuff, during the 30 days preceding the survey; males only. ' During the respondent's lifetime. q During last sexual intercourse, among students who had sexual intercourse during the 3 months preceding the survey. Epide»tivlogy 91 4 TIMN 0138943

Surgeon General's Report CONNOLLY GN, WINN DM, HECHT SS, HENNINGFIELD JE, WALKER B JR, HOFFMANN D. The reemergence of smokeless tobacco. New England Journal of Medicine 1986;314(16):1020-7. FINKLEA JF, HASSELBLAD V, SANDIFER SH, HAMMER DI, LOWRIMORE GR. Cigarette smoking and acute non- influenzal respiratory disease in military cadets. American Journal of Epidemiology 1971;93(6):457-62. CRAIG WY, PALOMAKI GE, JOHNSON AM, HADDOW JE. Cigarette smoking-associated changes in blood lipid and lipo- protein levels in the 8- to 19-year-old age group: a meta- analysis. Pediatrics 1990;85(2):155-8. CREATH CJ, SHELTON WO, WRIGHT JT, BRADLEY DH, FEINSTEIN RA, WISNIEWSKI JF. The prevalence of smoke- less tobacco use among adolescent male athletes. Journal of the American Dental Association 1988;116(1):43-8. DIFRANZA JR, GUERRERA MP. Alcoholism and smoking. Journal of Studies on Alcohol 1990;51(2):130-5. DOLL R. The age distribution of cancer: implications for models of carcinogenesis. Journal of the Royal Statistical Society 1971;134(2):133-66. DOLL R, PETO R. Cigarette smoking and bronchial carci- noma: dose and time relationships among regular smokers and lifelong non-smokers. Journal of Epidemiology and Commu- nity Health 1978;32(4):303-13. DOMINO EF, VON BAUMGARTEN AM. Tobacco cigarette smoking and patellar reflex depression. Clinical Pharmacology and Therapeutics 1969;10(1):72-9. EAKIN E, SEVERSON H, GLASGOW RE. Development and evaluation of a smokeless tobacco cessation program: a pilot study. In: National Cancer Institute. Smokeless tobacco use in the United States. Monograph No. 8. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute. Bethesda (MD): NIH Publication No. 89-3055,1989, 95-100. EDWARDS SW, GLOVER ED, SCHROEDER KL. The effects of smokeless tobacco on heart rate and neuromuscular reactiv ity in athletes and nonathletes. The Physician and Sports Medi- cine 1987;15(7):141-7. ENOS W F, HOLMES RK, BEYER J. Coronary disease among United States soldiers kilkd in action in Korea. Journal of the American Medical Association 1986;256(20):2859-62. ESCOBEDO LG, MARCUS SE, HOLTZMAN D, GIOVINO GA. Sports participation, age at smoking initiation, and the risk of smoking among U.S. high school students. Journal of the American Medical Association 1993;269(11):1391-5. EVANS NJ, GILPIN E, PIERCE JP, BURNS DM, BORLAND R, JOHNSON M, ET AL. Occasional smoking among adults: evidence from the California Tobacco Survey. Tobacco Control 1992;1(3):169-75. 44 Health Consequences FISCHMAN MW, MELLO NK, editors. Testing forabuse liabil- ity of drugs in humans. Monograph No. 92. US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse. Bethesda (MD): DHHS Publication No. (ADM) 89-1613,1989. FLEMING BP, BARRON KW, HEESCH CM, DIANA JN. Re- sponse of the arteriolar network in rat cremaster muscle to intraarterial infusion of nicotine. International Journal o f Micro- circulation: Clinical and Experimental 1989;8(3):275-92. FREEDMAN DS, NEWMAN WP 111, TRACY RE, VOORS AW, SRINIVISAN SR, WEBBER LS, ET AL. Black-white differences in aortic fatty streaks in adolescence and early adulthood: the Bogalusa Heart Study. Circulation 1988; 77(4):856-64. GALLUP ORGANIZATION. Despite increasing hostility, one in four Americans still smokes. Gallup Mirror of America Poll. Princeton (NJ): Gallup Organization, December 1, 1991. GARDNER SE. National drug/alcohol collaborative project: issues in multiple substance abuse. US Department of Health, Educa- tion, and Welfare. DHEW Publication No. (ADM) 80-957,1980. GIDDING SS, XIE I, LIU K, MANOLIO T, FLACK J, PERKINS L, ET AL. Smoking has race/gender specific effects on resting cardiac function: theCARDIAstudy. Circulation 1992;85(2):877. GIOVINO GA. Public-health perspectives. In: Henningfield JE, Stitzer ML, editors. New developments in nicotine-delivery systems. Proceedings of a conference held at Johns Hopkins Univer- sity, Baltimore, Maryland. September 24, 1990. Johns Hopkins University. New York: Cortlandt Communications, 1991. GLANTZ SA, PARMLEY WW. Passive smoking and heart disease: epidemiology, physiology, and biochemistry. Circulation 1991;83(1):1-12. GLOVER ED, CHRISTEN AG, HENDERSON AH. Just a pinch between the cheek and gum. Journal of School Health 1981;51(6):415-8. GLOVER ED, SCHROEDER KL, HENNINGFIELD JE, SEVERSON HH, CHRISTEN AG. An interpretative review of smokeless tobacco research in the United States. Part I. Journal of Drug Education 1988;18(4):285-310. GLOVER ED, SCHROEDER KL, HENNINGFIELD JE, SEVERSON 1$i, CHRISTEN AG. An interpretative review of smokeless tobacco research in the United States. Part II. Jour- nal of Drug Education 1989;19(i):1-19. TIMN 0138897

E-IORGER BA, GILES MK, SCHENK S. Preexposure to am- phetamine and nicotine predisposes rats to self-administer a low dose of cocaine. Psychopharmacology 1992;107(2-3):271-6. HSU SC, POLLACK RL, HSU AF, GOING RE. Sugars present in tobacco extracts. Journal of the American Dental Association 1980;101(6):915-8. HUBA GJ, WINGARD JA, BENTLER PM. A comparison of two latent variable causal models for adolescent drug use. Jourrml of Personalit_yand Social Psychology 1981;40(1):180-93. HUGHES JR. Genetics of smoking: a brief review. Behavior Therapy 1986;17(4):335-45. HUGHES JR, HATSUKAMI D. Signs and symptoms of tobacco withdrawal. Archives of General Psychiatry 1986;43(3): 289-94. INTERNATIONAL AGENCY FOR RESEARCH ON CAN- CER.IARC monographs on the evaluation of the carcinogenic riskof chemicals to humans: tobacco smoking. Vol. 38. Switzerland: World Health Organization, 1985. JAAKKOLA MS, ERNST P, JAAKKOLA JJ, N'GAN' GA LW, BECKLAKE MR. Effect of cigarette smoking on evolution of ventilatory lung function in young adults: an eight year longitudinal study. Thorax 1991;46(12):907-13. JAFFE JH. Drug addiction and drug abuse. In: Gilman AG, Goodman LS, Rall TW, Murad F, editors. Goodman and Gilman's the pharmacological basis of therapeutics. 7th ed. New York: Macmillan Publishing Company, 1985. JANERICH DT, THOMPSON WD, VARELA LR, GREENWALD P, CHOROST S, TUCCI C, ET AL. Lung cancer and exposure to tobacco smoke in the household. New England Journal of Medicine 1990;323(10):632-6. KANDEL DB. Stages in adolescent involvement in drug use. Science 1975;190(4217):912-4. KANDEL DB, MARGUILIES RZ, DAVIES M. Analytical strat egies for studying transitions into developmental stages. Soci- ology of Education 197851(3):162-76. KANDEL D, YAMAGUCW R. From beer to crack: develop- mental patterns of drug involvement. American Journal of Public Health 1993;83(6):851 5. KARK JD, LEBIUSH M. Smoking and epidemic influenza-like illness in female military recruits: a brief survey. American Journal of Public Health 1981;71(5):530-2. KARK JD, LEBIUSH M, RANNON L. Cigarette smoking as a risk factor for epidemic A(H1N1) influenza in young men. Neto England Journal of Medicine 1982;307(17):1042-6. 46 Health Consequences Surgeon General's Report KEENAN RM. The association between chronic ethanol expo- suce arid cigarette smoking topography [dissertation]. Minne- apolis (MN): University of Minnesota, 1988. KELLAM SG, ENSMINGER ME, SIMON MB. Mental health in first grade and teenage drug, alcohol, and cigarette use. Drug and Alcohol Dependence 1980;5(4):273-304. KILLEN JD, FORTMANN SP, TELCH MJ, NEWMAN B. Are heavy smokers different from light smokers? A comparison after 48 hours without cigarettes. Journal of the American Medi- cal Association 1988;260(11):1581-5. KOTTKE TE, BREKKE ML, SOLBERG LI, HUGHES JR. A randomized trial to increase smoking intervention by physi- cians: doctors helping smokers. Round I. Journal o f the Ameri- can Medical Association 1989;261(14):2101-6. KOZLOWSKI LT. Tar and nicotine delivery of cigarettes: what a difference a puff makes. Journal of the American Medical Association 1981;245(2):158-9. KOZLOWSKI LT. Tar and nicotine ratings may be hazardous to your health. Toronto (Canada): Alcoholism and Drug Adaic tion Research Foundation, 1982. KOZLOWSKI LT. Rehabilitating a genetic perspective in the study of tobacco and alcohol use. British Journal of Addiction 1991;86(5):517-20. KOZLOWSKI LT, HENNINGFIELD JE, KEENAN RM, LEI H, LEIGH G, JELINEK LC, ET AL. Patterns of alcohol, ciga- rette, and caffeine and other drug use in two drug abusing populations. Journal of Substance •Abuse Treatment 1993; 10(2):171-9. KRAMER IR, LUCAS RB, PINDBORG JJ, SOBIN LH. Definition of leukoplakia and related lesions: an aid to studies on oral precancer. Oral Surgery Oral Medicine Oral Pathology 1978; 46(4):518-39. KSIR C, HAKAN RL, HALL DP JR, KELLAR KJ. Exposure to nicotine enhances the behavioral stimulant of nicotine and increases binding of (3H)acetylcholine to nicotine receptors. Neuropharnurcology 1985;24(6):527-31. KSIR C, HAKAN RL, KELLAR KJ. Chronic nicotine and locomotor activity: influence of exposure dose and test dose. Psychopharmacology 1987;92(1):25-9. - KUJALA P. Smoking, respiratory symptoms and ventilatory capacity in young men. European Journal of Respiratory Diseases 1981;62(114 Supp1):1 55. LANGLEY JN. On the reaction of cells and of nerve-endings to certain poisons, chiefly as regards the reaction of striated muscle to nicotine and to curari. Journal of Physiology (London) 1905 December.374-413. TIMN 0138899

Surgeon Gerteral's Report remained higher among white adolescent males than among black adolescent males. Smoking prevalence gradually increased among white males during the six decades covered by the data. Among black males, preva- lence declined between 1950 and 1980. Among female adolescents, the reconstructed prevalence of current smoking increased steadily from 1920 through 1980; in 1980, the prevalence among fe- males surpassed that among males for the first time during the six-decade study period. Prevalence among white females has been higher than among black females since 1950. The data indicate a sharp increase in female smoking prevalence between 1970 and 1980. Trends in current smoking prevalence over the past two decades indicate that for both males and females, past-month smoking declined sharply in the late 1970s or early 1980s (Table 15). Progress then slowed consider- ably, especially for males. In the MTFP surveys, the past- month smoking prevalence among males actually increased from 27 percent in 1981 to 29 percent in 1992; in the NHSDA and the NHLS, male smoking prevalence was about the same in 1985 and in 1991. The prevalence among adolescent females in the MTFP and NHIS surveys was only slightly lower in 1991 and 1992 than in 1985; in the 1991 NHSDA, female smoking prevalence was about the same as in 1985. By the early 1980s, smoking was gener- ally more common among females than among males. By 1991, however, adolescent females and males had almost equivalent smoking prevalence. In all three surveys with information on race, the prevalence of current smoking declined during the late 1970s or early 1980s for both black and white older adolescents (Table 16). In the middle 1970s, current smoking was almost equally common among blacks and whites. At the end of that decade, black adolescents were less likely to be current smokers than white adoles- cents; this trend continued during the 1980s. Among white high school seniors in the MTFP, current smoking was more prevalent in 1992 (32 percent) than in 1981 (30 percent). In all three surveys, prevalence among older white adolescents was slightly higher in 1991 and 1992 than it was in 1985. Wallace and Bachman (1991) reported that white high school seniors were more than twice as likely as black high school seniors to report smoking in the past month, even after statistical control was made for factors such as parental education, number of parents living at home, urban or rural location, educational plans, academic per- formance, and religious attitudes and practices. MTFP trend data are available for daily smoking among racial ar4d ethnic subgroups (Bachman eta1.1991). In general, for Asian, black, white, Hispanic, and Ameri- can Indian male and female high school seniors, the preva lence of daily smoking declined from 1976-1984. The decline continued at a reduced rate during the late 1980s for most groups and ceased altogether among white males. Overall, the prevalence of daily smoking among high school seniors was 29 percent in 1976,21 percent in 1980, and 17 percent in 1992. Among males, the preva- lence was 28 percent in 1976,19 percent in 1980, and 17 percent in 1992; among females, 29 percent smoked daily in 1976, 24 percent in 1980, and 17 percent in 1992. Among whites, the prevalence of daily smoking de- clined from 29 percent in 1976 to 22 percent in 1980; the prevalence was 20 percent in 1992. Among blacks, the- prevalence of daily smoking declined from 27 percent in 1976 to 16 percent in 1980 and continued to decline to 4 percent in 1992 (Bachman, Johnston, O'Malley 1980a, 1981; ISR, University of Michigan, unpublished data). Data on smoking among the nation's high school seniors have also been reported as a function of parental education (NCHS 1993). Interestingly, the prevalence of past-month smoking decreased slightly from 1980 through 1991 among those seniors whose parents had completed fewer years of formal education and increased slightly during that period among those seniors whose parents had relatively more years of formal education. For example, among those seniors whose parents, on average, did not graduate from high school, the preva- lence of past-month smoking decreased from 33 percent in 1980 to 31 percent in 1991; among seniors whose parents graduated from high school, prevalence of smok- ing was 34 percent in •1980 and 29 percent in 1991. Among seniors• whose parents had some postgraduate educa- tion, the prevalence of smoking was 24 percent in 1980 and 27 percent in 1991. Age or Grade When Smoking Begins The age at which people become regular cigarette smokers has been measured in national surveys con- ducted in 1955, 1966, 1970, 1978, 1979, 1980, 1987, and 1988 (Haenszel, Shimkin, Miller 1955; NCHS 1970; USDHHS 1980, 1989b, 1991b; CDC 1991b). Data from the 1955 Current Population Survey (Haenszel, Shimkin, Miller 1955) suggest that during the first half of the century, people became regular smokers at progressively younger ages. The data for males are limited, however, because before 1974 many of the reports for men were provided by proxy respondents. To reduce proxy responses, Ahmed and Gleeson (NCHS 1970) limited their analysis of data from the 1966 Current Population Survey to females. These investiga- tors concluded that between 1955 and 1966, U. S. women began smoking at an earlier age. For the• present report, the likelihood of having become a regular cigarette smoker by age 18 was deter- mined for females surveyed in the 1970,1978-1980, and 74 Epidemiology ~~~~ 01389Z6

Surgeon Getreral': Report 1984,1986,1991,1992; Bachman, Johnston, O'Malley 1984, 1985, 1991; ISR, University of Michigan, unpublished data). The percentage of female seniors who did not mind being around smokers changed little over time. From 1981 through 1991, the proportion of high school seniors who did not mind being around people who were smoking decreased by about 50 percent among blacks and by only 5 percent among whites (Figure 7). Smokers' acceptance of being around other smokers re- mained constant, at approximately 70 percent, from 1981 through 1989, whereas the percentage of nonsmokers who did not mind being around smokers decreased from 25 to 21 percent (1981-1989 MTFP surveys, CDC, OSH, unpublished data). Adult Implications of Adolescent Smoking Some notable findings regarding young people's expectations to smoke, or to abstain from smoking, have emerged from the MTFP (see Johnston, O'Malley, Bachman 1992b). In their senior year, respondents who answered one of five questionnaire forms were asked, "Do you think you will be smoking cigarettes five years from now?" Overall, about 1 percent said they "definitely" would be smoking in five years, 14 percent said they "prob- ably" would, 27 percent said they probably would not, and 58 percent said they definitely would not (Table 19). About 55 percent of past-month smokers and about 45 percent of daily smokers stated that they probably would not or defi- nitely would not be smoking in five years. Of the seniors in the full panel, 68 percent indicated that they had not smoked in the 30 days preceding the senior-year survey; 9 percent had smoked less than one cigarette per day; 8 percent had smoked one to five ciga- rettes per day; 7 percent had smoked about one-half pack per day; and 8 percent had smoked a pack or more per day (Table 20). Five years after graduation, the same total proportion (32 percent) were past-month smokers. Some- what more (26 vs. 23 percent), however, were daily smokers. Further, for each smoking group defined by senior-year smoking level, those who continued to smoke increased their frequency of smoking (Tables 20-21). Of the respondents who were nonsmokers at the end of their senior year, 86 percent remained nonsmok- ers five to six years later, whereas only 13 percent of those who smoked one pack each day in their senior year became nonsmokers (Table 20). Those students who smoked one-half pack per day in their senior year were nearly as likely to continue use as were those students who smoked one pack daily; 81 percent of half- pack-a-day smokers still smoked, and the majority of them increased their rate of smoking (Table 21). Seventy percent of respondents who in their senior year smoked one to five cigarettes per day continued to smoke five years later; most of these continuing smokers increased their rate of use. Even among the seniors who smoked the least * (less than one cigarette per day), 42 percent continued to smoke five to six years later, and two-thirds of these had increased their rate of smoking. When earlier smoking behavior is controlled, se- niors' expectations to smoke had very limited power to predict subsequent smoking behavior (Table 22). Many seniors.who smoked one pack per day had expectations of discontinuing use. These expectations showed no relationship to the actual rate of smoking five to six years later. The same is true for those seniors who smoked Table 19. High school seniors predicting whether they will be smoking in five years, by smoking status in senior year, Monitoring the Future Project, United States,1976-1986 senior classes Predicted likelihood of smoking in five years (%)* Senior year smoking status (use in past 30 days) Definitely will Probably will Probably will not Definitely Number will not (weighted) None 0.4 1.3 21.0 77.3 1,926 < 1 cigarette/day 0.5 14.7 56.5 28.3 248 1-5 cigarettes/day 1.8 37.6 44.1 16.5 211 About %z pack/day 0.6 57.7 30.3 11.3 197 > I pack/day 5.1 62.9 26.7 5.2 228 Total ' 0.9 14.2 27.0 58.0 2,810 Source: Institute for Social Research, University of Michigan (unpublished data). *Entries are row percentages. 84 Epidemiology TIIVIN 0138936

Preventing Tobacco Use Among Young People SCHOENDORF KC, KIELY JL. Relationship of Sudden Infant Death Syndrome to maternal smoking during and after preg- nancy. Pediatrics 1992;90(6):905-8. SCHROEDER KL, CHEN MS JR. Smokeless tobacco and blood pressure. New Eneland Journal of Medicine 1985; 312(14):919. SCHROEDER KL, SOLLER HA, CHEN MS, NEAL CJ, GLOVER ED. Screening for smokeless tobacco lesions: recom- mendations for the dental practitioner. Journal of the American Dental Association 1988;116(1):37-42. SCHWARTZ RD, KELLAR KJ. In vivo regulation of ('H)acetylcholine recognition sites in brain by nicotinic cholin- ergie drugs. Journal of Neurochemistry 1985;45(2):427-33. SCHWARTZ J, ZEGER S. Passive smoking, air pollution, and acute respiratory symptoms in a diary study of student nurses. American Review of Respiratory Disease 1990;141(1):62-7. SEELY JE, ZUSKIN E, BOUHUYS A. Cigarette smoking: objective evidence for lung damage in teenagers. Science 1971;172(3984):741-3. SHAPIRO L. Warning: chewing tobacco and snuff may be dangerous to your health. Coal Age 1981;86(12):74-9. SHERRILL DL, MARTINEZ FD, LEBOWITZ MD, HOLDAWAY MD, FLANNERY EM, HERBISON GP, ET AL. Longitudinal effect of passive smoking on pulmonary func- tion in New Zealand children. American Review of Respiratory Disease 1992;145(5):1136-41. SHIFFMAN S. 'Tobacco chippers': individual differences in tobacco dependence. Psychopharmacology 1989;97(4):539-47. SHIFFMAN S. Refining models of dependence: variations across persons and situations. British Journal of Addiction 1991;86(5):611-15. SHIFFMAN S, FISCHER LB, ZETTLER-SEGAL M, BENOWf IZ NL. Nicotine exposure among nondependent- smokers. Archives of General Psychiatry 1990;47(4):333-6: SIDNEY S, STERN _ L7 B, GIDDING SS,. JACOBS DR JR, BILD DE, OBE T Ar. ET AL. Cigarette smoking and submaximal exe ' + duration in a biracial population of young adults: the- IA study. Medicine and Science in Sports and Exercise 1993;25(8):911 916. _ SIGNS SA, SCHECHTER MD. Nicotine-induced potentiation of ethanol discrimination. Pharmacology, Biochemistry and Behavior 1986;24(3):769-71. SLADE J. Adolescent nicotine use and dependence. Adoles- cent Medicine: state of the art reviews 1993;4(2):305-320.: SLOTKIN TA, LAPP[ SE, TAYYEB MI, SEIDLER FJ. Chronic prenatal nicotine exposure sensitizes rat brain to acute post- natal nicotine challenge as assessed with ornithine decarboxy- lase. Li fe Sciences 1991;49(9):655-70. SLOTKIN TA, ORBAND-MILLER L, QUEEN KL. Develop- ment of ('H)nicotine binding sites in brain regions of rats exposed to nicotine prenatally via maternal injections or infu- sions. Journal of Pharmacology and Experimental Therapeutics 1987;242(1):232-7. SMITH WT IV, SEIDLER FJ, SLOTKIN TA. Acute stimulation of ornithine decarboxylase in neonatal rat brain regions by nicotine: a central receptor-mediated process? Developmental Brain Research 1991;63(1-2):85-93. SPINACI S, AROSSA W, BUGIANI M, NATALE P, BUCCA C, DE CANDUSSIO G. The effects of air pollution on the respiratory health of children: a cross-sectional study. Pediat- ric Pulmonology 1985;1(5):262-6. STANHOPE JM, PRIOR LAM. Smoking behaviour and respi- ratory health in a teenage sample: the Rotura Lakes Study, 1. New Zealand Medical Journal 1975;82(545):71-6. STEVENS VJ, SEVERSON HH, LICHTENSTEIN E, - 1TTLE SJ, LEBEN J. Making the most of a teachable momenr: smoke- less tobacco intervention in the dental office setting. American Journal of Public Health. In press. STRONG JP. Coronary atherosclerosis in soldiers. A clue to the natural history of atherosclerosis in the young. Journal of the American Medical Association 1986;256(20):2863-6: STRONG JP, RICHARDS ML. Cigarette smoking and athero- sclerosis in autopsied men. Atherosclerosis 1976;23(3):451-76. SWEDBERG MDB, HENNINGFIELD JE, GOLDBERG SR. Nicotine dependency: animal studies. In: Wonnacott S, Russell MAH, Stolerman IP; editors. Nicotine psychopharmacology: molecular, cellular, and behavioural aspects. Oxford (England): Oxford University Press, 1990. TAGER IB, MUIVOZ A, ROSNER B, WEISS ST, CAREY V, SPEIZER FE. Effect of cigarette smoking on the pulmonary function of children and adolescents. American Review of Respi- ratory Disease 1985;131(5):752-9. TAGER IB, SEGAL MR, MUhIOZ A, WEISS ST, SPEIZER FE. The effect of maternal cigarette smoking on the pulmonary function of children and adolescents. Analyses of data from two populations. American Review of Respiratory Disease 1987;136(6):1366-70. TAGER IB, SEGAL MR, SPEIZER FE, WEISS ST. The natural history of frorced expiratory volumes. Effect of cigarette smok- ing and respiratory symptoms. American Revieu+of Respiratory Disease 1988;138(4):837-49. Health Consequences 49 TIMN 0138902

;I SurXrcui Goncn:l's RrlnOrr Conclusions 1. Tobacco use primarily begins in early adolescence, typically by age 16; almost all first use occurs before the time of high school graduation. 2. Smoking prevalence among adolescents declined sharply in the 1970s, but the decline slowed signifi- cantlv in the 1980s. At least 3.1 million adolescents and 25 percent of 17- and 18-year-olds are current smokers. 3. 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, 104 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. 4. Many adolescent smokers are addicted to cigarettes; these young smokers report withdrawal symptoms similar to those reported by adults. 5. 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. T.Il.VdN 01389561

tilt!'til'trH Gc'IR'P,fl" kqrrrrr 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 26 24 22 20 ' - 1986 1987 Ever use 11 ..... Great risk 1988 1989 Year 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 1.5 to 3.9 times higher among users of thesedrugs than among nonusers. Most notably, 90 percentof 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 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) 102 Epidemiology TIMN 0138954,

Initiation of Smokeless Tobacco Use 140 p,a Sociodemographic Factors in the Initiation of Smokeless Tobacco Use 140 Environmental Factors in the Initiation of Smokeless Tobacco Use 1-II Factors That Influence Acceptability and Availability 141 Interpersonal Factors 141 Parental Use 141 Sibling Use 1•11 Peer Use 141 Perceived Environmental Factors 141 Norms 141 Social Support 142 Parental Reaction to Smokeless Tobacco Use 1-12 Behavioral Factors in the Initiation of Smokeless Tobacco Use 142 Academic Achievement 142 Smoking as a Risk Factor for Smokeless Tobacco 143 Other Adolescent Behaviors 143 Smokeless Tobacco Use as a Risk Factor for Smoking, Alcohol, and Other Drug Use 1 44 Risk Taking and Rebelliousness 144 Participation in Athletics 144 Personal Factors in the Initiation of Smokeless Tobacco Use 145 Knowledge of Long-Term Health Consequences 145 Functional Meanings 145 Social Image 145 Personality Traits 146 Smokeless Tobacco Use as a Risk Factor for Continued Use 146 Intentions to Use Smokeless Tobacco 146 Current Use of Smokeless Tobacco 1-16 Summary of Psychosocial Risk Factors for Smokeless Tobacco Use 147 Implications of Research for Preventing Tobacco Use: Modifying Psychosocial Risk 147 Conclusions 148 References 149 TIMN 0138974

P1't i t7IfUI1' ToluccJ Llst' AINWIg ~ UIUIg PCople Table 40. Smokeless tobacco use among young people in the United States - sources of national data, definitions of use, and measures of use, 1989-1991 Age/grade when respon- Ever use of dent first Current Former use Steps to smokeless used smoke- smokeless of smoke- improve data Source tobacco less tobacco tobacco use less tobacco validity 1989 Teenage Ever used Age when first Attitudes and chewing started using Practices tobacco or Surveys snuff (TAPS) National Ever used Household chewing Survevs on tobacco or Drug Abuse snuff or (NHSDA) other smoke- less tobacco * Ever regu- larly used chewing tobacco or snuff, but not now Assured confidentiality * Any use of * Assured chewing confidentiality tobacco or snuff or other smokeless tobacco during the past 30 days Monitoring Taken or Grade when the Future used smoke- first tried Project less tobacco smokeless (MTFP) (snuff, plug, tobacco (snuff, dipping plug, or tobacco, chewing chewing tobacco) tobacco ) at least once or twice Any use of No smoke- Assured smokeless less tobacco confidentiality tobacco use during during the ' -the past 30 past 30 days days among people who have ever used smoke- less tobacco regularly Youth Risk * * Use of chew- Behavior ing tobacco, Survev snuff, or both (YRBS) during the past 30 days * Assured anonymity Sources: TAPS: Allen et al. (1991, 1993); Moss et al. (1992); NHSDAc Abelson and Atkinson (1975); Abelson and Fishburne (1976); Fishburne, Abelson, Cisin (1980); Miller et al. (1983); U.S. Department of Health and Human Services ' (1988a, 1990a, 1991a,'1992a,1993);1991 NHSDA: Centers for Disease Control and Prevention (CDC), Office on Smoking and Health (unpublished data); MTFP: Bachman, Johnston, O'Malley (1987,1991); Johnston, Bachman, O'Malley (1991, 1992); Johnston, O'Malley, Bachman (in press); YRBS: Kolbe (1990), CDC (1992c, d). * Not all potential sources of data on youth smokeless tobacco use are used in this report. Epiderniology 113 . TIMN 0138965

Grade When Smokeless Tobacco Use Begins The MTFP asks high school seniors to report the school grade, if any, in which they first tried smokeless tobacco, including snuff, plug, or chewing tobacco. Attempts to Quit Using Smokeless Tobacco In the MTFP, former smokeless tobacco users are defined as respondents who ever used smokeless to- bacco regularly but who have not used smokeless to- bacco in the past 30 days. TAPS provides information on the number of times current and former smokeless tobacco users have tried to quit. Validity of Measures of Smokeless Tobacco Use Literature is sparse on the use of biochemical mark- ers to assess the validity of self-reported use of smokeless tobacco, and the few studies available are inconsistent. Cohen et al. (1988) reported that the use of a bogus pipeline before collecting self-reported data on smoke- less tobacco use among a sample of 282 male seventh- and eighth-grade students resulted in self-reports hav- ing 86 percent agreement with cotinine measurements (excluding smokers). These authors found that without the bogus pipeline, smokeless tobacco use was overreported. Bauman et al. (1989) studied 12- through 14-year-old adolescents in the southeastern United States. These investigators measured cotinine levels to indicate the use of some form of tobacco and distin- guished cigarette smokers from smokeless tobacco us- ers by values of thiocyanate and carbon monoxide. The authors found that fewer than half of the adolescents identified through chemical tests as smokeless tobacco users had reported such use in the past three days on a self-administered questionnaire in the home. Discrimi- nation between smokers and smokeless tobacco users was also obtained by lVoland et al. (1988) through mea- sures of saliva cotinine and thiocyanate. As was noted in this report's discussion of the validity of smoking measures (see Appendix 2), the home setting may be conducive to underreporting. Ernster et al. (1990) studied a sample of 1,109 major and minor league baseball players and found that serum cotinine (< 12 ng/mL) and serum thiocyanate (< 85 mmol/L) cor- rectly classified 95 percent of nonusers of smokeless tobacco and cigarettes. Other methods for validating smokeless tobacco use are being investigated, includ- ing the use of strontium in the buccal epithelium of smokeless tobacco users (Roberston and Bray 1988). 114 Epraemtolog,, ; TIMN 0138966

~ 4 il'~' . }tcr~e'cut Gc'itc'ntl'. l:~r c ,t 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' YRBSt Overall 15.1 33.2 31.8 Gender Male 17.1 38.8 35.8 Female 13.0 27.3 27.6 Race/Hispanic origing 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 NA" 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 vears ' 28.5 8th grade 20.5 9th grade 26.7 10th grade 27.6 29.6 11 th 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?" t1991 YRBS, grades 9-12. Based on responses to the questions, "During the past 30 days, on how many days did you smoke cigarettes?" and "During the past 30 days, did you use chewing tobacco, such as Redman, Levi Garrett, or Beechnut, or snuff, such as Skoal, Skoal Bandits, or Copenhagen?" NA = Not available. 100 Epidemiology TIMN 0138952

Chapter 4 Psychosocial Risk Factors for Initiating Tobacco 'Use Introduction 123 Initiation of Cigarette Smoking 124 Introduction 12•1 Developmental Stages of Smoking 124 Sociodemographic Factors in the Initiation of Smoking 125 Socioeconomic Status 127 Parental Education 127 Number of Parents Living in the Home 127 Developmental Challenges of Adolescence 127 Gender 128 Ethnicitv 128 Environmental Factors in the Initiation of Smoking 128 Factors That Influence Tobacco Acceptability and Availability 129 Interpersonal Factors 129 Parental Smoking 129 Sibling Smoking 130 Peer Smoking and Peer Behaviors 131 Social Bonding 131 Perceived Environmental Factors 131 Norms 732 Social Support for Smoking 132 Parental Reaction to Smoking 132 Adult Discrepancy 133 Behavioral Factors in the Initiation of Smoking 133 Academic Achievement 133 Other Adolescent Behaviors 133 Risk Taking, Rebelliousness, and Deviant Behaviors 134 Peer Groups 134 Participation in Athletics and Other Health-Enhancing Behaviors 134 Behavioral Skills 135 Personal Factors in the Initiation of Smoking 135 Knowledge of Long-Term Health Consequences 135 Functiorial Meanings of Adolescent Smoking 136 Subjective Expected Utility 136 Self-Esteem 136 Self-Image 136 Self-Efficacy 137 Personality Factors 137 Psychological Well-Being 137 Adolescent Smoking Behavior as a Risk Factor for Subsequent Smoking 138 Intentions to Smoke 138 Present Smoking Status 138 Summary of Psychosocial Risk Factors for Cigarette Smoking 138 TIMN 0138973,

Preiienting Tobacco Use Among Young People Human research is more limited than animal re- search in this area, but there is evidence that cigarette smoking is associated with up-regulation of nicotine receptors in the human brain. Balfour (1989, 1991a) has conducted a series of studies that included the examination of postmortem brain tissue from smokers and nonsmokers. He and others found evidence of signifi- cantly elevated concentrations of nicotine binding sites as well as smoking-related changes in other binding sites (such as 5-hydroxytryptamine) (Benwell, Balfour, Ander- son 1988; Balfour 1989, 1991a; Grant, McMurdo, Balfour 1989; Bock and Marsh 1990). Morphologic changes in the nervous system are presumed to reflect part of the body's adaptation (resulting in tolerance and physical depen- dence) to a prolonged exposure to nicotine (Marks and Collins 1982; Marks, Burch, Collins 1983; Marks et aL 1985, 1986; Marks, Stitzel, Collins 1985,1986,1987; USDHHS 1988). Physical Dependence Nicotine administered to animals and humans pro- duces altered spontaneous electroencephalograph (EEG) and evoked electrical potentials of the brain, altered local cerebral glucose metabolism, modulation of hormonal output by the adrenal glands, increased heart rate, and changes in skeletal muscle tension (USDHHS 1988). Most, if not all, of these effects are related to the dose of nicotine given, and tolerance develops to differing degrees across these effects. After a period of nicotine exposure that is assumed to be at least several weeks (APA 1987), physi- cal dependence on nicotine develops. The dependent person then appears to be functioning normally when under the influence of nicotine; conversely, the person may report feeling "abnormal" or "not right" when de- prived for more than a few hours (Casey 1987). Although basic pharmacologic research on nico- tine has been conducted primarily with adults, most people begin to smoke in adolescence and develop char- acteristic patterns of nicotine dependence before adult- hood (USDHHS 1988,1991a). That adolescents develop physical dependence, as evidenced by their experience of withdrawal symptoms, has been well documented by the NHSDA (USDHHS 1991c). Moreover, quantitative characteristics of tlie withdrawal syndrome appear to be the same in adolescents and adults (McNeill et a1.1986; McNeill, Jarvis, West 1987). The magnitude of the withdrawal syndrome is related to the previous level of nicotine intake, although differences in just a few cigarettes a day may not be correlated with the severity of the syndrome (Killen et al. 1988; USDHHS 1988). Environmental context is also a factor; in a novel environment (e.g., a hospital setting), the symptoms of nicotine withdrawal may be less than in the smoker's usual environment, with its various psychological cues for smoking (Hatsukami, Hughes, Pickens 1985). The time course of withdrawal symptoms varies among individuals and for different responses. Most withdrawal symptoms peak within the first few days of nicotine abstinence and then begin to recover along a variable course; the most severe total withdrawal syndrome usually lasts about three to four weeks (USDHHS 1988; Gross and Stitzer 1989). For example, certain measures of brain function (such as P300-evoked electrical potential) recover within a few days, but others may take weeks or more (such as N100-evoked potential, hunger, and craving). Powerful urges to smoke may recur for many years (Hughes and Hatsukami 1986; USDHHS 1988). Although questions remain, the pathophysiology of nicotine dependence clearly involves the brain, the endocrine system, and behavior, and the process begins when cigarette smoking is initiated. Moreover, although the effects of nicotine administration and deprivation are complex, they are orderly and are related to factors such as the amount of nicotine administered and the time since the last dose. The Clinical Course of Nicotine Dependence Like other drug addictions, nicotine dependence is a progressive, chronic, relapsing disorder. The level of dependence on nicotine in adults has been found to be inversely related to the age at initiation of smoking when measured by diagnostic criteria (APA 1987) of the APA (Breslau, Fenn, Peterson 1993) and by the Fagerstrom Tolerance Questionnaire Score (Henningfield et a1.1987). As is true for most drug addictions, tobacco use is not always constant from initiation on; the process of graduation from first use to addiction can take months or even years (USDHHS 1988). In fact, initial experiences with tobacco, as with other addictive substances, are sometimes negative and require social pressures and other factors to maintain exposure until the addiction develops (Haertzen, Kocher, Miyasato 1983). The per- centage of people who progress from smoking a few cigarettes to smoking at a regular, addictive level has been estimated to range from 33 to 94 percent. For example, Russell (1990) has reported that a survey of adults in Great Britain in the mid-1960s indicated that 94 percent of those who smoked more than three cigarettes became'long-term regular smokers." These data, which precede widespread public awareness of the hazards of smoking, may have a limited applicability to current smoking behavior. Recently collected data in the United States and Great Britain suggest that between 33 and 50 percent of people who try smoking cigarettes escalate to regular patterns of use (Hirschman, Leventhal, Glynn 1984; McNeill 1991; Henningfield, Cohen, Slade 1991). Health Consequences 33 TIMN 0138886

Prc^,vritur,~ T0haCiO ll;C.-l~rtL)iIg 1'riuig ('roE4c• Number of cigarettes smoked each day Lifetime smoking Average number of cigarettes 11-item scale smoked, per day during the (TAPS) past 7 days (TAPS) Average number of cigarettes smoked per day during the past 30 days * Average number of cigarettes 5-item scale smoked per day during the 6-item scale past 30 days Average number of cigarettes smoked on the days smoked during the past 30 days * . . Frequent and Heavy Smoking . Measures of more frequent or heavy use are avail- able from four of the surveys. In TAPS and the YRBS, the reported number of days smoked in the previous 30 days is used to describe the frequency of use. For this report, frequent smoking is defined as smoking on 20 of the 30 days preceding the survey. The MTFP asks re- spondents how frequently they have smoked during the previous 30 days. Possible responses are "not at all," Former smoking Steps to improve data validity No smoking during the past Assured 30 days among respondents confidentiality who have smoked at least 100 cigarettes (TAPS); quit attempts during the previous 6 months (TAPS) Assured confidentiality No smoking during the Assured past 30 days among people confidentiality' who have ever smoked regularly; interest in quitting; difficulty quitting * Assured anonymity Does not smoke cigarettes Assured now; length of time confidentiality since last smoked cigarettes regularly "less than one cigarette per day; '• "one to five cigarettes per day," "about one-half pack per day,." "about one pack per day," "about one and one-half packs per day;' and "two packs or more per day,." The NHSDA uses a similar question with similar response categories to clas- sify usewithin the previous 30 days. For this report, heavy smoking is defined as smoking at least one-half pack of cigarettes per day. MTFP participants who re- sponded that they smoked at least one to five cigarettes Epidemiology . 109 TIMN 0138961

51/YNe'UII Ge'7le'Yril '; Re'pVYi Figure 10. Self-reported prevalence of smoking one or more cigarettes per day during the past month and reported prevalence of smoking among friends, high school seniors, Monitoring the Future Project, United States, 1976-1991 ....... Most or all of friends smoke ~- 1+ cigarettes per day 10 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 Year Sources: Bachman, Johnston, O'Malley (1980a,1981,1984,1985,1987,1991); Johnston, Bachman, O'Malley (1980a, b, 1982, 1984, 1986, 1991, 1992); Institute for Social Research, University of Michigan (unpublished data). Appendix 3. Measures of Smokeless Tobacco Use Although little research has focused on how smoke- less tobacco use develops from trial use to current use, it is probable that, like smoking, smokeless tobacco use occurs over time and in multiple stages. Several mea- sures can be derived from the national surveys to de- scribe this process (see Table 40). Ever Use of Smokeless Tobacco TAPS, the NHSDA, and the MTFP include ques- tions on initial (and thus "ever") use of smokeless tobacco. TAPS asks respondents whether they have ever tried using chewing tobacco or snuff. The NHSDA asks how recently respondents have used chewing tobacco or snuff or other smokeless tobacco; "never used smokeless to- bacco in lifetime" is a precoded response category. In the 112 Epidemiology MTFP, respondents are asked, "Have you ever taken or used smokeless tobacco (snuff, plug, dipping tobacco, chewing tobacco)?" Respondents who report that they have taken or used smokeless tobacco at least "once or twice" are classified as ever users. Current Use of Smokeless Tobacco Current use of smokeless tobacco is assessed in the MTFT', the NHSDA, and the YRBS. Any reported use of smokeless tobacco in the 30 days preceding the survey has been classified in this report as "current use." Because TAPS creates a subcategory of current regular use from the category of respondents who have ever used smoke- less tobacco regularly, this report does not use TAPS data to assess the current use of smokeless tobacco. TIMN 0138964

SurYeori Gtnrrii!'s Report infer that the risk of smoking-related cancer for sites other than the lungs would increase, at a given adult age, in inverse proportion to the age an adolescent begins smoking. Recent studies indicate that earlier onset of cigarette smoking is also associated with heavier smok- ing (Taioli and Wynder 1991; Escobedo et al. 1993). Nicotine Addiction in Adolescence Heavier smokers are not only more likely to experience tobacco-related health problems, they are the least likely to quit smoking (Hall and Terezhalmy 1984; USDHHS 1989). Early use of cigarettes thus appears to influence intensity as well as duration of use and increases the potential for long-term health consequences. Introduction Nicotine dependency through cigarette smoking is not only the most common form of drug addiction but the one that causes more death and disease than all other addictions combined (USDHHS 1988). Most human research on nicotine addiction has been conducted with adult subjects, but the basic biologic processes that underlie this dependency appear to be similar in ad- olescents and adults. The research literature on nicotine addiction examines its chemistry and addiction poten- tial, its severity, and its pathophysiology and clinical course. Background and Nomendature Drug addiction is the term most widely used to label vario,us medical and social disorders related to the compulsive ingestion of psychoactive chemicals. The primary criteria for drug dependence are that the behav- ior is highly controlled or compulsive, the chemical is one whose mood-altering or psychoactive effects are central elements of the drug's activity, and the drug itself has the demonstrated capability of reinforcing behavior (Table 4). The American Psychiatric Association (APA) has identified two medical disorders that pertain to nico- tine addiction: nicotine dependence and nicotine withdrawal (APA 1987). Nicotine dependenceisclassified asa psychoactive substance-use disordeF characterized by "a cluster of ~~,,d cognitive, behavioral,-and physiologic symptoms that indicate that the person has impaired control of psychoactive substance use and continues use of the substance despite adverse consequences" (APA 1987, p. 166). In the case of nicotine, the most common form of use is cigarette smoking, in part because the rapid ab- sorption of nicotine through the processes of smoking "leads to a more intensive habit pattern that is more difficult to give up" than other forms of use (APA 1987, p. 181). Nicotine dependence also occurs through other routes of delivery, including smokeless tobacco and nicotine gum. 30 Health Consequences Nicotine withdrawal, an organic mental disorder induced by the removal of psychoactive substance, is described as "a characteristic withdrawal syndrome due to the abrupt cessation of or reduction in the use of nicotine-containingsubstances (e.g., cigarettes, cigars and pipes, chewing tobacco, or nicotine gum) that has been at least moderate in duration and amount. The s-yndrome includes craving for nicotine; irritability, frustration, or anger; anxiety; difficulty concentrating; restlessness; de- creased heart rate; and increased appetite or weight gain" (APA 1987, p. 150). Physical dependence refers to the condition in which withdrawal symptoms have been observed. Physical dependence can complicate the process of achieving and Table 4. Criteria for drug dependence Primary criteria Highly controlled or compulsive use Psychoactive effects Drug-reinforced behavior Additional criteria Addictive behavior often involves the following: Stereotypic patterns of use Use despite harmful effects Relapse following abstinence Recurrent drug cravings Dependence-producing drugs often manifest the following: Tolerance Physical dependence Pleasant (euphoric) effects Source: Adapted from USDHHS (1988). TIMN 0138883

!'r<vrrrtrrr,t T01,a«O List' 1't mri~: ,Y0E1lC 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 survevs 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' 6 32 19 District of Columbiax 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 Pennsvlvania* 2 29 16 Tennessee 1 34 17 Wisconsin 3 19 11 Wyoming 5 31 19 Localsurveys 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. °Fourteen sites had overall response rates below 60 percent or had unavailable documentation; weighted estimates were not reported. Epidemiology 99 TIMN 0138951

tiurxccvi Gon,ndl', Rr00r; Table 39. Smoking among young people in the United States-sources of national data, definitions of use, 1968-1991 Source National Teenage Tobacco Surveys (NTTS) and 1989 Teenage Attitudes and Practices Survey (TAPS) National House- hold Surveys on Drug Abuse (NHSDA) Ever smoking Any smoking, even a few puffs (TAPS); smoke now or have smoked at least 100 cigarettes (for trends, 1968-1979) Age/grade when respondent first tried smoking Age when smoked first whole cigarette Current smoking status Smoke now (1968-1979); any smoking during the past 30 days (TAPS); number of days smoked during the past 30 days (TAPS) Ever tried a cigarette; ever smoked daily Monitoring Smoked cigarettes at the Future least once or twice Project (MTFP) Age when first tried a cigarette; age when first started smoking daily Any smoking during the past 30 days Grade when smoked first Any smoking during cigarette; grade when the past 30 days first smoked on a daily basis Youth Risk Any smoking, even one Age when first smoked Any smoking during Behavior or two puffs; a whole cigarette; age the past 30 days; Survey ever smoked regularly when first started number of days smoked (YRBS) , e c least one cigarette smoking regularly during the past 30 days Wlery day for 30 days) (at least one cigarette every day for 30 days) National Smoked at least 100 Age when first started Smoke cigarettes now; Health Interview cigarettes in entire smoking cigarettes reconstructed prevalence Surveys (NHIS) life fairly regularly of smoking Sources: NTTS: U.S. Ltepartment of Health, Education, and Welfare (1972,1976,1979b); TAPS: Allen et al. (1991,1993); Moss et al. (1992); NHSDA: Abelson and Atkinson (1975); Abelson and Fishbume (1976); Fishburne, Abelson, Cisin (1980); Miller et al. (1983); U.S. Department of Health and Human Services (USDHHSI (1988a, 1990a, 1991a, 1992a, 1993); MTFP: Bachman, Johnston, O'Malley (1980a, b,1981,1984,1985,1987,1991); Johnston, Bachman, (YMalley (1980a, b, 1982,1984,1986, 1991,1992); Johnston, aMalley, Bachman (in press); YRBS: Kolbe (1990); Centers for Disease Control (1992c, d); NHIS: National Center for Health Statistics (1958, 1975, 1985, 1988a, b, 1989); USDHHS (1991b). *Not all potential sources of data on youth smoking are used in this report. TIMN 0138960 108 Epidemiology

Surgevn Geircral's Report determine if they are psychoactive and if they can serve as reinforcers in animals and humans (Brady and Lukas 1984; USDHHS 1988; Fischman and Mello 1989; Henningfield, Cohen, Heishman 1991). These methods to test for abuse liability are reliable enough for the Food and Drug Administration (FDA) and the World Health Organization (WHO) to use them to develop policies regarding regulation of new drugs with possible addic- tion potential (USDHHS 1988; Barcelona Conference 1991). Nicotine meets the criteria for addiction potential in all of the standardized tests used by the FDA and the WHO (USDHHS 1987, 1988, 1991a). In humans and animals, nicotine produces discrete subjective effects more similar to those produced by cocaine than to those pro- duced by sedatives, and nicotine injections are biologi- cally reinforcing to humans and to at least five animal species (Henningfield, Miyasato, Jasinski 1985; Henningfield and Goldberg 1988; USDHHS 1988). Such findings confirm the conclusion of the 1988 report of the Surgeon General: nicotine is a drug with a liability for addiction (USDHHS 1988). Pathophysiology of Nicotine Dependence The pathophysiology of drug dependence and the clinical course of nicotine and other drug dependencies have been described in detail elsewhere (Jaffe 1985; USDHHS 1988; Benowitz 1992; Henningfield 1992a). In brief, exposure to a psychoactive chemical leads to re- petitive self-administration because of the chemical's capacity to condition behavior. This powerful condi- tioning action of nicotine is mediated at least in part by the activation of nicotinic receptors in the brain (USDHHS 1988; Bock and Marsh 1990) and the modulation of levels of hormones such as epinephrine (adrenaline) and corti- sol (Pomerleau and Pomerleau 1984; Sachs 1987; USDHHS 1988). The mesolimbic dopaminergic reward system, which mediates the addicting actions of cocaine, is also thought to be involved in producing nicotine's addictive effects (Pomerleau and Pomerleau 1984; USDHHS 1988; Bock and Marsh 1990; Balfour 1991a, b; Benwell and Balfour 1992). Behavt~rs that are followed by intense neural activation can become highly persistent and diffi- cult to modify (Pomerleau and Pomerleau 1984; Jaffe 1985; USDHHS 1988). Each year, the daily cigarette smoker may experience 50,000 to 100,000 such pairings of puffing on cigarettes and resultant effects in the brain, thus establishing a persistent need for cigarette smoking. Tolerance Tolerance refers to a diminishing response to a drug through iepeated exposures (Jaffe 1985; USDHHS 1988). Tolerance is often demonstrated when increased dose levels are required to obtain the effects formerly produced by lower doses. Tolerance to nicotine appears to be acquired as people progress from initially smoking a few cigarettes to smoking greater numbers of cigarettes more often (see "Initiation Continuum of Smoking" and "Adult Implications of Adolescent Smoking" in Chapter 3 and "Developmental Stages of Smoking" in Chapter 4). The development of tolerance to the aversive effects of nicotine, such as nausea and dizziness, may also facili- tate the development of dependency (USDHHS 1987; Shiffman et a1.1990; Shiffman 1989,1991; McNeill, Jarvis, West 1987). Tolerance of nicotine increases over time; experienced smokers can self-administer doses of nico- tine that would make nonsmokers ill. The tolerance the nervous system develops to nico- tine exposure can be at least partially overcome by increasing the dose. This effect was studied near the beginning of the 20th century and has been the subject of considerable study since then (Langley 1905; USDHHS 1988; Benowitz and Jacob 1993). Tolerance to various behavioral, physiologic, and subjective effects of nicotine has been studied (USDHHS 1988). For example, administering nicotine to a tobacco-deprived cigarette smoker can produce a substantial increase in heart rate and measures of euphoria, along with a decrease in the strength of the knee reflex. With repeated doses, the heart rate stabilizes at a level between that produced by the first dose and that which occurs when nicotine- deprived; subjective effects are minimal, and the knee reflex may become normal (Domino and Von Baum- garten 1%9; USDHHS 1988; Swedberg,'Henningfield, Goldberg 1990). Some tolerance of nicotine is lost.each night as the smoker's nicotine levels fall; the nicotine from the first few cigarettes of the day produces effects on heart rate, mood, and other measures that are stronger than the effects produced by subsequent doses during the day (USDHHS 1988). Repeated exposure to nicotine leads to morphological changes in the brain that cause the devel- opment of new binding sites for nicotine receptors, which mediate the effects of nicotine (Bock and Marsh 1990; USDI-iHS 1988,1991a). Animal research has shown that nicotine exposure results in an increased expression (defined as up-regula- tion) of nicotine receptors in various regions of the brain (Ksir et al. 1985; Morrow, Loy, Creese 1985; Nordberg et al. 1985; Schwartz and Kellar 1985; Ksir, Hakan, Kellar 1987). Prenatal exposure to nicotine also produces up- regulation of nicotine receptors in tissue collected from newborn animals (Slotkin, Orband-Miller, Queen 1987; Slotkin et al. 1991; Smith, Seidler, Slotkin 1991). These data suggest the broad applicability of this up-regulation effect, which7may be one of the ways in which tolerance of nicotine occurs (USDHHS 1989). 32 Health Consequences TIMN 0138885

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, 1989,1991, 1992 Characteristic NHSDA* MTFPtx YRBS9 Overall 3.4 11.4 10.5 Gender Male 6.0 20.8 19.2 Female 0.6 2.0 1.3 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 IVA' 5.5 Male 2.1 NA 10.7 Female 0.3 NA 0.6 Age/grade 12-14 vears 1.5 15-16 years 3.6 17-18 vears 5.9 8th grade 7.0 9th grade • 9.0 10th grade 9.6 10.1 11 th 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 V HSDA, 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?" iWith the exception of data for 8th- and 10th-grade students, all other data points for the MTFP survey reflect estimates for high school seniors. • '1991 YRBS, grades 9-12. Based on response to the question, "During the past 30 days, did you use chewing tobacco, such as Redman, Levi Garrett, or Beechnut, or snuff, such asSkoal, Skoal Bandits, or Copenhagen?" `NA = Not available. 98 Epidemiology !TIMN 0138950

Preventing Tobacco Use Amon~g Young People concluded that virtually everyone who used illegal drugs such as marijuana or cocaine had previously used cigarettes, alcohol, or both. These findings, primarily among white youths, have been repeatedly extended and replicated (e.g., Fleming et al. 1989; Kandel and Yamaguchi 1993). More recent data from the Monitoring the Future Project (MTFP) by NIDA (USDHHS 1988) confirm that illegal drug use is rare among those who have never smoked and that cigarette smoking is likely to precede the use of alcohol or illegal drugs. The 1985-1989 MTFP showed that first use of tobacco had occurred at the same age as first use of alcohol for 33 percent of the sample; cigarettes were used before alcohol by 49 percent of the sample. The same survey showed that among those who had used both cigarettes and marijuana, 23 percent be- gan using both in the same year, and 65 percent smoked cigarettes before marijuana. The latter relationship was more pronounced for cocaine: 98 percent of persons who had used both cocaine and cigarettes smoked cigarettes first (see Tables 24-26 in Chapter 3). These findings were extended in another longitu- dinal study that assessed 12-, 15-, and 18-year-olds in New Jersey and reinterviewed them at three-year inter- vals (USDHHS 1987). This study showed that among 15- year-olds, the use of cigarettes, alcohol, or marijuana was the strongest predictor of cocaine use when these same persons were reinterviewed *three years later; at that time, the persons using cocaine were likely to be using cigarettes and alcohol as well. Cigarette smoking in combination with alcohol use appears to be especially predictive of illegal drug use. A longitudinal study by Yamaguchi and Kandel (1984) examined initial data from students in the tenth and eleventh grades in New York State in 1971. When the authors reevaluated the same students in 1981 (av- erage age, 25 years), the mostt common sequence of drugs used was alcohol, cigarettes, marijuana, illegally used psychoactive or prescription drugs, and other iIle- gal drugs. The investigators found that for 87 percent of the men, alcoholl use preceded marijuana use; alco- hol and marijuaria_use preceded other illegal drug use; and use of alcohoarettes, and marijuana preceded the use of other choactive drugs. For 86 percent of the women, a sui~r: but not identical, pattern emerged: alcohol or cigarettes preceded marijuana; alcohol, ciga- rettes, and marijuana preceded other illegal drugs; and alcohol and either cigarettes or marijuana preceded other psychoactive drugs. These findings were repli cated with 1,108 high school seniors in New York in 1988 (Kandel and Yamaguchi 1993). This study confirmed the importance of cigarette and/or alcohol use in the progression of illegal drug use, with early- cigarette. use being of particular importance in the develop- ment of other drug use among females. Early onset of cigarette smoking and/or alcohol use was a strong pre- dictor of further drug use. The relationship between alcohol use and cigarette smoking is more complex than would be suggested by examining any one survey. In some studies, alcohol is more likely to precede than to follow cigarette smoking. This variability might be explained by the differing study criteria for alcohol use. For example, among many adoles- cents, alcohol consumption is characterized by the occa- sional light use of beer or wine-a pattern that often neither escalates into patterns of heavy drinking nor pre- dicts other drug use (Kandel, Marguilies, Davies 1978; Huba, Wingard, Bender 1981; O'Donnell and Clayton 1982). This finding is consistent with the observation that approximately 85 percent of people who drink alcoholic beverages do so in patterns that do not meet criteria for abuse (USDHHS 1988). On the other hand, consumption of "hard liquor," ' sometimes accompanied by heavy drink- ing patterns, appears to develop either along with or following the development of regular patterns of cigarette smoking (Kozlowski et al: 1993; DiFranza and Guerrera 1990). These observations are consistent with the find- ings of the 1985 NHSDA, which showed that among 12= through 17-year-old adolescents who had neversmoked, only 3 percent had binged (i.e., had five or more drinks in a row) in the past 30 days, whereas nearly 40 percent of daily smokers in this age group had binged in the past 30 days (USDHHS 1988). The progression from cigarette smoking and occasional consumption of alcoholic beverages to heavier drinking and illegal drug use does not appear limited to any single population group. However, there is some evidence that boys with conduct disorders in school and at home may be at especially high risk of progression from any use of tobacco and alcohol to addictive patterns of multiple-drug use. A recent study of 61 males aged 14 through 18 who had conduct disorders found sequences of acquisition of drug use similar to those found among adoles- cents in general, but with higher rates of addictive use of the tobacco-alcohol-marijuana duster and earlier initiation of these substances (Mikulich, Young, Crowley 1993). Cigarette Smoking and Other Drug Use Cigarette smoking is neither necessary nor sufficient for other drug abuse or dependence. Not all cigarette smokers subsequently abuse other drugs, and a small percentage of abusers of alcohol and illegal drugs do not use tobacco. However, several studies have revealed'that cigarette smoking is a predictor of whether an indi-Adual is using other drugs and of what that individuaPs level of other drug use is. The 1985 NHSDA Health Consequences 35 TIMN 0138888

PYi'z'c'i/fN1,~ To1'dtii' U>e Alilollg 1 olUl\ PeUhli 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 lnhalants= 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. 'Includes "coke," "crack," and "rock." t Glue, 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 Futuie ` Project (MTFP), 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 1.3 2.0 2.3 0.9 0.4 0.2 3.2 10.3 10 0.6 0.7 1.0 1.5 0.2 0.1 2.3 6.4 11 0.1 0.5 0.7 0.5 0.5 0.1 1.5 3.9 12 * 0.3 0.2 0.1 0.1 0.3 0.9 1.9 Never used 2.0 2.7 1.9 1.1 1.3 0.2 28.3 37.6 Column tota], : 13.3 16.9 11.0 6.9 4.0 1.4 46.7 ' 100.0 Source: Centers foc 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 team (Table 29). This finding is opposite to that found had or by whether they had used a condom during their for cigarette smoking and sports. Smokeless tobacco use most recent sexual intercourse. Lastly, students were was also more likely among students who had used consistently more likely to currently use smokeless to- steroids without a doctor's prescription. bacco if they had participated on a sponsored sports Epidemiolt~gy 103 ' TIMN 0138955

Preventing Tobacco Use Among Young People LEBOWITZ MD, HOLBERG CJ. Effects of parental smoking and other risk factors on the development of pulmonary func- tion in children and adolescents. Analysis of two longitudinal population studies. American Journal of Epidemiology 1988;128(3):589-97. LIM TPK. Airway obstruction among high school students. American Revieu; of Respiratory Disease 1973;108(4):985-8. MALLOY MH, KLEINMAN JC, LAND GH, SCHRAMM WF. The association of maternal smoking with age and cause of infant death. American Journal of Epidemiology 1988;128(1): 46-54. MARKS MJ, BURCH JB, COLLINS AC. Genetics of nicotine responses in four inbred strains of mice. Journal of Pharmacol- ogy and Experimental Therapeutics 1983;226(1):291-302. MARKS MJ, COLLINS AC. Characterization of nicotine binding in mouse brain and comparison with the binding of alpha-bungarotoxin and quinuclidinyl benzilate. Molecular Pharmacology 1982;22(3):554-64. MARKS MJ, ROMM E, BEALER S, COLLINS AC. A test battery for measuring nicotine effects in mice. Pharmacology, Biochemistry and Behavior 1985;23(2):325-30. MARKS MJ, ROMM E, CAMPBELL SM, COLLINS AC. Varia- tion of nicotinic binding sites among inbred strains. Pharma- colog,y, Biochemistry and Behavior 1989;33(3):679,89. MARKS MJ, STITZEL JA, COLLINS AC. Time course study of the effects of chronic nicotine infusion on drug response and brain receptors. Journal of Pharmacologyand Experimental Thera- peutics 1985;235(3):619-28. MARKS MJ, STITZELJA,COLLIIVSAC. Dose-responseanaly- sis of, nicotine tolerance and receptor changes in two inbred mouse strains. Journal of Pharmacology and Experimental Thera- peutics 1986;239(2):358-64. MARKS MJ, STIi'ZEL JA, COLLINS AC: Influence of kinetics on nicotine administration on tolerance development and re- ceptor levels. Pharmacology, Biochemistry and Behavior 1987; 27(3):505-12. .~.~ MARKS MJ, S JA;: ~tO)1dM. E, WEINER JM, COLLINS AC. Nicotinic bd g yites in rat and mouse brain: compari- son of acetylcholirte,:nicotine; and alphabungarotoxin. Mo- lecular Pharmacology 1986;30(5):427-36. MARSEE V. UNITED STATES TOBACCO COMPANY, 639 F. Supp. 466 (W.D. Okla 1986) af f d, 866 F:2d319 (I0thCir.1989). MARTI B, ABELIN T, MINDER .CE,. VADER JP: Smoking, alcohol consumption, and endurance capacity: an analysis.of 6,500 19-year-old conscripts and 4,000 joggers. Preventive Medicine 1988;17(1):79-92. MCIVAMARA JJ, MOLOT MA, STREMPLE JF, CUTTING RT. Coronary artery disease in combat casualties in Vietnam. four- nal of the American Medical Association 1971;216(7):1185-7. MCNEILL AD. The development of dependence on smoking in children. British Journal of Addiction 1991;86(5):589 92. MCNEILL AD, JARVIS M, WEST R. Subjective effects of cigarette smoking in adolescents. Psychopharmacology 1987;92(1):115-7. MCNEILL AD, WEST RJ, JARVIS M, JACKSON P, BRYANT A. Cigarette withdrawal symptoms in adolescent smokers. Psychopharmacology 1986;90(4):533-6. MIKULICH SK, YOUNG SE, CROWLEY TJ. Acquisition rates of ten drug classes: conduct disordered boys. In: Harris L, editor. Problems of drug dependence 1992: proceedings of the 54th annual scientific meetings. Monograph No. 132. US Depart- ment of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, National Institute on Drug Abuse. Bethesda (MD): NIH Pub- lication No. 93-3505,1993. MODEER T, LAVSTEDT S, AHLUND C. Relatiodbetween tobacco consumption and oral health in Swedish sChoolchil- dren. Acta Dermatologica Scandinavica 1980;38(4):223=7. MOOLGAVKAR SH, DEWANJI A, LUEBECK G. Cigarette smoking and lung cancer: reanalysis of the British doctors' data. Journal of the National Cancer Institute 1989; 81(6):415-20. • MORROW AL, LOY R, CREESE I. Alteration of nicotinic cholinergic agonist binding sites in hippocampus after fimbria transection. Brain Research 1985;334(2):309-14. MOSKOWITZ WB, MOSTELLER M, SCHIEKEN RM, BOSSANO R, HEW1TT JK, BODURTHA JN, ET AL. Lipopro- tein and oxygen transport alterations in passive smoking pre- adolescent children. The MCV twin study. Circulation 1990;81(2)586r92. NATIONAL RESEARCH COUNCIL, COMMITTEE ON PASSIVE SMOKING. Environmental tobacco smoke: measuring exposures and assessing health effects. Washington (DC): Na- tional Academy Press, 1986. NEWMAN- WP, FREEDMAN DS, VOORS AW, GARD PD, SRINNASAN SR; CRESANTA JL, ET`AL. Relation of serum lipoprotein levels and systolic blood pressure to early athero- sclerosis.' The Bogalusa heart study. New England Journal of Medicine 1986;314(3):138=44. NIEWOEHNER DE, KLEINERMAN J, RICE DB. Pathologic changes irnthe peripheral airways of youngcigarette smokers. New Engfand Journal of Medicine 1974;291(15):755-8. '' Health Consequences 47 TIMN 0138900

1'rc;'a'ntutSZ TUhaiio Llsc .-l1nou1g Y0nutg t'eoFh' (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 ,vears old. Black non-Hispanic adolescent mothers were less likely to have smoked than those 20 through-19 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 (Hosmerand Lemeshow 1989). Alcohol use was also included as a covariate for the measures of staving at home because of not feeling well and of overall physical health. Current smokers were more likely than never smokers to report all of the symptoms or indicators listed. A trend test (using the linear contrast of the estimated regression coefficients for smoking history [Miller 19861) revealed that these adolescent smokers were more likely than never 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 likelv 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 (%'a) 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). 0 Epidemiology 93 TIMN 0138945

Surgeon General's Report References ADAMS L, LONSDALE D, ROBINSON M, RAWBONE R, GUZ A. Respiratory impairment induced by smoking in children in secondary schools. British Journal of Medicine 1984;288(6421):891-4. ADDINGTON W W, CARPENTER RL, MCCOY JF, DUNCAN KA, MOGG K. The association of cigarette smoking with respiratory symptoms and pulmonary function in a group of high school students. Oklahoma State Medical Journal 1970;63(11):525-9. AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic and statistical manual of mental disorders. 3rd rev. ed. Washington (DC): American Psychiatric Association, 1987. ARMITAGE P, DOLL R. The age distribution of cancer and a multistage theory of carcinogenesis. British Journal of Cancer 1954;VIII(1):1-11. ARY DV, LICHTENSTEIN E, SEVERSON HH. Smokeless tobacco use among male adolescents: patterns, correlates, predictors, and the use of other drugs. Preventive Medicine 1987;16(3):385-401. AXrLL T, HOLMSTRUP P, KRAMER IRH, PINDBORG JJ, SHEAR M. International seminar on oral leukoplakia and associated lesions related to tobacco habits. Community Den- tistry and Oral Epidemiology 1984;12(3):145-212. BACKHOUSE CI. Peak expiratory flow in youths with vary- ing cigarette smoking habits. British Medical Journal 1975;1(5954):360-2. BAILEY SL. Adolescents' multisubstance use patterns: the role of heavy alcohol and cigarette use. American Journal of Public Health 1992;82(9):1220-4. BALFOUR DJK. Influence of nicotine on the release of monoamines in the brairi: In: Nordberg A, Fuxe K, Holmstedt B, and Sundwall A, edito s Progress in Brain Research, Vol. 79. Aft. New York: Elsevier,198q: _ k. BALFOUR DJK. The influence of stress on psychophanmaco- logical responses to nicotine. British Journal of Addiction 1991a; 86(5):489-93. BALFOUR DJK. The neurochemical mechanisms underlying nicotine tolerance and dependence. In: Pratt J, editor. The biological bases on drug tolerance and dependence. Downers Grove (IL): Academic Press Ltd., 1991b. 42 Health Consequences BARCELONA CONFERENCE. Barcelona meeting on clinical testing of drug abuse liability: consensus statement and recom- mendations. British Journal of Addiction 1991;86(12):1527-8. BATES DV. Respiratory function in disease. 3rd. ed. Philadel- phia (PA): W.B. Saunders Company, 1989. BECK GJ, DOYLE CA, SCHACHTER EN. A longitudinal study of respiratory health in a rural community. American Review of Respiratory Disease 1982;125(4):375-81. BENOWITZ NL. Sodium intake from smokeless tobacco. New England Journal of Medicine 1988;319(13):873-4. BENOWITZ NL. Cigarette smoking and nicotine addiction. Medical Clinics of North America 1992;76(2):415-37. BENOWTTZ NL, HALL SM, HERNING RI, JACOB P` III, JONES RT, OSMAN AL. Smokers of low-yield cigarettes do not consume less nicotine. New England Journal of Medicine1983; 309(3):139-42. BENOWITZ NL, JACOB P III. Nicotine and carbon monoxide intake from high- and low-yield cigarettes. Clinical Pharmacol- ogy and Therapeutics 1984;36(2):265-70. BENOWITZ NL, JACOB P III. Nicotine and cotinine eliniina- tion pharmacokinetics in smokers and nonsmokers. Clinical Pharmacology and Therapeutics 1993;53(3):316-23. BENOWITZ NL, PORCHET H, SHEINER L, JACOB P. Nico- tine absorption and cardiovascular effects with smokeless to- bacco use: comparison with cigarettes and nicotine gum. Clinical Pharmacology and Therapeutics 1988;44(1):23-8. BENWELL MEM, BALFOUR DJK. The effects of acute and repeated nicotine treatment on nucleus accumbens dopamine and locomotor activity. British Journal of Pharmacology 1992;105(4):849-56. BENWELL MEM, BALFOUR DJK, ANDERSON JM. Evi- dence that tobacco smoking increases the density of -(-)('H) nicotine binding sites in human brain. Journal of Neurochemis- try 1988;50(4):1243-7. BERENSON GS, WATTIGNEY WA, TRACY RE, NEWMAN WP III, SRINIVASAN SR, WEBBER LS, ET AL. Atherosclero- sis of the aorta and coronary arteries and cardiovascular risk factors in persons aged 6 to 30 years and studied at necropsy (the Bogalusa.heart study). American Journal of Cardiology 1992;70(9):851-8. TIMN 0138895

Prc.'t'tttltiS T0l1AiO Lhc'.lttt~~titi 1<<tut~ PcOhlc' noninstitutionalized adult population of the United States (NCHS 1958, 1975, 1985, 1989). For the serial cross-sec- tional analvses, data from surveys conducted during or after 1974 are used to eliminate proxy reports from the comparisons. In 1985, the sample design was changed to produce more precise estimates for blacks by oversampling. Most interviews were conducted in the home; when re- spondents could not be interviewed in person, telephone interviews were conducted. The sample was then poststratified by age, gender, and racial distribution of the U.S. population for the survey year and weighted to pro- vide national estimates. The overall NHIS response rate for surveys on smoking is at least 85 percent (NCHS 1985, 1988a, b; CDC, OSH, unpublished data). In other analyses, trends in the recunstntcttd preva- lence of cigarette smoking among persons 10 through 19 years old are reported using data from the 1970, 1978, 1979, 1980, and 1987 surveys (USDHHS 1992a). In addi- tion, age at initiation of regular smoking is reported for respondents to the 1970,1978,1979,1980,1987, and 1988 surveys. The 1978, 1979, and 1980 surveys collected information on usual brand smoked; these data are re- ported for 18- and 19-year-old respondents. The 1970 NHIS also collected data on smokeless tobacco use among persons 17 through 19 years old. NHIS data on smoking are collected annually, un- til at least 1995. Appendix 2. Measures of Cigarette Smoking As is documented in Chapter 4 of this report (see "Developmental Stages of Smoking") and in the 1989 Surgeon General's report on smoking and health (USDHHS 1989b), the development of a pattern of daily smoking occurs in several stages over time. Several measures can be derived from the national surveys to capture patterns of tobacco use among young people (Table 39). Ever Smoking Four surveys-TAPS, the NHSDA, the MTFP, and the YRBS-have comparable definitions of ever smok- ing. In TAPS and the YRBS, ever smokers are those who have tried even a few puffs of a cigarette. In the NHSDA, respondents who report having tried a cigarette are clas- sified as ever users. In the MTFP, respondents who report having smoked at least once or twice are classified as ever smokers.. Published reports of the 1968-1979 tiTTS merge never smokers and experimenters (those who have smoked',at least a few puffs, but not as many as 100 cigarettes) info:one category (USDHEW 1972, 1976, 1979b); thus, the NTTS trend information on ever smok- ing for those years underestimates the actual prevalence of ever smoking. Current Smoking For TAPS, the NHSDA, the MTFP, and the YRBS; current usage patterns are defined as any use of cigarettes r within the 30 days preceding the survey. For tfie 1968- 1979 NTTS, current occasional smokers are defined as those who smoke less than one cigarette a week, and cunrent regular smokers a re those who smoke one or more cigarettes per week or one or more per day (USDHEW 1972, 1976, 1979b). In this chapter, current regular and current occasional smokers are combined into one category. The NHIS defines current smokers as those re- spondents who have smoked at least 100 cigarettes and who answer "yes" to the question, "Do you smoke ciga- rettes now?" NHIS data on age at initiation of regular smoking and on duration of abstinence for former smok- -ers have been used to reconstruct the prevalence of ciga- rette smoking for the decades in this century before systematic surveillance of cigarette smoking was con- ducted (USDHHS 1991b). Using information on a respondent's date of birth, age at initiation of smoking, and age at cessation (for former smokers), the smoking status of a respondent can be assessed for any given year. Similar analyses have been reported in previous Sur- geon General's reports (USDHHS 1980,1985) and in the published literature (Harris 1983; Escobedo and Remington 1989; Pierce, Naquin, et al. 1991). For this report, the reconstructed prevalence of smoking among those aged 10 through 19 years is reported for the years 1920-1980. These data are subject to recall bias; for some respondents, more than 50 years separated the year they were being surveyed and the recalled year they began smoking regularly. Epidemiology 107 TIMN 0138959

Eigure 1. Stages of smoking initiation.among children and adolescents Preparatory Stage Psvchosocial risk factors Adolescent forms attitudes include advertising and and beliefs about adult/sibling role models the utility of smoking. who smoke cigarettes. Never smokes Psychosocial risk factors include peer influences to smoke, the perception that smoking is normative, and the availabilitv of cigarettes. Trying Stage Adolescent smokes first few cigarettes. No longer smokes Experimental Stage Psvchosocial risk factors Adolescent smokes include social situations and repeatedly but irregularly. peers that support smoking, low self-efficacy in ability to refuse offers to smoke, and the availability of cigarettes. ' N 1 k Reg ular Use Psvchosocial risk factors include peers who smoke, the perception that smoking has personal utility, and few restrictions on smoking in school, home, and community settings. 0 onger smo es Adolescent smokes at least weekly across a variety of situations and personal interactions. Quits smoking Addiction/Dependent Smoker Adolescent has developed the physiological need for nicotine. Sources: Adapted from Flay (1993); U.S. Department of Health and Human Services (1991). breakdown and discrepancies between role aspirations behavioral factors, such as normative expectations of and achievements may lead to incomplete or inappro- smoking, that affect the choice to use tobacco (Flay 1993). priate social development of adolescents. Inappropriate Tobacco use may vary according to broad factors such as social development, in turn, can alter personal and an individual's socioeconomic status, familv 126 Psychosocial Risk Factors I TIMN 0138978

Promotional Efforts of the Tobacco Industry 185 Introduction 185 Public Entertainment 185 Sampling and Specialty Items 186 Other Promotional Expenditures 186 Research on the Effects of Cigarette Advertising and Promotional Activities on Young People 188 Introduction 188 Young People's Exposure to Cigarette Advertising 188 Opinions on Cigarette Advertising and Smoking Behaviors 189 Young People's Responses to Different Types of Cigarette Advertisements 189 Humor in Advertising 190 Responses to Advertisements for the Camel and Marlboro Brands 190 Young People's Self-Image and Implications for Tobacco Use 191 Young People's Misperceptions of Smoking Prevalence and Implications for Tobacco Use 192 Discussion 194 Conclusions 195 References 196 TIMN 0139010

tirngenrt Gon'ntl" Kq, 'I n•r 608 inner-city blacks aged 11 through 13 or in the longi- tudinal study of 2,209 primarily white 11- through 17- vear-olds in Minnesota (Mittelmark et al. 1987). In Quine and Stephenson's (1990) cross-sectional study of over 2,000 Australians aged 10 through 12, parental smoking was not associated with childreri s smoking but was related to children's intentions to smoke when older. Conrad, Flay, and Hill (1992) summarized the find- ings of 27 prospective studies on the onset of smoking that have been published since 1980 (see Table 3). In 15 of the studies, parental smoking factors were investigated. The researchers concluded that parental smoking was predictive in seven studies, predictive only for females in two studies, and not predictive in six others. Chassin et al. (1984) suggested that parental smoking may influence the preparatory or initial trying stages, as well as the stability of smoking patterns from adolescence to adulthood (Chassin et al. 1991), but pa- rental smoking appeared to be less influential during the transition to regular smoking. Sibling Smoking Over the past two decades, extensive research on the influence of sibling smoking indicates a primarily positive relationship between an older sibling's smoking and a younger (adolescent) sibling's beginning to smoke. In a 10-year longitudinal study of 6,311 ado- lescents (initially 11 through 13 years old), sibling smok- ing was found to be one of four factors that was predictive of increased risk of initiating regular smoking and predictive of smoking prevalence after 10 years (Swan, Creeser, Murray 1990). In the McNeill et al. (1988) longitudinal research with 2,159 British 11- through 13-year-olds, having a sibling who smoked appeared to increase the odds of smoking initiation by a factor of 1.69. Botvin et al. (1992) reported that sibling smoking was one of five variables that accounted for 29 percent of the variance in smoking in their cross- sectional study of 522 inner-city blacks aged 11 through 13. O'Connell et al. (1981) found sibling smoking to be among the first three factors associated with weekly Table 3. Predictors of smoking onset in 27 prospective studies Prediction of smoking onset Number of supportive findings Number of unsupportive findings Percent support Socioeconomic status 16 5 76 Environmental factors Family smoking 18 8 69 Family approval 6 8 43 Other adult influences 5 3 63 Peer use and approval 27 5 84 Normative estimates 4 1 80 Offers/availabilitv 7 1 88 Family bonding 9 6 60 Peer bonding 11 4 73 Schoolintluences. 20 5 80 Religious influences 0 1 0 Behavioral factors Skills 3 0 100 Other behaviors 12 2 86 Personal factors Knowledge/beliefs 16 9 64 Attitudes 8 3 73 Personalitv factors 23 7 77 Intentions to smoke 8 1 89 Source: Adapted from Conrad, Flay, and Hill (1992). TIMN 0138982 130 Psi/chosocial Risk Factors

I'nvrnti»,t Tohacco UsC.-1morig }iuug ('euple Table 32. Self-reported indicators of nicotine addiction among 12-18-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 ? 100 1-99 > 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 Indicatort (%) (%) (%) (~c) 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 cigarettesx 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 cigarettest 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 smokeLSS, tobacco were 18 percent for 12- through 18-year-q ids in#he 1989 TAPS, 13 percent for the same age group ui 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 Epidenciolv~g}t 95 TIMN 0138947

!'r<<'e'ttttHg Tc?ha«o Use .-ltttwts~ } Vtntt l'cvplc' white adolescents was higher than for Hispanics and blacks. 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 high school seniors varied according to several sociodemographic indicators, as shown by the 1986-1989 MTFP surveys (N [weighted ]= 5,277). The prevalence of current smokeless tobacco use was 28 percent among those who lived alone, 29 percent among those living in father-only households, 16 percent among those living in mother-only households, and 20 percent among those living with both parents. Current use was more common among male seniors living on farms (34 percent) and in the country (31 percent) than among those living in 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 who rated their performance as slightly above average (18 percent) or far above average (16 percent). Smokeless tobacco use was more common among male seniors who planned to enter the armed forces after high school than among those who did not have such plans (23 vs. 19 percent). The self-reported importance of religion did not affect the prevalence of smokeless tobacco use among these MTFP seniors. Grade When Smokeless Tobacco Use Begins The grade distribution for which MTFP seniors reported first trying smokeless tobacco was more similar to that reported for cigarettes than it was for those 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-#~wo 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 I percent of females had tried quitting two Ur 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 MTFP who believed that great risk is associated with smokeless tobacco use is plotted against the percentage of seniors who had used smokeless tobacco, the trends of these percentages are inversely related (Figure 9). Between 1986 and 1988, the percentage of seniors who believed that great risk is associated with smokeless tobacco use increa5ed 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 a1.1993). Epidemiol~gy 101 TIMN 0138953

tilll'\t't~ll Cnvlt' 111 (~t'l't , community actions provide external support for par- ents, teachers, and adolescents to assert their beliefs about t1-e health hazards of tobacco use and to assist their demand for tobacco-free environments. Such clear, normative messages emanating from the community level reinforce those messages given at school or at Conclusions home. Above all, community action at multiple lrvels of the social environment directly and consistentlv re- fuEes the notion that tobacco use is an attractive adult behavior. Community intervention should be a top priority in poorer communities, where the need for action is especially great. 1. The initiation and development of tobacco use among children and adolescents progresses in five stages: from forming attitudes and beliefs about tobacco, to trying, experimenting with, and regularly using to- bacco, to being addicted. This process generally takes about three years. 2. Sociodemographic factors associated with the onset of tobacco use include being an adolescent from a family with low socioeconomic status. 3. Environmental risk factors for tobacco use include accessibility and availability of tobacco products, perceptions by adolescents that tobacco use is nor- mative, peers' and siblings' use and approval of tobacco use, and lack of parental support and in- volvement as adolescents face the challenges of growing up. 148 . Psychosocial Risk Factors 4. Behavioral risk factors for tobacco use include low levels of academic achievement and school involve- ment, lack of skills required to resist influences to use tobacco, and experimentation with any tobacco product. 5. Personal risk factors for tobacco use include a lower self-image and lower self-esteem than peers, the be- lief that tobacco use is functional, and lack of self- efficacy in the ability to refuse offers to use tobacco. For smokeless tobacco use, insufficient knowledge of the health consequences is also a factor. TIMN 0139000

Prc^e'nttitti T)h7CiU Use'.-lnioitt 1 vtut~ ('coplc considered survey setting independent of the survey method, however, these two issues are considered together. Zanes and Matsoukas (1979) first reported that compared with school surveys, home surveys measur- ably underreported smoking, though the underreporting was largely limited to students who were frequently absent. Turner, Lessler, and Devore (1992) found that past-month smoking prevalence among 12- through 17- vear-olds were 10 to 30 percent higher if the self-admin- istered version of the NHSDA home survey was used. These investigators attributed their finding to the lack of privacy that is often found in interviewer-administered home surveys. Luepker et al. (1989) attempted to im- prove the efficiency of the home survey by using tele- phone interviews rather than face-to-face interviews, but found that the telephone method underestimated smok- ing rates by 10 to 15 percent among 17- through 21-year- olds. Comparison of the surveys reported in this chapter suggests that home-based interviews (whether face-to- face or by telephone) are more likely to underestimate smoking than school-based, self-administered question- naires. For example, for persons 17 and 18 years old, past-month smoking prevalence was estimated to be 28 percent in the 1989 TAPS (telephone home interviews) and 26 percent in the 1991 1VHSDA (face-to-face home interviews); the prevalence for the same age group was 30 percent in the 1991 YRBS and 28 percent in the 1991 MTFP (both school-based, self-administered question- naires). All four studies had high and comparable par- ticipation rates and were weighted to provide national estimates. Of 17- and 18-year-olds who remained in school and participated in the 1989 TAPS, 23 percent smoked in the past month. Despite the differences in reporting, surveys using home interviews complement school-based surveys and provide access to a popula- tion that is not available at school. Most notable, how- ever, is the similarity of the patterns of tobacco use across all of the surveillance systems. Substantial work to improve the validity of self- reported data has been limited largely to surveys that use school-based, self-administered questionnaires. Among these efforts has been the development of the "bogus pipeline"~approach (Jones and Sigall 1971) to school-based surveys, first introduced to cigarette smok- ing research by Evans, Hansen, and Mittelmark (1977). The approach has two components: (1) subjects must be told that the investigator has a biochemical test that will accurately assess a respondent's smoking patterns, and (2) this test must be administered (or the biological speci- men must be collected) when the usual self-reported data are collected. Several legitimate biochemical tetits have been used, including measuring carbon monoxide in expired air and measuring thiocvanate or cotinine in saliva. Generall,v, tests measuring nicotine and cotinine levels have higher sensitivitv and specificity-as well as higher cost-than tests measuring carbon monoxide and thiocyanate (e.g., Bauman et al. 1989; Biglan et al. 1985; Etze11990; Fears et a1.1987; Jarvis et al.1987,1988; tioland et al. 1988; Wall et a1.1988). Sensitivitv to these measures increases with age, since as adolescents become older, smoking becomes both more regular and-because it also becomes more socially acceptable-more likely to have occurred shortly before a test is administered. The bogus pipeline procedure has been generally associated with an increase in the percentage of adolescents who report smoking (Murray and Perry 1987), but this has not been shown uniformly (Campanelli, Dielman, Shope 1987; Hill, Dill, Davenport 1988; Werch et a1.1987). The proce- dure may also have the negative effect of reducing rap- port with adolescents by implying that the interviewer does not trust the respondent to be honest (Velicer et al. 1992). None of the surveillance systems described in this chapter used the bogus pipeline procedure. However, the care that all of the surveillance systems took to assure respondents of confidentiality or anonymity may have attenuated the potential for underreporting. Other pos- sible causes of differences in estimates among systems are the.varied, composition of the samples (including which schools and households participated in the stud- ies) and the varied wording of questions used in the surveys (Converse and Traugott 1986)'. Although underreporting will influence a point es- timate of prevalence, trends are likely to be consistent if the survey methodology (and thus any underreporting) remains constant over time. Changes in the social ac- ceptability of smoking and in attitudes towards smoking behavior are factors that across time may differentially affect self-reports (USDHHS 1989b). However, MTFP data can be used to compare the trends of self-reported cigarette smoking prevalence with the high school se- niors' reports of use by their friends, a measure for which there should be little reason to underreport. The trend in the percentage of seniors who report that most or all of their friends smoke is similar to the trend for self- reported prevalence, particularly over the past 10 years (Figure 10). These comparable trends hold for males and females and for whites and blacks (Bachman, Johnston, O'Malley 1980a, b,1981,1984,1985,1987,1991; Johnston, Bachman, O'Malley 1980a, b,1982,1984,1986;1991,1992; ISR, University of Michigan, unpublished data). Epidemiology 111 TIMN 0138963

~~l•~•;cvl~lll~ rccb4tl~<'A Ir(c4h,. illh( /ccl't'/t' and second trv. This observation sugKests that to delav both the onset of first trials as well as the progression to Sociodemographic Factors in the Initiation of Smoking regular use, it seems critical to examine risk factors for Sociodemographic factors involve the economic, first use. Since a young person may become a regular political, social, and educational systems of a societv. ~moktr in on1v two to three vears, the adolescent period of development (particularlv middle school, junior high school, and senior high school) is a crucial time for pre- vention efforts (Evans et al. 1978). These factors can be determinants of behavior, such as tobacco use, even if the svstems thev originate in are not directly associated with the choice to begin that be- havior. Within these systems, social disorganization or Table 2. Characteristics of 27 prospective studies of smoking onset, various countries, 1980-1991 Year of Study publication Place Age* (years) Time' Number= (months) (nonsmokers) Ahlgren et al. 1982 Minnesota 10-11, 11-12 6 562 Alexander et al. 1983 NSW Australia' 10,11,12 12 5,065 Arv et al. 1989 Oregon 12-13,14-15,15-16 6 801 Ary and Biglan 1988 Oregon 12-15,15-16 12 737, Bauman et al. 1984 North Carolina 14-15 12 519 Brunswick and Messeri 1984 New York City 12-16 8-1 3811 Charlton and Blair 1989 Manchester, UK 12-13 4 1,513 Chassin et al. 1984 Indiana 11-16 12 1,207' Chassin et al. 1986 Indiana 11-16 12 145 Collins et al. 1987 Los Angeles 12-13 16 1,354 iie Vries et a I. 1990 Netherlands Secondary 12 555 Goddard 1990 England 11-15 24 2,251 Kellam, Ensminger, Simon 1980 Chicago 6-7 120 705 ' Krohn et al. 1983 Iowa 12-18 12 NA° Lawrance and Rubinson 1986 Illinois 12-14 8 346 McCaul et al. 1982 Minnesota 12-13 12 268 McNeill et al. 1988 Bristol, UK 11-13 30 1,261 Mittelmark et al. 1987 Minnesota 12-14,14-16 18 887 Vturrav et al. 1983 Derbvshire, UK 11-12 48 2,217 Newcomb, McCarthy, Bentler 1989 Los Angeles 12-13,13-14,1 4-15 96 NA Pulkkinen 1982 Finland 8-9 144 135 `Semmer, Cleary, et al. 1987 Berlin-Bremen 12-13 24 761 Semmer, Lippert, et al. 1987 Berlin-Bremen 12-14 6 763 Skinner et al. 1985 Iowa 12-18 24 426 Stacv et al. ~" unpublished Los Angeles 12-13 16 1,116 Sussman et al: 1987 Los Angeles 12-13 16 338 C;rber);, Cheng, Sh 1991 Detroit suburb 13-14,16-17 12 NA Source: Adapted from Conrad, Flay, Hill (1992). *Age = Age (in years) of students at the beginning of the study. 'Time = Number of months from the beginning of the study to the final follow-up wave. 2\umber =\umber of nonsmoking students at the beginning of the study. °tiSW Australia =New• South Wales. Australia. 'tiA = Not available. _Psychosucial Risk Factors 125 TIMN 0138977

PrerenfitW Tobacco Use Among Young People GRANT DJ, MCMURDO MET, BALFOUR DJK. Nicotine and dementia. British Journal of Psychiatry 1989 November;155:716. GREER RO, POULSON TC. Oral tissue alterations associated with the use of smokeless tobacco by teen-agers. Part I. Clinical findings. Oral Surgery 1983;5b(3):275-84. GRITZ ER, BAER-W EISS V, BENOWITZ NL, VAN VUNAKIS H, JARVIK ME. Plasma nicotine and cotinine concentrations in habitual smokeless tobacco users. Clinical Pharmacology and Therapeutics 1981;30(2):201-9. GROSSJ, STITZER ML. Nicotine replacement: ten-week ef- fects on tobacco withdrawal symptoms. Psychopharmacology 1989;98(3):334-41. GUERIN MR, JENKINS RA, TOMKINS BA. The chemistry of environmental tobacco smoke: composition and measurement. Chelsea (MI): Lewis Publishers, Inc., 1992. HAERTZEN CA, KOCHER TR, MIYASATO K. Reinforce- ments from the first drug experience can predict later drug habits and/or addiction: results with coffee, cigarettes, alco- hol, barbiturates, minor and major tranquilizers, stimulants, marijuana, hallucinogens, heroin, opiates and cocaine. Drug and Alcohol Dependence 1983;11(2):147-65. HALL EH, TERZHALMY GT. Oral manifestations of the smokeless tobacco habit. U.S. Navy Medicine 1984;75(3):4-6. HATSUKAMI DK, GUST SW, KEENAN RM. Physiologic and subjective changes from smokeless tobacco withdrawal. Clinical Pharmacology and Therapeutics 1987;41(1):103-7. HATSUKAMI DK, HUGHES JR, PICKENS RW. Character- ization of tobacco withdrawal: physiological and subjective effects. In: Grabowski J, Hall SM, editors. Pharmacological ad juncts in smoking cessation. Monograph No. 53. US Depart- ment of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse. Bethesda (MD): DHHS Publication No. (ADM) 85-1333,1985. HATSUKAMI D, NELSON R, JENSEN J. Smokeless tobacco: current status and future directions. British Journal of Addiction 1991;86(5):559-63. HAYNES WF, KRSTULOVIC VJ, BELL ALL. Smoking habit and incidence of respiratory tract infections in a group of adolescent males. American Review of Respiratory Disease 1966;93(5):730-4. HENNINGFIELD JE. Behavioral pharmacology of cigarette smoking. In: Thompson T, Dews PB, Barrett JE, editors. Ad- vances in behavioral pharmacology. Vol. 4. New York: Academic Press, 1984. HENNINGFIELD JE. Nicotine: an old-fashioned addiction. In: Sanberg PR, Snyder SH, Jacobs BL, Jaffe JH, editors. The encyclopedia of psychoactive drugs. New York: Chelsea House Publishers, 1992a. HENNINGFIELD JE. Occasional drug use: comparing nic- otine with other addictive drugs. Tobacco Control 1992b;1(3): 161-2. HENNINGFIELD JE, CLAYTON R, POLLIN W. Involvement of tobacco in alcoholism and illicit drug use. British Journal of Addiction 1990;85(2):279-92. HENNINGFIELD JE, COHEN C, HEISHMAN SJ. Drug self- administration methods in abuse liability evaluation. British Journal of Addiction 1991;86(12):1571-7. HENNINGFIELD JE, COHEN C, SLADE JD. Is nicotine more addictive than cocaine? British Journal of Addiction 1991;86(5):565-9. HENNINGFIELD JE, GOLDBERG SR. Pharmacologic deter- minants of tobacco self-administration by humans. PF.armacol- ogy, Biochemistry and Behavior.1988;30(1):221-6. HENNINGFIELD JE, LONDON ED, BENOWITZ NL. Arte- rial-venous differences in plasma concentrations of nicotine after cigarette smoking. Journal of the American Medical Associa- tion 1990;263(15):2049-50. HENNINGFIELD JE, MIYASATO K, JASINSKI DR. Abu'se ' liability and pharmacodynamic characteristics of intravenous and inhaled nicotine. Journal of Phannacologyand Experimental Therapeutics 1985;234(1):1-12. HENNINGFIELD JE, NEMETH-COSLETT R. Nicotine de- pendence, interface between tobacco and tobacco-related dis- ease. Chest 1988;93(2 Suppl):37S-55S. HENNINGFIELD JE, NEMETH-COSLETT R, GRABOWSKI J, HAERTZEN C, SNYDER F, RADZIUS A. Acquisition of dependence to cigarettes and smokeless tobacco. In: Annual report of the Addiction Research Center. US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse, 1987. HIRSCHMAN RS, LEVENTHAL H, GLYNN K. The develop- ment of smoking behaviorr conceptualization and supportive cross-sectional survey data. Journal of Applied Social Psychology 1984;14(3):184-206. HOLLAND W W, ELLIOTT A. Cigarette smoking, respiratory symptoms, and anti-smoking propaganda. An experiment. Lancet 1968;1(532):41-3. Health Consequences 45 TIMN 0138898

Chapter 5 Tobacco Advertising and Promotional Activities The Role of Advertising and Promotion in the Marketing of Tobacco Products 159 Introduction 159 Cigarette Advertising and Promotional Expenditures 160 Smokeless Tobacco Advertising and Promotional Expenditures 163 A History of Cigarette Advertising to the Young 164 Ads Targeting Women 164 Ads Targeting Young People 166 Promotion Through Radio and Television 167 Promotion Through Schools 167 Sponsorship of Sports 168 Criticism of Advertising and Promotional Activities 168 Self-Regulatory Cigarette Advertising Codes 170 Candy Cigarettes 170 Changes in the Style of Cigarette Advertising 171 Motivation Research and the Image Era 171 Consequences of Image Advertising 172 Conveying Male and Female Images 172 Historical Perspectives on the Effectiveness of Cigarette Advertising 172 Academic and Industry Analyses 172 Advertising Professionals 173 The Uiitted States Tobacco /ournal 173 The "Maturity" of the Cigarette Market 174 Contemporary Strategies of the Tobacco Industry 175 Researching the Young 175 Portraying Youthful Behavior 176 Conveying Pictures of Health 176 Projecting Images of Independence 176 Images of the American Ideal 177 Historical Content Analyses of Cigarette Advertising 179 Introduction 179 Increasein Visual and Vivid Advertising 179 Becoming Pictures of Health 180 Advertising That Targets Youthful Audiences 181 Imaging Individualism, Independence, and Self-Reliance 182 Other Related Research 183 Perceptions of Models' Ages 183 Ads That Target Women 184 Ads That Target Blacks 184 TIMN 0139009

tiiir~iv»> C;crrcna!'~, IZcF w•t t per day have been classified traditionallv as "dailv " smok- ers (USDHHS 1989b; Johnston,O'Malley, Bachman 1991a) and are so classified in this report. However, some persons who average one or more cigarettes per day during a given month may not have smoked on every day of that month. Age or Grade When Smoking Begins Age at initiation is measured as the age when a respondent first tried a cigarette (NHSDA), smoked the first whole cigarette (TAPS, YRBS), first became a daily smoker (YRBS, NHSDA), or started smoking fairly regu- larly (NHIS). The MTFP records the school grades in which the respondent first smoked a cigarette and first smoked on a daily basis. The NHIS measure of the age when the respondent first started smoking fairly regu- >larly can be used to estimate the percentage of adults who became regular smokers during their adolescent years. Number of Cigarettes Smoked Each Day Besides inquiring about the average number of cigarettes smoked during the 30 days preceding the sur- vey, TAPS asks respondents to report the number of cigarettes smoked on each of the seven days preceding the survev. The YRBS, on the other hand, determines the average number of cigarettes smoked on the days ciga- rettes were smoked during the previous 30 days. Lifetime Patterns of Smoking The MTFP asks participants if they have ever smoked cigarettes. The response categories ("never," "once or twice," "occasionally, but not regularly;' "regu- larly in the past," and "regularly now") can be used to summarize lifetime patterns of use. To assess the relationship between cigarette smoking and various health status indicators, a five-item scale is used: never smoked cigarettes or.snioked once or twice; smoked occasionally, but never.-regularly; smoked regularly in the past, but not in the previous 30 days; smoke regularly now and began daily smoking in grades 10 through 12; and smoke regularly now and began daily smoking before grade 10. A more detailed initiation continuum can be de- fined through responses to three TAPS questions that measure the likelihood of smoking in the future. Re- spondents who have never tried cigarette smoking are asked, "Do you think you will try a cigarette soon?" Respondents who have never smoked and respondents who have had only a few puffs of a cigarette are asked, "If one of yuur best friends were to otfer you a cigarette, would you smoke it?" All respondents are asked, "Do you think you will be smoking cigarettes one year from now?" By using responses to these questions on per- ceived susceptibility to smoking in the future and by using responses to other questions on current smoking patterns, one can construct an uptake continuum that records how likely the respondent is to become a smoker and whether or not a person has tried smoking, smoked a whole cigarette, smoked 100 cigarettes, smoked at all in the past 30 days, and smoked on 20 or more of the past 30 days. Attempts to Quit Smoking For the MTFP, Johnston, O'Malley, and Bachman (1991a) have defined "noncontinuance" as no smoking during the past 30 days among high school seniors who report that they have smoked regularly. The MTFP also measures interest in quitting ("Do you want to stop smoking now?") and difficulty in quitting ("Have you ever tried to stop smoking and found that you couldn't?"). TAPS respondents who have smoked at least 100 ciga- rettes and have not smoked in the past 30 days can be considered former smokers. TAPS also records how many times a smoker has tried to quit during the previous six months. Validity of Measures of Smoking Smoking patterns among youth are most frequently assessed through self-reported data. However, because smoking is not considered a socially desirable behavior for youth, especially among parents regarding their own children's smoking, young people may not report hon- estly. Various survey methods thus try to improve the validity of self-reported data. Factors that may influence this validity include (1) the survey setting (e.g., at school or at home), (2) the survey method (e.g., self-adminis- tered questionnaire, in-person interview, or telephone interview), (3) the use of the "bogus pipeline" manipula- tion, described later, and (4) the degree of anonymity available to the respondent. Home- or telephone-based surveys might be ex- pected to yield higher estimates of adolescent smoking than school-based surveys, since nonschool surveys are much more likely to include chronic absentees and drop- outs-groups known to have dramatically higher levels of smoking (Pirie, Murray, Luepker 1988; CDC 1991a). On the other hand, the greater anonymity afforded by self-administered, school-based surveys might yield higher estimates of adolescent smoking than face-to-face or telephone interviews. Because few studies have 110 Epidemiology TIMN 0138962

1'rt':'t'NftN,t Tohri1-0 Lb~c r11MU/t' 1 Ul/llt' f t'(Th' Table 1. Domestic cigarette advertising and promotional expenditures, 1963-1990 Total advertising* dollars Year (in millions) Total promotional' dollars (in millions) Total advertising and promotional dollars (in millions) Advertising as percentage of total dollars 1963 228.9 13.2 249.5 91.7 1964 240.9 14.6 261.3 92.2 1965 242.3 14.7 263.0 92.1 1966 272.7 17.9 297.5 91.7 1967 285.6 20.3 311.9 91.6 1968 283.1 21.6 310.7 91.1 1969 283.6, 13.4 305.9 92.7 1970 296.6 .64.4 361.0 82.1 1971 220.4 27.0 251.6 87.6 1972 226.7 22.9 257.6 88.0 1973 220.9 15.2 247.5 89.3 1974 266.5 31.1 306.8 86.9 1975 330.8 160.4 491.3 67.3 1976 425.9 213.2 639.1 66.6 1977 505.8 273.6 779.5 64.9 1978 543.1 331.9 875.0 62.1 1979 682.8 400.6 1,083.4 63.0 1980 790.1 452.2 1,242.3 63.6 1981 899.3 648.3 1,547.7 58.1 1982 923.2 870.6 1,793.8 51.5 1983 910.8 990.0 1,900.8 47.9 1984 930.2 1,065.0 2,095.2 44.4 1985 932.0 1,544.4 2,476.4 37.6 1986 796.3 1,586.0 2,382.4 33.4 ~ 1987 719.2 1,861.3 2,580.5 27.9 1988 824.5 2,450.4 3,274.9 25.2 1989 868.3 2,748.7 3,617.0 24.0 1990 835.2 3,156.9 3,992.0 20.9 Source: Federal Trade Commission (1992). •[ncludes print advertising in newspapers, magazines, billboards, and public transit and (until ban effective January 1, 1971) on television and radio. 'Includes promotional allowances, sampling distributions, specialty item distribution, public entertainment, direct mail, endorsements, testimonials, coupons, audio-visual, and retail value-added, point-of-sale advertising, except for 1963-1974 and 1971-1974; for 1963-1969 and 1971-1974, only direct mail expenditures are included ("others" category not included). Advertising and Promotion 161 TIIViN 0139013

tilll'"l'rrll Gt'llt'r,iI ~~ kr f Table 2. Domestic cigarette sales and per capita consumption, 1963-1990 ear Total number of cigarettes sold (in billions) Cigarette consumption (per capita) Cigarette sales revenue (in millions) Total advertising and promotional dollars (in millions) 1963 516.5 4,286 NA* 249.5 1964 505.0 4,143 NA 261.3 1965 521.1 4,196 NA 263.0 1966 529.9 4,197 NA 297.5 1967 525.8 4,175 " NA 311.9 1968 540.3 4,145 NA 310.7 1969 527.9 3,986 NA 305.9 1970 534.2 3,969 NA 361.0 1971 547.2 3,982 NA 251.6 1972 561.7 4,018 NA 257.6 1973 584.7 4,112 NA 247.5 1974 594.5 4,110 NA 306.8 1975 603.2 4,095 NA 491.3 1976 609.9 4,068 NA 639.1 1977 612.6 4,015 15,594 779.5 1978 615.3 3,965 16,856 875.0 1979 621.8 3,937 17,668 1,083.4 1980 628.2 3,858 19,035 1,242.3 1981 636.5 3,818 20,822 1,547.7 1982 632.5 3,733 22,093 1,793.8 1983 603.6 ~w „~ 3,513 25,724 1,900.8 1984 ` 6a. 4 3,497 27,370 2,095.2 1985 599, 3 3,400 28 918 2 476 4 ;. ' , , . 1986 586.4 3,288 30,293 2,382.4 1987 575.4 3,190 32,145 2,580.5 1988 560.7 3,073 33,042 3,274.9 1989 525.6 2,846 37,048 3,617.0 1990 523.7 2,829 39,616 3,992.1 Sources: Federal Trade Commission (1992); U.S. Department of Commerce (1992a, b). *NA = Not available. 162 Advertising and Promotion TIMN 0139014

/'rc'c-c'ritui,ti Tt'htc'LO Ll,c•.-lrrwnt 1`t,rialt Pcvfdc Introduction Tobacco use begins primarily through the dvnamic interplay of sociodemographic, environ- mental, behavioral, and personal factors. These psychosocial risk factors increase a persori 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, for example) areconsidered proximal riskfactors, 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 persori 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 matureself- identitv. 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 researcch studies that have been published pri- marily in peer-refereed journals or books during the past 15 vears.. Results from these studies were grouped according to psychosocial risk factor, and conclusions were based on the availabilitv 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 Risk factors Smokeless Smoking tobacco Sociodemographic factors Low socioeconomic status x Developmental stage x x Male gender x Environmental factors Accessibility x x Advertising x x Parental use Sibling use x Peer use x x Normative expectations x x Social support x Behavioral factors Academic achievement x x Other problem behaviors x x Constructive behaviors x Behavioral skills x Intentions x x Experimentation x x Personal factors Knowledge of consequences x Functional meanings x x Subjective expected utility x Self-esteem/self-image x x Self-efficacy x Personality factors x Psychological well-being x Psychosocial Risk Factors 123 TIMN 0138975

Surgeon General's Report TAGER IB, WEISS ST, MUNOZ A, ROSNER B, SPEIZER FE. Longitudinal study of the effects of matemal smoking on pulmonary function in children. New England Journal of Medi- cine 1983;309(12):699-703. TAGER IB, WEISS ST, ROSNER B, SPEIZER FE. Effect of parental cigarette smoking on the pulmonary function of chil- dren. American Journal of Epidemiology 1979;110(1):15-26. TAIOLI E, WYNDER EL. Effect of the age at which smoking begins on frequency of smoking in adulthood [letter]. New England Journal of Medicine 1991;325(13):968-9. TOWNSEND J, WILKES H, HAINES A, JARVIS M. Adoles- cent smokers seen in general practice: health, lifestyle, physi- cal measurements, and response to antismoking advice. Brit- ish Medical Journal 1991;303(6808):947-50. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. The health consequences of smoking for women. A report of the Surgeon General. US Department of Health and Human Ser- vices, Public Health Service, Office of the Assistant Secretary for Health, Office on Smoking and Health, 1980. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. Drug abuse and drug abuse research. The second triennial report to Congress from the Secretary, Department of Health and Human Services. US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration. DHHS Publication No. (ADM) 87-1486,1987. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. The health consequences of smoking: nicotine addiction. A report of the Surgeon General, 1988. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Health Promotion and Education, Office on Smoking and Health. DHHS Publication No. (CDC) 88-8406,1988. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. Reducing the health consequences of smoking: 25 years of progress. A report of the Surgeon General. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS Publication No. (CDC) 89-8411,1989. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. The health consequences of smoking: the changing cigarette. A report of the Surgeon General. US Department of Health and Human Services, Public Health Service, Office on Smoking and Health. DHHS Publication No. (PHS) 81-50156,1981. US DEPARTMENT OF HEALTH AND I NMAhI SERVICES. The health consequences o f smoking: cancer. A report of the Surgeon General. US Department of Health and Human Services, Pub- lic Health Service, Office on Smoking and Health. DHHS Publication No. (PHS) 82-50179,1982. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. The health consequences of smoking: cardiovascular disease. A report of the Surgeon General. US Department of Health and Human Services, Public Health Service, Office on Smoking and Health. DHHS Publication No. (PHS) 84-50204,1983. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. The health consequences of smoking: chronic obstructive lung dis- ease. A report of the Surgeon General. US Department of Health and Human Services, Public.HeaIth Service, Office on Smok- ing and Health. DHHS Aublication No. (PHS) 8450205,1984. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. The health consequences of involuntary smoking. A report o,f the Surgeon General. US Department of Health and Human Ser- vices, Public Health Service, Centers for Disease Control. DHHS Publication No. (CDC) 87-8398,1986a. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. The health consecl'uences of using smokeless tobacco. A report of the advisor>> committee to the Surgeon General. US Department of Health• and Human Services, Public Health Service, National Institutes of Health. NIH Publication No. 86-2874,1986b. 50 Health Consequences US DEPARTMENT OF HEALTH AND HUMAN SERVICES: The health benefits of smoking cessation. A report of the Surgeon General. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Of- fice on Smoking and Health. DHHS Publication No. (CDC) 90-8416,1990. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. Drug abuse and drug abuse research. The third triennial report to Congress from the Secretary, Department of Health and Hu- man Services. US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration. DHHS Publication No. (ADM) 91-1704,1991a. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. Guidelines for the diagnosis and management of asthma. National asthma education program. Expert panel report. US Depart- ment of Health and Human Services, National Institutes of Health. Publication No. 91-3042. Bethesda (MD): 1991b. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. National household survey on drug abuse: main findings 1990. DHHS Publication No. (ADM) 91-1788,1991c. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. Smokeless tobacco or health: an international perspective. Mono- graph No. 2. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute. Bethesda (MD): NIH No. 92-3461,.1992a. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. Spit tobacco and youth. US Department of Health and Human Services, Office of Inspector General. Publication No. OEI 06- 92-00500,1992b. TINY.N 0138903

Tohlttat Ll:-a' .'I »lt~ilti ~ Ulll 1 PiUFt1i 1988 (in thousands) % of total 1989 (in thousands) % of total 1990 (in thousands) % of total 105,783 3.2 76,993 2.1 71,174 1.8 355,055 10.8 380,393 10.5 328,143 8.2 319,293 9.7 358,583 9.9 375,627 9.4 44,379 1.4 52,294 1.4 60,249 1.5 222,289 6.8 241,809 6.7 303,855 7.6 879,703 26.9 999,843 27.6 1,021,427 25.6 74,511 2.3 57,771 1.6 100,893 2.5 190,003 5.8 262,432 7.3 307,037 7.7 88,072 2.7 92,120 2.5 125,094 3.1 42,545 1.3 45,498 1.3 51,875 1.3 781 • - - 874,127 26.7 959,965 26.5 1,183,798 29.6 78,366 2.4 89,290 2.5 62,917 1.6 3,274,853 100.0 3,616,993 100.0 3,992,008 100.0 to women. His cigarette campaign began in the 1920s with an advertisipg budget of $400,000, which grew to $19 million by 1931x This budget supported a print advertising cam that featured women and associ- t~Sn ated cigarettes with:the attribute of bodily slimness. The principal selling idea was that smoking was an aid to diet behavior and weight control-a notion explicitly com- municated by the slogan, "Reach for a Lucky Instead of a Sweet" (Gunther 1960). The American Tobacco Company viewed the prospect of reaching the potential female market as "opening a new gold mine right in our front yard" (Bernays 1965, p. 383). Through Edward Bernays, perhaps the nation's most famous public relations con- sultant, the American Tobacco Company hired A. A. Brill, a psychoanalyst who advised the company to promote cigarettes as "symbols of freedom" (Bernays 1965, p. 386). Bernays then organized women to smoke in public in the 1929 New York Easter Parade (Schudson 1984) and to carry placards identifying their cigarettes as "torches of liberty" (Bernays 1965, p. 197). Photos and articles were distributed to small-town newspa- pers across the nation (Schudson 1984). Bernays called this public relations activity "the engineering of con- sent" (Bernays 1965, p. 390).. Advertising for other firms and brands also in- creasingly featured women and aimed advertising at women. In 1926, the Chesterfield brand of Liggett & Myers displayed a young woman saying, "Blow Some My Way" (Howe 1984). This ad precipitated public Advertising and Promotion 165 TIMN 0139017

P1'tvt'titlll~: It'I't7cc tLI•c',17Nttif~ 1t4ltiti I'c't'I,It' structure, age, gender, and ethnicity, especiallv when examined across an entire population. 'Aanv of these factors are covered in Chapter 3 (see "Recent Patterns of Cigarette Smoking"). Socioeconomic Status Low socioeconomic status (SES) has been shown to predict smoking initiation in multiple longitudinal stud- ies (Conrad, Flav, Hill 1992). Semmer, Lippert, et al. (1987) examined tobacco use among students in two schools in Germany. These investigators found that seventh- and eighth-grade students from the school in a low-income area (children of primarily blue-collar par- ents) had higher baseline rates of tobacco use than youth from the school in a higher-income area. Low-income students were also more likely to begin smoking over the course of this six-month study. Low-income students had greater expectations of positive consequences of smoking, lower self-image scores, and more friends who smoked. One possible explanation of the impact of SES supported by these findings is that lower-income stu- dents may have to cope more often with stressful situa- tions, such as lacking sufficient resources or living in a one-parent family, and are therefore more likely to per- ceive smoking as a quick, easy coping strategy for stress or loneliness-and as a strategy that is socially accepted and effective (Semmer, Cleary, et al. 1987). Adolescents from low-income families mav also have more role mod- els who smoke and less supervision to discourage ex- perimentation than adolescents from higher-income families (Perry, Kelder, Komro 1993). Parental Education The level of parental education has been shown to have a significant impact on adolescent smoking be- havior in some studies. Although Ary et al. (1983) failed to find a relationship between parental education and children's smoking behavior, in a later report, Arv and Biglan (1988) found that low educational attain- ment among fathers was predictive of smoking onset in middle schoolyouth. Waldron and Lye (1990) re- ported that high-school seniors who had less-educated parents were more likely to have tried a cigarette and to have adopted cigarette smoking and were less likely to have quit smoking. Finally, Mittelmark et al. (1987) found that both adolescent females at all grade levels and adolescent males in grades 9 through 11 who began to smoke during the course of the study had parents with fewer years of formal education•than their peers who remained nonsmokers. However, for seventh-and eighth- grade males in this study, parental educational level did not help to predict smoking initiation. See "Trends <~nal~.i~ in Cigarette Smoking" in Chapter 3 for a trend of adolescent smoking behavior and level of parental education. Number of Parents Living in the Home Several studies document an association between beginning to•smoke during childhood or adolescence and living in a single-parent home (Oei, Egan, Silva 1986; Elder, Molgaard, Gresham 1988; Isohanni, Moilanen, Rantakallio 1991; Goddard 1990; see "Sociodemographic Risk Factors for Smoking" in Chapter 3). These findings must be interpreted with caution, since most are from cross-sectional studies that were unable to determine with certainty which occurred first-living in a single- parent home or smoking. If a predictive relationship does exist, a mechanism described by Castro et al. (1987) may help to explain the causal link. Their analyses found that living in a disrupted family system is an initial stressor that appears to predict social nonconfor- mity and affiliation with cigarette-smoking peers. In turn, as will be discussed later in this chapter, both social nonconformity and peer affiliation are significant pre- dictors of cigarette smoking among adolescenti. Developmental Challenges of Adolescence The life stage of adolescence itself has been a con- sistent predictor of smoking initiation across studies (Alexander et al. 1983; Coombs, Fawzy, Gerber 1986; Bauman et al. 1990). The transition vears from elemen- tary to secondary school seem to be a particularly high- risk time for adolescent initiation of tobacco use (Alexander et al. 1983; Coombs, Fawzy, Gerber 1986). Indeed, both the rate of onset of smoking and the preva- lence of regular smoking may level off during the high school years (Kandel and Logan 1984; McDermott et al. 1992). The relationship between adolescence and smok- ing initiation that is seen in these studies may be related to the developmental challenges of adolescence and to the social meaning of smoking. Adolescence is characterized by three major types of developmental challenges (Hooker 1991). The first involves physical maturation, particularly sexual matu- ration, and the establishment of intimate relationships. A second group of challenges involves responses to cul- tural pressures to begin making the transition to adult roles and responsibilities and to emotional independence from parents. The third area, the personal, involves establishing a coherent sense of self and a set of values to guide future behavior. As adolescence begins, efforts to meet these various challenges are characterized by ex- perimentation and risk-taking behaviors (Konopka 1991). Cigarette smoking is a risk behavior portrayed by Psychosocial Risk Factors 127 TIMN 0138979

5urNewn Gev+e•ra!'- iieporr Table 3. Domestic cigarette advertising and promotional expenditures,* 1986-1990 Expenditures ' 1986 (in thousands). %'~ of total 1987 (in thousands) % of total Newspapers 119,629 5.0 95,810 3.7 Magazines 340,160 14.3 317,748 12.3 Outdoor 301,822 12.7 269,778 10.5 Transit 34,725 1.5 35,822 1.4 Point-of-purchase 135,541 5.7 153,494 5.9 Promotional allowances 630,036 26.4 702,730 27.2 Sampling distribution 98,866 4.1 55,020 2.1 Speciality item distribution 210,128 8.8 391,351 15.2 Public entertainment 71,439 3.0 71,389 2.8 Direct mail 187,057 7.9 187,931 7.3 Endorsements and testimonials 384 - 376- Coupons and retail value-added -- All otherst 252,570 10.6 299,355 11.6 Total= 2,382,357 100.0 2,580,504 100.0 Source: Federal Trade Commission (1992). *[n U.S. dollars. 'Expenditures for audiovisuals are included in the "all others" category to avoid disclosure of individual company data. tBecause of rounding, sums of percentages may not equa1100. A History of Cigarette Advertising to the Young Ads Targeting Women In the first quarter of the twentieth century, ciga- rette firms demonstrated their ability to target and de- velop specific market segments. In the 1920s, cigarette smokers were predominately males, but the industry recognized females as a large and potentially lucrative market segment open to development Encouraging the growth of smoking among women was an explicit goal of industry leaders and the focus of both advertising and major public relations efforts. The American Tobacco Company hired advertising expert A. D. Lasker of Lord & Thomas to work on Lucky Strike advertising. Previ- ously, Lasker had successfully handled the delicate prob- lem of advertising sanitary products (i.e., the Kotex brand) 164 Advertising and Promotion TIMN 0139016

r advertising and role models as a way to be attiacfive to one's peers (see "Contemporary Strategies of the To- bacco Industry" in Chapter 5), and smoking appears to contribute to a positive social image in some settings (Sussman et al. 1987). The functions of smoking estab- lished by advertising and adult role models coincide with the challenges of adolescence and thus make this age group the most vulnerable for experimentation and initiation. Gender Although current smoking prevalence is roughly equal among males and females in the United States, different historical trends for men and women are evi- dent (Grunberg, Winders, Wewers 1991). Between 1974 and 1985, smoking initiation declined from 45 to 33 per- cent among young men but remained constant at 34 percent among young women (Fiore et al. 1989; see "Trends in Cigarette Smoking" in Chapter 3). Two stud- ies have discussed the impact of changing gender roles (e.g., more women are in traditionally male positions of authority) on smoking behavior and the resulting differ- ence in meaning that smoking has for males and females (Gritz 1984; Gilchrist, Schinke, Nurius 1989). Though some have suggested that generic factors that influence smoking initiation, such as appealing to the opposite gender, become more pronounced for one gender or the other at certain ages (Chassin et al. 1986), others have further concluded that the complex combinAtions of risk factors and processes leading to smoking are fundamen- tally different for females and males (Brunswick and Messeri 1984). In a review of research on gender differ- ences, Clayton (1991) found both considerable similari- ties (for instance, the influence of peer and parent models) and a number of possible differences between adoles- cent females and males who smoke. For example, ado- lescent girls who smoke are more socially skilled (e.g., more at ease with their peers, with strangers, or with adults) than their nonsmoking peers, whereas adoles- cent bovs who smok,e~tend to lack such skills. Concern v,~, ~.... . about body weight-~d the belief that smoking might help control body weigItt may also lead adolescent fe- males to begin smoking (Gritz and Crane 1991; Camp, Klesges, Relyea 1993). Further longitudinal research is needed to investigate gender differences in the determi- nants of tobacco use and thus to clarify the effect of gender on smoking initiation. Ethnicity Research also indicates that the rate of smoking initiation varies among ethnic groups. Sussman et al. (1987) found, that among California youth progressing 128 Psychosocial Risk Factors fr6m sz~~enth to eighth grade, onset rates were higher for Hispanics and blacks than for whites and were lowest for Asians. Similarly, Maddahian, Newcomb, and Bentler (1986) found that among California students followed from 7th through 12th grades, black youth maintained higher rates of smoking than youth of other ethnic groups. White and Hispanic students had intermediate rates of smoking, and Asian youth reported the lowest levels, although this difference decreased over time. Other national reports, however, indicate a higher percentage of smoking among white adolescents and young white adults than among their black or Hispanic counterparts (Remington et al. 1985; Fiore et al. 1989; Bachman et al. 1991; see "Trends in Cigarette Smoking" in Chapter 3). These findings suggest different onset and quitting pat- terns among ethnic groups, as well as potential regional differences in these patterns. Maddahian, Newcomb, and Bentler (1986) have proposed antecedents that may help explain these ethnic differences in tobacco use, including income levels that preclude or enable the acquisition of cigarettes, different levels of tobacco availability, and psychosocial influ- ences associated with belonging to a particular ethnic group. These investigators found that among California students, the level of income earned by youth had a significant impact on explaining ethnic differences in tobacco use. However,'ethnic differences were virtually eliminated when availability and ease of cigarette acqui- sition from friends were considered. Sussman et al. (1987) found that unique combina- tions of psychosocial factors may be relevant to the eth- nic differences in smoking initiation. Three variables-availability of cigarettes, difficulty in refus- ing offers of cigarettes, and intentions to smoke in the future-were significant predictors among youth from all ethnic groups included in their study. However, only among select groups were certain other variables impor- tant predictors of smoking initiation. For instance, social environmental variables (including peer smoking and adult smoking) were important predictors for white youth, but direct personal and social reinforcement vari- ables (including improved self-image and adult and peer approval of smoking) were more important variables for Hispanic youth. General risk-taking behavior was an important additional predictor for black youth only. The strongest additional predictors for Asian students in- cluded lack of general self-esteem and decreased school- related self-esteem. Environmental Factors in the Initiation of Smoking Environmental factors are those that are exter- nal (or perceived as external) to adolescents and yet TIMN 0138980

I 'Pt'i'PiTr!!1\' TUhdlY0 LI>c'.I 11kVlt Ycm tlt I'lvFiIL' mav influence and affect their behavior. These fac- tors include the availability of cigarettes in the com- munity, the acceptability of smoking, peer and parental smoking, and adolescents' perceptions of the environment. Factors That Influence Tobacco Acceptability and Availability Factors that increase the acceptability and avail- ability of cigarette use at a societal or community level serve also to influence adolescent smoking behavior. Acceptability and availability are affected, in part, by the tobacco industry through advertising and other promo- tional activities; this topic is discussed thoroughly in Chapter 5. Acceptability of tobacco use may also be accomplished through persuasive, multiple, attractive role models who smoke on television programs or in movies (Bandura• 1977). Acceptability is further rein- forced by community norms and policies that make to- bacco products relatively accessible for adolescents-for . example, through sales to underage buyers and unre- stricted access to cigarette vending machines (see "Re- strictions on Minors' Access to Tobacco" in Chapter 6). The National Adolescent Student Health Survey (Ameri- can School Health Association et al. 1989) found that 79 percent of 8th graders and 92 percent of 10th graders considered it to be"verv easv" or "fairly easy" to get cigarettes. Likewise, in the 1991 Monitoring the Future Project studv (Johnston, O'Mallev, Bachman 1992) 73 percent of 8th graders and 88 percent of 10th graders reported that it would be "fairly easy" or "very easy" to get cigarettes. In a study of adolescents in southern California, Sussman et al. (1987) found that both genders and all racial/ethnic groups except Asians tended to believe that they could obtain cigarettes with little diffi- culty. Findings from a national sample of teenaged (12- 17 years old) smokers confirm these perceptions and suggest that 1.3 million of an estimated 2.6 million un- derage smokers buy. their own cigarettes (Centers for Disease Control CL~C1.1992). Of those who buv their ~, own cigarettes, . percent purchase them from a small ~% store, 50 percentfi%a;large store, and 14 percent from ~. .:; . . a vending mach~,,either often or sometimes (CDC 1992). These reports have been substantiated by obser- vational studies of cigarette buying by young teenagers (see "Studies of Young People's Access to Tobacco" in Chapter 6). Several studies have found that the general availability of cigarettes predicts the onset of smoking (Bauman et a1.1984; Semmer, Cleary, et a1.1987). Factors that increase acceptability and availability support a social milieu in which cigarette smoking may appear socially functional. On the other hand, a social milieu can decrease the risk of adolescent smoking-if, for example, communities choose to restrict vtpu~ure to tobacco-promoting images or restrict access to tobacco products (see Chapter 6 for further discussion of Such restrictions). Currentlv, as more communities and states adopt a variety of restrictive policies and programs, evaluation research is needed to examine the effective- ness of these strategies for reducing onset of tobacco use. Interpersonal Factors Interpersonal factors in the initiation of smoking involve opportunities for adolescents to perceive, through modeling by adults and peers who smoke, apparent advantages of smoking. These role models (particularly peers) also provide the situations (e.g., parties, staving overnight) in which cigarettes are first tried by adoles- cents (Lawrance and Rubinson 1986). Interpersonal fac- tors have also been labeled "social learning variables" (Bandura 1977; Flay 1993) because the social functions or meanings of smoking are learned in the context of social interactions. The research on interpersonal factors has carefully explored the roles of parents, siblings,_friends, ~ and peers in the process of initiation. Parental Smoking The research on the influence of parents' smoking behavior on their children's cigarette use has included multiple studies of the relative risk of initiation if one or both parents smoke. Bauman et al. (1990) found a consis- tent relationship between parental and adolescent smok- ing in a cross-sectional study of 12- through 14-year-olds in 10 urban areas in the southeastern United States. Com- pared with adolescents whose parents had never smoked, those whose parents currently smoked were almost twice as likely to smoke; those whose parents had once smoked were three times as likely to smoke. A similar influence of parental smoking was noted by Chassin et al. (1986) for females in a longitudinal study of 12- through 18- vear-olds from the°midwestem United States. In Sussman et al. (1987), a longitudinal study of 11- through 14-year- olds in southern California, parental smoking was pre- dictive of a child's smoking for whites but not for Hispanics, blacks, or Asians. This finding matches that of Hunteret al. (1987) in a longitudinal study of 8- through 17-year-olds in the southern United States, in which pa- rental behavior was predictive of children's smoking initiation for whites but not for blacks. By contrast, parental smoking behavior was a poor predictor of smoking initiation in several other studies, including the longitudinal study McCaul et al: (1982) conducted among 11- through 14-year-old whites living in the north-central United States. No relationship was found in the Botvin.et al. (1992) cross-sectional study of _ Psychoyncinl Risk Factors 129 TIMN 0138981

PPC'Z't'riflll~ rt'E'rTt.'ir'U-;c'AN/tm~ Pc't'f!h' Smokeless Tobacco Use" in Chapter 3); lower parental education (Bauman, Koch, Lentz 1989; Botvin, Baker, Tortu 1989); blue-collar parental occupation (Burke et al. 1989; Elder, Molgaard, Gresham 1988; Novotny et al. 1989); and rural environment (Olds 1988; Botvin, Baker, Tortu 1y89; Rouse 1989; Lisnerski et al. 1991; see "Sociodemographic Risk Factors for Smokeless Tobacco Use" in Chapter 3). As is reported in Chapter 3 (see "Current Use of Smokeless Tobacco"), prevalence varies among regions and is somewhat lower in the Northeast than in other regions. Environmental Factors in the Initiation of Smokeless Tobacco Use Factors That Influence Acceptability and Availability Ease of access to smokeless tobacco appears to be an important factor in initiation, and young people seem.to have little trouble obtaining smokeless tobacco (USDHHS 1992a, CDC 1993). In interviews conducted by the Office of Inspector General (USDHHS 1986), 90 percent of smokeless tobacco users in junior and senior high school reported that they purchased their own smokeless tobacco; 94 percent reported that although they were minors, it was either never or only rarely difficult for them to purchase smokeless tobacco. Conve- nience stores were the most frequent purchase site (55 percent); supermarkets and grocery stores accounted for an additional 33 percent of sales. Barovich et al. (1991) found that 50 percent of store personnel were willing to sell to minors. In another study (Leopardi et al. 1989), junior high school students reported that their leading sources of smokeless tobacco were friends (43 percent) and direct store purchase (30 percent); senior high school students' chief sources were direct purchase (62 percent) and friends (25 percent). In a recent study in Texas, minors successfully purchased smokeless tobacco in 59 percent of stores selling the product (CDC 1993). Interpersonal Factors Parental Use As in the research on cigarette smoking, the evi- dence depicts either a modestly positive or no significant association between parental use of smokeless tobacco and adolescent use. The only prospective study that examined parental use foundd no link to onset or contin- ued use of smokeless tobacco among youth (Ary, Lichtenstein, Severson 1987). However, several cross- sectional studies have reported significant relationships between concurrent use by parents and youth (Cohen et al. 1987; Hall and Dexter 1988; Colborn, Cummings, Michalek 1989; Glcn•er et al. lytiy; Brownscm et al. lyyl)1. Bauman, Koch, and Lentz (1989) found that an adcile,;- cent was more likely to use smokeless tobacco if the father did, although there was an interaction with the level of the father's education. Two cross-sectional stud- ies found no significant association between con- current use of smokeless tobacco by parents and adoles- cent offspring (Chassin et al. 1985; Ary, Lichtenstein, Severson 1987). Sibling Use The evidence from cross-sectional studies gener- ally supports a relationship between a sibling's use of smokeless tobacco and an adolescent's use. However, one prospective study did not find significant sibling relationships (Ary, Lichtenstein, Severson 1987), and an- other study found no effect for "older family members" (Chassin et al. 1985). The sole longitudinal study did not find that sibling use was related to adolescent onset (Ary, Lichtenstein, Severson 1987). Peer Use Although a substantial amount of cross=sectional research has examined the use of smokeless tobacco by peers, only two longitudinal studies have been pub- lished. Every cross-sectional study found that peer use was significantly related to adolescent use (Cohen et al. 1987; Hall and Dexter 1988; Lucas and Christen 1988; Glover et al. 1989; Leopardi et al. 1989; Riley, Barenie, Myers 1989; Brownson et al. 1990; Hunter, Vizelberg, Berenson 1991). Peer use of smokeless tobacco was related to the onset of adolescent use at the 9-month follow-up in one longitudinal study (Ary et al. 1989) but not in another study (Ary 1989) at the 6- and 12-month follow-up times. However, peer use was found to be related to continued use among initial daily users of smokeless tobacco at 6-, 9-, and 12-month follow-ups (Ary, Lichtenstein, Severson 1987; Ary 1989). Perceived Environmental Factors Norms Current evidence indicates that most adolescents who use smokeless tobacco perceive that this behavior is socially acceptable. The Office of Inspector General (USDHHS 1986) reported the following findings from a survey of male adolescents who used smokeless to- bacco: • 86 percent perceived that most or some students at their school approved of smokeless tobacco use. Psychosocial Risk Factors 141 TIMN 0138993

rtni%: T',,h it 'k ~1 t/,<•.Innori•~ 1 (I irrI t 1'olph• Implications of Research for Preventing Tobacco Use: Modifying Psychosocial Risk Although substantial research has examined the onset of tobacco use for individual adolescents, there is clearlv a need to examine how change in community and cultural factors may modify onset rates. This review of the literature strongly suggests that the onset_ of to- bacco use is sociallv learned and is a social behavior for adolescents, with socially relevant meanings, images, and functions. Therefore, rather than focusing only on individuals and families as the primary targets of pre- vention efforts, atten'.ion should also be directed to the social environment of adolescents. These efforts should consistently and persuasively promote the prevention and cessation of tobacco use and should demonstrate that the meanings of tobacco use are negative. Preven- tion efforts should portray tobacco use as a behavior that is nonnormative, unattractive, addictive, and immature. Although the meanings of tobacco use are learned in childhood, earlv to middle adolescence appears to be the time of greatest need for direct intervention. This idea is not only supported epidemiologically by the oc- currence of highest onset rates during this time, but also developmentally, in that the challenges of adolescence can expose vouth to the perceived utility of tobacco use. The meanings of tobacco use that have been established in our sc~cietv become personally relevant during adoles- cence. Tobacco use becomes a mechanism to establish social relationships, display independence, and create a new, mature identity. Moreover, because many adoles- cents believe themselves to be all but invulnerable, have a short perspective on their future, have limited abstract cognitive abilities, and highly value their associations with same-age peers, adolescents may view tobacco use as particularly functional to them and not potentially harmful. Adolescence is clearlv a vulnerable time when adult involvement and protection is still warranted and required. Adults should see the prevention of adoles- cent tobacco use as an important part of their responsi- bilitv in the healthful socialization of the young. The onset of tobacco use is strongly associated with peer influences, peer smoking, and peer approval of smoking. Programs that prevent tobacco use should systematically seek peer-group involvement and enlist peer role models who do not use tobacco. The emphasis of this involvement should be to affect peer-related norms and to persuade adolescents that most people their age do not use tobacco, that tobacco use has negative social consequences, and that tobacco use projects an image that, instead of being "cool," is unattractive, unpopular, and immature. Parents should also pay attention to the amount of time adolescents spend with peers, to peers' behavior, and to unsupervised peer-group activities. The increased need for social competencies during adolescence (i.e., the ability of young people to decipher, cope with, and deal with the social environment) should be a critical focus of comprehensive efforts to prevent tobacco use. Adolescents need skills to help them iden- tifv, resist, and refute environmental influences-whether from the media, adults, or peers-to use tobacco. Similarly, adolescents may need to be taught how to cope better with difficult, stressful situations at home or at school. Without such skills, many youth may con- tinue to use tobacco as a mechanism to deal with low self-esteem, depression, and the feelings of helpless- ness that can result from the ordinary challenges of growing up. Positive social bonding with familyand schools and health-enhancing behavior, such as physical:. activity, should be encouraged among youth as protective factors against tobacco use. Students who perform poorly in school should be offered tutoring and academic counsel- ing; besides being personally motivating, such support can increase students' affiliation with school and decrease their involvement in tobacco use. Encouraging sports participation (and countering the negative role models of some professional athletes by providing explicit mes- sages about the health consequences of smokeless tobacco use), regular physical activity, and a healthy diet may increase adolescents' valuation of, and attachment to, health and a healthy body that might be compromised by tobacco use. Parents may also need to demonstrate their support for academic achievement, health activities, and a greater link between home and school. Finally, to substantially modify tobacco use and to provide adolescents with consistent messages against tobacco use, the community (and society on the whole) should embrace the prevention of tobacco use. A focus on individuals, families, or peer groups is necessary but not sufficient to address the origins of tobacco's appeal to young people. Limiting the acceptability of tobacco use through restrictive policies, such as legislation support- ing clean indoor air and school policies banning tobacco use, provides a clear message to adolescents that tobacco use is not acceptable as a public behavior. Severely limiting adolescents' access to tobacco products makes it clear that cigarettes and smokeless products are danger- ous substances. Mandating tobacco-use prevention pro- grams in schools signals the importance of this topic through-the use of explicit, earmarked resources. These Psychosocial Risk Factors 147 TIMN 0138999

I I''t':'t'17tilI~: l('f'Jt.4 'L I,c'.X 7'I( '11ti ~i'IIII~: I 'tY'1 4c' cigarette use and the pathways to regular use mav vary by gender. Finally, differences by ethnic group do not appear to show a consistent pattern across communities, particularly when income level and cigarette availability are considered. The review of sociodemographic factors thus concludes that a young adolescent from a low-SES family is at highest risk to begin smoking. Proximal environmental factors, such as the influ- ence of peers, friends, and siblings, play a powerful role in the initiation of adolescent smoking. Smoking initia- tion appears to be a component of peer associations and peer bonding in adolescence, as peer groups establish shared behaviors to differentiate themselves from other adolescents and from adults. Adolescents usually try their first cigarettes with their peers; peer groups may subsequently provide expectations, reinforcement, and opportunities for continuation. The influence of peers seems to be particularly potent in the stages of smoking that precede regular use; in later stages, personal and pharmacological factors appear to predominate. Data on the influence of parental smoking are not as compelling as those on peer influence; only about half of the prospective studies show a clear predictive rela- tionship. The influence of parental smoking appears to be strongest for whites and females, particularly in the early stages of smoking onset. This review suggests that parental influence might include other important fac- tors, such as parents' approval or disapproval of smok- ing, their involvement in free-time supervision, their manner and extent of communication on health-related matters, or theiis promotion or nonpromotion of aca- demic achievement for their children. Lastly, young people are exposed not only to role models but also to the consequences of the behavior of these role models; having a parent who smokes might even serve to deter an adolescent from smoking if the parent is struggling with cessation or displays the health consequences of tobacco use. Ho-w adolescents perceive their social environment also influences their smoking behavior. Adolescents overestimate the number of young people and adults who smoke, and those with the highest estimates are ,., more likely to become smokers. In addition, young people are moreYlikely to smoke if they feel that their peers approve of smoking, and particularly if adults do not seem to disapprove. In each of these cases, the perceived environment could accurately reflect the ac- tual environment. Those who begin to smoke may actu- ally be exposed to more role models who smoke, more peers who approve of smoking, and fewer adults who disapprove than those who never begin to smoke. Families in which parents are considered' to be generally concerned and supportive, or in which the children are involved in family decisions, are home environments in which adolescents are less at risk tor smoking initiation. Parental strictness and parental approval or disapproval of smoking have indirectly and inconsistently predicted initiation and are there- fore less influential on adolescent smoking behavior than the general family environment. The research on parental skills in coping with adolescent smoking is limited and warrants further investigation. The behavioral factors examined were consistentlv associated with the initiation of cigarette smoking. Pat- terns of behavior that are associated with smoking in- clude alcohol and drug use, risk-taking and rebellious actions, and involvement in peer groups in early adoles- cence. Patterns of behavior that are associated with less risk of smoking include academic achievement, involve- ment in sports (for females), healthy eating and physical activity patterns, and the ability to resist offers of ciga- rettes. Thus, encouraging and providing opportunities for health-enhancing activities and academic achieve- ment might, by fulfilling some of the needs that smoking apparently meets for adolescents, prevent some young people from trying their first cigarette. The personal factors-those most proximal to the individual and to the immediate decision'to:smoke a cigarette-reflect, in part, the adolescent's internaliza- tion of the social environment. An adolescent's knowl- edge of the health consequences of smoking is a poor predictor of subsequent cigarette use, although smoking risks that are personalized appear to be important. More significant predictors include the meanings, the perceived positive functions, and the expected utility of cigarette use. These aspects are linked to having a positive social image, bonding with peers, and being "mature"-all of which are particularly socially relevant for adolescents. Compared with nonsmoking adolescents, those who begin to smoke appear to have lower self-images and lower self-esteem; for them, smoking becomes a self- enhancement mechanism. Similarly, self-efficacy toward avoiding cigarettes seems particularly linked with the ability to resist cigarette offers from peers. Of the person- ality variables, symptoms of depression, helplessness, aggression, pessimism, and a limited ability to conceptu- alize the future were all found to be smoking-predictive in a small number of studies. The most predictive per- sonal factors were those linked to the social environ- ment, to peers, and to the meanings of cigarette smoking learned in youth. Intentions to smoke and prior experimentation with cigarettes strongly predict subsequent smoking. The adverse physiological reactions to first tries at smoking wane with repetition, and tolerance levels to nicotine increase. Adolescents who smoke are more likely than nonsmokers to discount the negative health consequences of smoking, report positive functions of smoking, and Psychosocial Risk Factors 139 TIMN 0138991 -

'Ifi~'*t, ,ti lrtI :! ''i( • :\;': SWAN AV, CREESER R, M(:RRAY M. When and why chil- dren first start to ~,moke. International lournal of Epulentiology 19y0;19(2023-30. S6VEANOR D, BALLIN S, CORCORAN RD, DAVIS A, DEASY K, FERRENCE RG, ET AL. Report of the tobacco policy research study group on tobacco pricing and taxation in the United States. Tobacco Control 1992;(1 Suppl) Septem- ber: S31-S36. THOMPSON EL. Smoking education programs 1960-1976. American lottrnal of Pitblic Health 1978;68(3):250-7. URBERG KA, CHENG C, SHYU S. Grade changes in peer influence on adolescent cigarette smoking: a comparison of two measures. Addictive Behavior 1991;16(1-2):21-8. US DEPARTMENT OF HEALTH AND HLNAN SERVICES. Youth use of >>nokeless tobacco: inore than a pinch of trouble. US Department of Health and Human Services, Office of Inspec- tor General. Control No. P-06-86-0058,1986. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. Strategies to control tobacco use in the United States: a blueprint for public health action in the 1990s. Monograph No. 1. US Depart- ment of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute. Bethesda (MD): NIH Publication No. 92-3316, 1991. US DEPART4IENTOF HEALTH A\D HL%IA\ SERVICES. Snivkeless tobncco or henltlc an unternahonal her<lectivr. Mcrno- Kraph No. 2. C;S Department of Health and Human Services, Public Health Service, National Institutes of Health, Na- tional Cancer Institute. Bethesda (MD): NIH Publication No. 92-3461, 1992a. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. Spit tobacco and uouth. US Department of Health and Human Services, Office of Inspector General. Publication No. OEI 06-92-00500,1992b. WALDRON I, LYE D. Relationships of teenage smoking to educational aspirations and parents' education. lonrnal of Substance Abuse 1990;2(2)201-15. WILLIAMS T, GUYTON R, MARTY PJ, 'viCDERIvIOTT RJ, YOUNG ME. Smokeless tobacco use among rural high school students in Arkansas. Journal of School Health 1986;56(7):282-5. WILLS TA, SHIFFMAN S, editors. Coping and substance use: a conceptual frarnetvork. New York: Academic Press, 1985. YOUNG M, WERCH CE. Relationship between self-esteem and substance use among students in fourth through twelfth grade. Wellness Perspectives: Research, Theor-y and Practice 1990;7(2):31-44. 156 Psychosocial Risk Factors TTMN 0139008

tiltYkC~ !I Lolt r'ill '• IZt'I " '~ t smaller than in subsequent years (Johnston and Bachman 1980). A mtiltistage sampling design is used to ran- domly select high school seniors in public and private schools within the 48 contiguous states. Self-adminis- tered standardized questionnaires are provided by trained personnel to students in their classrooms. From 125 to 133 high schools are selected each year. From 66 percent to 80 percent of selected schools have partici- pated, and 77 percent to 86 percent of sampled seniors have participated (nearly all nonparticipation has been due to absenteeism) (Johnston, O'Malley, Bachman 1991a). The data are weighted to provide national esti- mates, and approximately 16,000 completed interviews are obtained each year. For this report, longitudinal analyses were also conducted by using panel data from nationally represen- tative samples of the senior classes of 1976 through 1986. These students were then followed up five to six years after high school, from 1981 through 1991, when the respondents were 23 to 24 years old (Johnston, O'Malley, Bachman 1992b). Data from 11 classes were combined to produce an adequate sample ~ize for analysis, yielding a total of 13,665 respondents. Of those students sampled, a random fifth received a question regarding their future expectations to smoke. From 70 to 80 percent of the surveyed seniors remained in the panel five years later (Johnston, O'Malley, Bachman 1991b). The MTFP collected information on the prevalence of smokeless tobacco use from 1986 through 1989, and again in 1992. MTFP data are collected annually; 1993 data were not available for this report. Youth Risk Behavior Survey CDC developed the Youth Risk Behavior Surveil- lance System to measure six categories ofpriority health- risk behaviors among adolescents: (1) behaviors that contribute to unintentional and intentional injuries; (2) tobacco use; (3) alcohol and other drug use; (4) sexual behaviors thatresult inunintended pregnancy and sexu- allv transmitted disease, including HIV infection; (5) unhealthful dietary behaviors; and (6) physical inactiv- ity. Data were collected through national, state, and local school-based surveys of high school students dur- ing the spring of odd-numbered years and through a 1992 national household-based survey of youths aged 12 through 21 (Kolbe 1990; Kolbe, Kann, Collins 1993). Only the 1991 state and local data are used in this report. The 1991 national school-based YRBS used a three-stage cluster sample design. The target population consisted of all public and private school students in grades 9 through 12 in the 50 states and the District of Columbia. Schools with substantial.numbers of black and Hispanic students were sampled at relatively higher rates than all other schools. Survey procedures were designed to protect stu- dent privacy and allow anonymous participation. The 75-item questionnaire was administered in the class- room by trained data collectors, and students recorded responses on answer sheets designed for scanning by computer. Parental notification was completed before survey administration. The school response rate was 75 percent, and the student response rate was 90 percent. A total of 12,272 students completed questionnaires in 137 schools. The data were weighted to provide national estimates of 9th- through 12th-grade students. In addition to the 1991 national YRBS, individual surveys were conducted that year among samples of high school students by 23 state and 10 local depart- ments of education. CDC reports weighted data when the overall (school and student) response rates are at least 60 percent (CDC 1992d). Nine questions on the survey measured tobacco use. These questions addressed experimentation with cigarette smoking, age at initiatibn of cigarette smoking, regular use of cigarettes, age,' at initiation.of regular cigarette smoking, number of days cigarettes were smoked during the previous 30 days, number of cigarettes smoked per day, number of attempts to quit smoking, and use of smokeless tobacco. YRBS data are collected every odd year at both the national and local levels; 1993 data were not available. To provide greater access to youths who do not attend school, the CDC and the Bureau of the Census incorporated a Youth Risk Behavior Supplement to the 1992 National Health Interview Survey. The supplement was conducted among 12- through 21-year-old youths from a national probability sample of households. School- age youths not attending school were oversampled. The questionnaire for this survey was adminis- tered through individual portable cassette players with earphones; after listening to questions, respondents marked their answers on standardized answer sheets. This methodology should help young people with reading problems to complete the survey and •should enhance confidentiality during household administra- tion (Kolbe, Kann, Collins 1993). Data from this survey were not available for this report. National Health Interview Surveys To determine cigarette smoking trends among older adolescents (aged 18 and 19), this analysis used data from NHIS from 1974,1978,1979,1980,1983,1985,1987, 1988,1990, and 1991 (NCHS 1985,1988a, b; CDC, OSH, unpublished data). Since 1957, NCHS has been collect- ing health data from a probability sample of the civilian, 106 Epidemiology TIMN 0138958

lc'hItut ' U•c'.I INiUJ~ ~'il1l~ whites, blacks, and Hispanics in southern California (Sussman et al. 1987). Role models who smoke are frequently seen to have socially desirable attributes- they seem tough, sociable, and sexually attractive (Chassin, Presson, Sherman 1990). Adolescents who believe that smoking bestows these attributes may see smoking as a powerful mechanism for self-enhancement. These young people may experiment with smoking to try to adopt a perceived positive social image and thereby improve the way others, particularly peers, view them (Chassin, Presson, Sherman 1990; Leventhal et al. 1991). If peers respond favorably to this strategy, these new young smokers may continue to smoke, since the behav- ior has proved functional for them in creating an accept- able self-image. Self-Efficacy An individual's efficacy (ortonfidence) in perform- ing specified skills and behaviors is a significant media- tor of peer influences to smoke (Bandura 1986). Ellickson and Hays (1990-91) found that low self-efficacy, as mea- sured on a scale of having little or much confidence in resisting offers of drugs, was associated with drug use, including smoking. DeVries, Kok, and Dijkstra (1990) found that self-efficacy in resisting offers to smoke was the best predictor of smoking among adolescents in the Netherlands over a one-year interval. Similarly, Lawrance and Rubinson (1986) found that young adolescents' per- ceptions of their ability to resist cigarette smoking corre- sponded to their self-reported smoking. Finally, Stacy et al. (1992) found in their cross-sectional study of high school students not only that low self-efficacy in resisting social influence was a significant predictor of smoking, but also that high self-efficacy was the only significant mediator of friends' social influences on smoking. There- fore, self-efficacy, a personal factor, appears to act as a buffer that protects adolescents from potent peer influ- ences to smoke (Conrad, Flay, Hill 1992). Personality Factora_, The research on personal factors has also examined many personalitX factors for their association with onset, inparttoassesswhetherunderlyingemotionalorpsycho- • logical problems predictadolescentsmoking. Personality characteristics that are related to deficiencies in self- control, such as impulsiveness and sensation-seeking tendencies, are important and were discussed earlier in this chapter in connection with behavioral factors. Psychological Well-Being Several studies have associated cigarette smoking and symptoms of depression among adolescents. Covey and Tam (lyy0) showed an indepencient relation ot depressive mood, friends' smoking behavior, and living in a single-parent home with cigarette smoking among 205 urban 11th-grade males and females. Depression scores correlated with the number of cigarettes smoked. Malkin and Allen (1980) found a significant association between smoking and depression among males in a study of 229 rural 8th- and 11th-grade students, a finding that was replicated for both genders by Kaplan et al. (1984). Stein, Newcomb, and Bentler (unpublished data) found that cigarette use was positively associated with being extroverted and negatively associated with having symptoms of depression among junior high school stu- dents in Los Angeles. Cigarette use, however, signifi- cantly predicted symptoms of depression in these young people four and eight years later (Newcomb, McCarthy, Bentler 1989). These findings may reflect the addictive quality of tobacco use beyond the earliest experimental states and the relationship between smoking and de- pression, since depression is a personality factor that usually persists over time. Smoking might be a short- term, self-medicating, response to symptoms associated with depression. In the long-term, however, this effect would diminish; as tolerance to nicotine increases, the possible antidepressant effects of smoking (such as alert- ness, euphoria, and calm) dissipate (Newcomb, McCarthey, Bentler 1989). Similarly, Leventhal, Fleming, and Glynn (1988) found that reported feelings of help- lessness were associated with more rapid movement to a second and third experiment with smoking; however, these feelings were not related to the initial experimenta- tion. The association of smoking and. suicide attempts, another clearly serious symptom of depression, is pre- sented in Chapter 3 (see "Cigarette Smoking and Other Health-Related Behaviors"). Flay (1993) suggests that symptoms of depression may be a response to distress associated with stress and poor family bonding. He points out that stress and distress have been associated with drug use,, including tobacco use (Wills and Shiffman.1985). The research of Kellam, Ensminger, and Simon (1980) suggests that this cycle may begin early in life. In their study of first-graders (aged five through seven) in Chicago, they found that males rated by observers as aggressive or as alternately shy and aggressive had the highest rate of drug use, including cigarette use, 10 years later; no long-term psy- chological predictors were found for females. In another study (Brunswick and Messeri 1984), adolescent males were more likely to begin smoking if they were pessimis- tic about the likelihood of the world becoming any better or if they held low expectations for their own future; for adolescent females, a shortened time perspective (i.e., a Psychosocial Risk Factors 137 TIMN 0138989

[I I/1L [( b'dcc, , L I ~c'.-I /N1~1/ti }cillll~: I Yc~/4c' The Role of Advertising and Promotion in the Marketing of Tobacco Products Introduction Businesses use advertising and promotion to influ- ence the marketplace-to prepare a place for their prod- uct by signaling how it meets an existing or newly perceived need of the consumer. In the following discus- sion of such tactics for the tobacco-product marketplace, "advertising" refers to company-funded advertisements that appear in paid media (e.g., broadcasts, magazines, newspapers, outdoor advertising, and transit advertis- ing), whereas "promotion" includes all company-sup- ported nonmedia activity (e.g., direct-mail promotions, allowances, coupons, premiums, point-of-purchase dis- plays, and entertainment sponsorships). The general role of advertising is to communicate accurate information and to influence attitudes and be- liefs (Kotler 1991). The information that advertising com- municates can be either factual (e.g., product ingredients or features) or suggestive (e.g., images of types of people who might use a product, or associations of a product with a certain setting or emotion). Much of the regula- torv activity for advertising is directed at factual cominu- nication; most of the criticism of advertising is directed at suggestive communication-at the images it creates and at the potentially misleading implications of user ben- efits that can be drawn from those images (Kotler and Armstrong 1991). Advertising can be used to create primary de- mand-that is, to bring new users of a product category into the marketplace (Ray 1982). These users are at- tracted by advertising that demonstrates how a particu- lar product can satisfy a customer need, either physical or psychological, that is currently either unmet or unsat- isfied. Users also can be brought into a product market- place by advertising that causes them to feel a previously unacknowledged need fora particular product. Primary demand can be increased through generic category ad- vertising (such as trade association advertising for com- modities like milk or beef). The advertising of a specific brand can sometimes both promote that brand and in- crease demand for an overall product category; for ex- ample, advertising fora particular computer can promote computers in general for first-time buyers: Advertising also can be used to create selective (or secondary) demand-that is, to convince consumers to switch from one specific brand of product to another (McCarthy and Perreault 1984). Creating selective de- mand calls for advertising that demonstrates a brand's superior performance, price, or value. Alternatively, advertising can create selective demand by projecting that a brand has a more desirable image than its competi- tors (such as Avis Rent A Car's well-known slogan, "We're number two ... but we try harder"). Consumers overestimate the effect of advertising on overall market factors, but underestimate its effect on them personally (Bauer and Greyser 1968). Thus, con- sumers may criticize advertising as being dishonest and manipulative, but they are unlikely to be able to provide examples of purchases they have made because of what they would consider advertising dishonesty or manipu- lation. In fact, they are unlikely to be able to identify any purchases they have made because of advertising. For most products, the role of advertising is to create in the consumer a structure of attitudes and beliefs about a product that will facilitate its purchase when the con- sumer is stimulated by a behavioral prod (Ray 1982). That prod can come from the social environment (for example, from another consumer's recommending the product), from a retailer, or from a promotional incen- tive, such as a coupon or a free sample. The actual purchase of a product or service in a marketplace thus is often achieved by marketers' use of a specific promotion (Popper 1986; Davis and Jason 1988). Such activities are used to build on consumers' attitudi- nal predispositions and lead consumers to act. Promo- tion, in fact, is the fastest-growing category of all product marketing activity (Kotler 1991). This growth is partly a response to the proliferation of advertising as well as to the limited direct effect that advertising has been found to have on people's actions. Over the past few decades, the superabundance of advertising messages has made it increasingly difficult for a given ad to rise above the clutter of competing messages both in its own product category and in the plethora of advertisements in gen- eral. This competition is particularly true for products with well-established images and reputations. Thus, profit return of even a successful advertising expendi- ture may eventually diminish. Accordingly, the best sales returns for most industries result from effective advertising and promotion working in concert. Promotional activities can take many forms. Pro- motional expenditures can stimulate retailers to place and display products in ways that will maximize the opportunity for purchase (e.g., supplying retailers with point-of-purchase displays to locate products at Adrertising and Promotiorr 159 TIMN 0139011

tittr•,yt'rn! C~c'rIc'~•ul' 1~~'~rrv • 98 percent said their best male friends either approved of, or were neutral toward, their smokeless tobacco use. • 93 percent said their parents knew of their smokeless tobacco use. • 68 percent said their fathers and 45 percent said their mothers approved of, or were neutral toward, their smokeless tobacco use. • 91 percent said their brothers and 71 percent said their sisters either approved of, or were neutral toward, their smokeless tobacco use. • 87 percent listed their home as a setting where they regularly used smokeless tobacco. • 43 percent whose dentist knew of their use were not advised by that professional to quit. • 51 percent said their coaches either approved of, or were neutral toward, their smokeless tobacco use. These findings were replicated in the 1992 Office of the Inspector General study on Spit Tobacco and Youth (USDHHS 1992b). The adolescents in this study who used smokeless tobacco said that the greatest influences on their trying smokeless tobacco were peer pressure and other family members' use. The majority of these young users felt their parents would agree that their using smokeless tobacco was preferable to smoking ciga- rettes (USDHHS 1992b). In another study, only 14 percent of smokeless tobacco users reported that their father disapproved of their smokeless tobacco use, whereas 60 percent said their mother disapproved (Marty, McDermott, Williams 1986). Williams et al. (1986) found that 55 percent of smokeless tobacco users indicated that their parents dis- approved of their use. In a study by Ary et al. (1989), only 13 percent of daily smokeless tobacco users re- ported that their dentist had said anything to them about their use. BrubAer'.and Loftin (1987) found that smokeless tobacco users reported greater peer accep- tance of, and less parental opposition to, their use than did nonusers. Social Support Chassin, Presson, and Sherman (1988) examined the relationship between family social support and current use of smokeless tobacco. Three cross-sectional analyses found no pattern of relationships between smokeless to- bacco use and perceived parental expectations (for'success or academic accomplishment), parental supportiveness, parental strictness, agreement between parents, parent- peer agreement, or the adolescent's reported motivation to comply with parents. Similarly, two sets of analyses examining one-year prediction of smokeless tobacco on- set found no statistically significant effects for the same set of factors, although the statistical power to detect such effects was minimal because the sample contained few cases of smokeless tobacco onset. Parental Reaction to Smokeless Tobacco Use Parents appear to be more accepting of smokeless tobacco use than of cigarette smoking. About 40 percent of high school smokers reported that their parents knew about their smoking, whereas smokeless tobacco users reported that 71 percent of their parents knew of their use (Chassin et al. 1985). Similarly, young people who did not use tobacco reported that their parents and peers were more accepting of smokeless tobacco use than of smoking (Chassin et al. 1985; Ary et al. 1989). These findings suggest that adolescents may begin using smoke- less tobacco partly because they perceive that it is less deviant than smoking or other drug use and therefore is more likely to be accepted by their peers and parents (Hahri et a1.1990). Some research evidence indicates that the antici- pated parental response to an adolescent's use of smoke- less tobacco is related to that youth's likelihood of using smokeless tobacco. Riley, Barenie, and Myers (1989) found that high school students' anticipation of their parents' response was highly predictive of the first trial of smokeless tobacco and of the level of continued use. Brubaker and Loftin (1987) found that adolescents who did not currently use smokeless tobacco but who intended to become users reported that it would be unlikely that their parents would respond by taking away their privileges, reprimanding them, becoming an- gry, expressing disappointment, or prohibiting them from continued use. These youth also reported that it was likely that their parents would ignore their smokeless tobacco use. Behavioral Factors in the Initiation of Smokeless Tobacco Use Academic Achievement For males, smokeless tobacco use was related to poor academic performance (Jones and Moberg 1988) and to a low grade point average (Brownson et a1.1990). The NIDA national household survey indicated that for males, the prevalence of daily use of smokeless tobacco was highest among school dropouts (13 percent) and lowest among college students (6 percent) (Rouse 1989). TIMN 0138994 142 Psychosocial Risk Factors

tiin,tircai (,t•1r0nil'. IZCEn0rt be more inclined to begin smoking to fit iri than`'if they were aware that only 5 to 7 percent of their peers ac- tualh• smoke. Vorms Norms may be defined as what an individual in a particular group perceives she or he ought to do and what is perceived as acceptable behavior for a given age l;rou p, gender, or other subgroup. Gerber and Newman's (1989) research on smoking-related norms details ado- lescents' perceptions of the percentage of all adults, peers, and classmates thev think are smokers. These investiga- tors found that experimental adolescent smokers who increased their smoking levels over the course of the one-year study period perceived more smoking among their classmates than did those who had decreased their smoking in the same time period. Similarly, Leventhal, Fleming, and Glynn (1988) report that youth who partici- pated in their studies greatly overestimated the propor- tion of peers and adults who smoke. The adolescents believed that 66 percent of their peers and 90 percent of adults «•ere smokers, thus overestimating smoking preva- lence by at least a factor of three. Collins et al. (1987) examined the predictive influ- ence of norms in a longitudinal study of 3,295 students aged i l and 12 in 56 junior high schools in Los Angeles. Like Chassin et al. (Chassin et a1.1984; Chassin, Presson, Sherman 1990), thev found that adolescents who made relatively high estimates of regular smoking prevalence were more likely to try smoking, to become smokers, or to increase the amount they smoked over 1 and 1.5 years of the study. Sussman et al. (1993) discussed further aspects of normative influence and implications for the content of prevention programs. Previous smoking and peer smoking were the main predictors of overestimates in the Collins et al. (1987) study. In Shean's (1991) re- search in Australia, beliefs about the number of adoles- cents and adults who smoke predicted smoking in young adulthood eight yea~ }ater. In part, these normative expectations may b~~~i,ction of these beginning smok- ers' . ers' actual exposu :a disproportionate number of smokers, includingaand peers. Social Support for Smoking Social support includes perceived approval or dis- approval of adolescent cigarette smoking by parents, siblings, peers, and important others, such as teachers or employers. One way that social support is manifested is through peer-group pressure, either through support or discouragement of smoking. Peer pressure is not always negative; it has been used successfully in many prevention programs (Klepp, Halper, Perry 1986). Still, in the study by Hahn et al. (1990), the urging of one or more acquaintances-most likely peers or close friends-prompted over half the instances of adolescents' trying a cigarette for the first time. In the Chassin et al. (1986) study, females who saw their friends as more supportive than critical about their smoking were more likely than those who saw their friends as less supportive to become regular smokers one year later. Similarly, many adolescent smokers in another study reported, "My friends like me because I smoke" (Hunter et al. 1987). In the same study, smokers were less likely than nonsmokers to report, "My parents don't want me to smoke." Peer approval of smoking was an important predictor for smoking onset among whites and Hispanics, whereas adult approval was an important predictor for Hispanics and Asians among 874 southern California 11- through 13-ti ear-olds (Sussman et a1.1987). Social support also includes the general support or approval the adolescent receives from others. This kind of support appears to play a role in predicting onset:(see "Trends in Knowledge and Attitudes About Smoking" in Chapter 3). Chassin et al. (1986) found that those adolescents who reported that their parents were gener- ally supportive of them were less likely to begin smoking or to become regular smokers than were those who perceived that their parents were not generally support- ive of them. However, those who reported that their friends were supportive of them were more likely to become smokers than were those who did not report such support. Similarly, males who reported that they lived in families in which they had limited involvement in family decisions were more likely to become smokers than males from families where high involvement in family decisions was reported (Mittelmark et al. 1987). Adolescents who reported regularly caring for them- selves after school were at increased risk of smoking (Richardson et al. 1989). Finally, adolescents who be- lieved that parents, siblings, friends, and teachers would not care if they smoked were at higher risk of initiating smoking after 2.5 years than were those who believed that others would care if they smoked (McNeill et al. 1988). Lack of concern by parents appears to increase risk, particularly for males (Swan, Creeser, Murray 1990). General parental support of the adolescent and concern about the adolescent's smoking appears to decrease risk. Parental Reaction to Smoking Parental reaction to use and perceived parental strictness have- also been associated with onset Hansen et al. (1987) examined the influence of perceived parental reactions to cigarette smoking (as well as alcohol and marijuana use) among 293 Los Ange- les 10- through 12-year-olds. Parental anger toward the 132 Psyclrosocial Risk Factors TIMN 0138984

I'rt•,•c„rnr,~ Tolat<<, uA.l„r~,{~ l'rOF'lt• smoking among 6,22-1 students aged 10 through 12 in New South Wales, Australia. Mittelmark et al. (1987) found that experimenting with cigarettes was associated with sibling smoking only for females and.l l- through 13-vear-old students. This finding was similar to the Chassin et al. (1984) research that found sibling smoking more influential in the early stages of cigarette use than in the later stages. Gender and race differences in the effect of sibling smoking have also been noted. Hunter et al. (1987) found sibling smoking predictive for white males, a sister s smoking predictive for white females, and a brother's smoking predictive for black males and fe- males. Brunswick and Messeri (1983) found sibling smok- ing influential only for males. In the Muscatine Study (Krohn, Naughton, Lauer 1987), the maintenance (not initiation) of smoking was associated with a brother's smoking. Finally, in Conrad, F1ay, and Hill's (1992) re- view of 27 prospective studies, four of the five studies that examined this factor indicated that sibling smoking was associated with onset. Peer Smoking and Peer Behaviors One of the areas of widest investigation in the antecedents of cigarette smoking concerns peer smoking and related peer behaviors. Peers may be, defined as persons of about the same age who feel a social iden- tification with one another. The influence of peers has been posited as the single most important factor in deter- mining when and how cigarettes are first tried. Flay et al. (1983) suggest that smoking may primarily represent an effort to achieve social acceptance from peers and that it may particularly be an experimental "adult" activity that is shared with the peer group. Leventhal and Keeshan (1993) suggest that adolescents are not only influenced b,v, but also influence and construct, their peer groups. These researchers propose that small groups of adolescents "construct shared social environments in which they perceive themselves and other(s) as having mutual cognitive, ennofional, and valuative reactions.... ~..l the intersubjectivi ~ created by sharing generates a sense of wellness. This °' of mutuality enhances the attrac- tiveness of the and may lead to incorporation of the self-image of tJie 6thers into the image of one's own self" (p. 269). Multiple cross-sectional and longitudinal studies worldwide substantiate the relationship between smoking onset and peers' (or friends') smoking (Shean 1991; O'Connell et al. 1981; Ogawa et a1.1988). In their research, Bauman et al. (1990) found that smoking most often occurred. in the presence of best friends. Sixty percent of 11- through 17-year-olds reported that they had first smoked, and 72 percent reported that they had most recently smoked, with close friends (Hahn et al. 1990). Among 12- through 14-year-olds, those whose best friend smoked were four times more likely to be smokers than those whose best friend did not smoke. Best friend's smoking predicted both smoking experi- mentation and prevalence among urban San Diego ado- lescents from a variety of ethnic groups (Elder, Molgaard, Gresham 1988) and among white and black 8- through 17-year-olds in Louisiana (Hunter, Vizelberg, Berenson 1991). Best friend's cigarette use was predictive of the first try at smoking, whereas having a majority of friends who smoke was predictive of the second cigarette (Leventhal, Fleming, Glynn 1988). In the Conrad, Flay, and Hill (1992) review of the recent prospective research, friends' smoking was pre- dictive of some phase of smoking in~ all but one (Newcomb, McCarthy, Bentler 1989) of 16 studies. A positive association of peer smoking with onset of smok- ing in 88 percent 'of these more rigorous, longitudinal studies suggests a clear link between peers' smoking and cigarette use. This link may be mediated by personal factors, such as self-efficacy (or self-confidence), and ap- pears to be most potent in the earlier stages of sirioking (Pomerleau 1979; Pederson and Lefcoe 1986; Chassin, Presson, Sherman 1990). Social Bonding The interpersonal environment has also been char- acterized by the degree of social bonding, or attach- ment, between the adolescent and important others or institutions. The findings on family bonding variables in smok- ing onset, particularly attachment to mothers or fathers, have been inconsistent; those related to peer bonding, including the number of friends, level of social life, participation in antisocial activities, and having a boy- friend or girlfriend, were all found to be predictive of onset (Conrad, Flay, Hill 1992). Bonding with peers who smoke appears to increase the risk of smoking, perhaps because such bonding takes precedence over attachments to the family. Perceived Environmental Factors The perceived environment includes the smoking- related norms, social support, expectations, reactions, and barriers that adolescents sense in their environment. The perceived environment may be a more proximal influence on smoking initiation than the actual environ- ment (Jessor and Jessor 1977). For example, 12-year-olds who believe that "lots of people" their age smoke may Psychosocial Risk Factors 131 TIMN 0138983

Initiation of Cigarette Smoking Introduction Early public health efforts to prevent smoking among adolescents were largely informed by health- related and demographic findings from research stimu- lated by the landmark 1964 Surgeon General's report on smoking and health (Public Health Service 1964; Chassin, Presson, Sherman 1990). By the mid-1970s, the ineffectiveness of these attempts to reduce rates of smok- ing onset among adolescents further stimulated research into what motivates young people to begin smoking (Thompson 1978). Significant support for such research was provided by the National Clearinghouse for Smok- ing and Health, the National Institutes of Health, the National Institute on Drug Abuse (NIDA), and various private health organizations, including the American Lung Association, the American Cancer Society, and the American Heart Association. The application of psychosocial theories to the area of adolescent smoking behavior provided a major break- through in the understanding of smoking initiation and development, pioneered by the conceptual and pilot work of Leventhal (1968), Bandura (1977), Evans et al. (1978), McAlister, Perry, and Maccoby (1979), and McGuire (1984). Rather than view cigarette smoking as a health behavior, these researchers examined smoking as a so- cial behavior, with social causes, functions, and rein- forcements. Although this early work involved mostly correlational research, such as examining the relation- ship between parental smoking and childreri s smoking behavior, research became increasingly theory-driven, longitudinal, prospective, and multivariate during the 1980s (Chassin, Presson, Sherman 1990). Conrad, Flay, and Hill (1992) recently reviewed 27 prospective studies on smoking initiation published since 1980 (see Table 2 for characteristics of these studies). The large number of such methodologically sophisticated studies provides a sufficient base of knowledge to begin drawing conclu- sions about the relative importance of a variety of risk factors for the onset of tobacco use. The process of onset requires clarification. Regard- less of the age at which they smoke their first cigarette, young people appear to progress through a sequence of stages that takes them from receptivity to dependence on tobacco use (Leventhal and Cleary 1980; Flay et al. 1983). Not all young people who try a cigarette become daily smokers; still, almost all of those who become daily smokers have experienced simi- lar, well-defined stages in the behavior-acquisition 124 Psychosocin! Risk Factors process. The risk factors for each of these stages appear to differ; this variation suggests that even within the seven years of adolescence (ages 11 through 17), devel- opmentally appropriate prevention programs should be used (Leventhal, Fleming, Glynn 1988). Developmental Stages of Smoking Flay (1993) discusses the five primary stages of smoking initiation among children and adolescents (Fig- ure 1). During the first or preparatory stage, attitudes and -beliefs about the utility of smoking are formed. At this stage, even if no actual smoking behavior is enacted, the child or adolescent may see smoking as functional- as a way to appear mature, cope with stress, bond with a new peer group, or display independence (Perry, Murra,v, Klepp 1987). The second or trying stage encompasses the first two or three times an adolescent smokes. Peers are usually involved in situations that encourage trying (Conrad, Flay, Hill 1992). Whether the physiological effects of smoking are perceived to be negative and whether these tries are socially reinforced determine if an adolescent will proceed to the next stage (Leventhal, Fleming, Ershler, unpublished data), experimentation, which includes repeated but irregular smoking. At this third stage, smoking is generally a response to a particu- lar situation (such as a party) or to a particular person (such as a best friend). These influences will not vet have prompted a regular pattern of use. In the fourth stage, regular use, an adolescent smokes on a regular basis, usually at least weekly, and increasingly across a variety of situations and personal interactions. The final stage, nicotine dependence and addiction (see "Nicotine Ad- diction in Adolescence" in Chapter 2), is characterized by a physiological need for nicotine. This need includes tolerance for nicotine, withdrawal symptoms if the per- son tries to quit, and a high probability of relapse if the person does quit (Flay 1993). These stages have been further quantified and validated by Stem et al. (1987). The tirine interval from the initial try to the stage of regular use takes an average of two to three years, with considerable interval variation among individuals (Leventhal, Fleming, Glynn 1988). McNeill (1991) found in a prospective study that of those who experimented with cigarettes, approximately half were smoking on a daily basis within one year. Leventhal, Fleming, and Glynn (1988) suggest that the time interval from the initial try to the stage of regular use may be extended, particularly if the time is lengthened between the first TIMN 0138976

1're vetttuts TohaCiu Utie .-lttuuty Ytutttg 1'rvhle Sun•ey (ALTS) (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 percent 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 MTFP survey, however, past-month use of smokeless tobacco was 11 percent for all respondents, 14 percent for whites, and 21 percent for males (ISR, University of Michigan, unpublished data). In the NHSDA, the 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 survev, 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 daiii• use of smokeless tobacco. Almost 60 per- cent of the i•iack users reported that they had used the product less than once each week. Among past-month users, 46 percent of those living in the West and 43 percent of those from the South had used smokeless tobacco at least once each day. Thirty-three percent of users who lived in the north-central and 22 percent from the northeast United States used smokeless tobacco on a daily basis. Use of Smokeless Tobacco and Cigarettes As was shown in Table 23,43 percent of male high school seniors who used smokeless tobacco also smoked cigarettes. Tobacco, either in the form of cigarettes or smokeless tobacco, was used by 15 percent of 12- through 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 97 TIMN 0138949

tillr'tt'Ull Cn7/t'r~ll'~ Rt'l~tV! CENTERS FOR DISEASE CONTROL. Selected tobacco-use behaviors and dietarv patterns among high schcwt stuaents- C'nitet.i States, Iq9L. ,1Aorbidity and Murtalittt Werklu Report lyy'_c:-il('-1):-117 ?1. CENTERS FOR DISEASE CONTROL. Tobacco, alcohol, and other drug use among high school students-United States, Iy91. Morl+iditutlntlMortalittt M'ekltt Report 1992d;-I1(37):698- ;03. FINCHER J. Sean Marsee's smokeless death. Rc'adc'r'< Dl,`r.~t 1985;127(; 62):107-12. FISHBURti E PM, ABELSON HI, CISIN IH. National ;u/zmetr cnl drug ahuse: main findilgti: 1979. US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse. Bethesda (MD): DHHS Publication No. (ADM) 80-976, 1980. CENTERS FOR DISEASE CONTROL AND PREVENTION, DIVISION OF ADOLESCENT AND SCHOOL HEALTH. Unpublished data. CENTERS FOR DISEASE CONTROL AND PREVENTION, OFFICE ON SMOKING AND HEALTH. Unpublished data. COHEN SJ, KATZ BP, DROOK CA, CHRISTEN AG, vICDONALD JL, OLSON BL, ET AL. Overreporting of smoke- less tobacco use by adolescent males. Journal of Behavioral Medicine 1988;11(4):383-93. CONVERSE PE, TRAUGOTT MW. Assessing the accuracy of polls and surveys. Science 1986;234 November:1094-8. DIFRANZA JR, RICHARDS JW, PAULMAN PM, WOLF- GILLESPIE N, FLETCHERC, JAFFE RD, ETAL. RJR Nabisco's cartoon camel promotes Camel cigarettes to children. journal of the American Medical Association 1991;266(22):3149-53. ERNSTER VL, GRADY DG, GREENE JC, WALSH M, ROBERTSON P, DAtiIELSTE, ET AL. Smokeless tobacco use and health effects among baseball players. Journal of the Ameri- call Mcdical A:sucitltivtl 1990;264(2):218-24. ESCOBEDO LG, MARCUS SE, HOTZMAN D, GIOVINO GA. Sports participation, age of smoking initiation, and the risk of smoking among U.S. high school students. journal of the Ameri- can Medical Association 1993;269(11):1391-5. ESCOBEDO LG, REMINGTON PL. Birth cohort analysis of smoking prevalence among Hispanics in the United States. journal of the American Medical Association 1989;261(1):66-9. ETZEL RA. A review of the use of saliva cotinine as a marker of tobacco smoke exposure: Preventive Medicine 1990;19(2): 190-7. EVANS RI, HANSEN WB, MITTELMARK MB. Increasing the validity of self-reports of smoking behavior in children. journal of Altplied Psyclwlot•it 1977;62(4):521-3. FEARS BA, GERKOVICH MM, O'CONNELL KA, COOK MR. Evaluation of salivary thiocyanate as an indicator of smoking behavior. Health Psucholvgy 1987;6(6):561-8. 116 Epidemiology FLAY BR, D'AVERNAS JR, BEST JA, KERSELL MW, RYAN KB. Cigarette smoking: why young people do it and ways of preventing it. In: McGrath P, Firestone P, editors. Pediatric and adolescent behavioral medicine. Vol. 10. New York: Springer Publishing, 1983. GEORGE H. GALLUP INTERNATIONAL INSTITUTE. Teen-age attitudes and behavior concerning tobacco: report of the findings. Princeton (NJ): George H. Gallup International Institute, 1992. GFROERER J. Personal communication. 1993. HAENSZEL W, SHIMKIN MB, MILLER HP. Tobacco smvking patterns in the United States. Public Health Monograph No. 45. US Department of Health, Education, and Welfare, Public Health Service, Office on Smoking and Health. DHEW Publica- tion No. (PHS) 463,1955. HALL RL, DEXTER D. Smokeless tobacco use and attitudes toward smokeless tobacco among Native Americans and other adolescents in the Northwest. American Journal of Public Health 1988;78(12):1586-8. HARRIS JE. Cigarette smoking among successive birth cohorts of men and women in the United States during 1900-80. journal of the National Cmlcer Institute 1983;71(3):473-9. HILL PC, DILL CA, DAVENPORT EC. A reexamination of the bogus pipeline. ' Educational and Psychological Measurement 1988;48(3):587-.601. HOSMER DW, LEMESHOW S. Applied logistic regression. New York: John Wiley & Sons, Inc., 1989. INSTITUTE FOR SOCIAL RESEARCH, UNIVERSITY OF MICHIGAN. Unpublished data. JARVIS MJ, RUSSELL MA, BENOWITZ NL, FEYERABEND C. Elimination of cotinine from body fluids: implications for noninvasive measurement of tobacco exposure. American /our- nal of Public Health 1988;78(6):696-8. JARVIS MJ, TUNSTALL-PEDOE H, FEYERBEND C, VESSEY C, SALOOJEE Y. Comparison of tests used to distinguish smokers from nonsmokers. American /ournal of Public Health 1987;77(11):1435-8. . TIMN 0138968

Prtr,,entinw TL)haccc) Lb;C.-1mUl1S ti"olut,~ l'wple Appendix 1. Sources of Data National Teenage Tobacco Surveys and Teenage Attitudes and Practices Survey The U.S. Public Health Service (primarily OSH, which was formerly called the National Clearinghouse for Smoking and Health) and the U.S. Department of Education collected data on cigarette smoking patterns among teenagers (aged 12 through 18) in 1968, 1970, 1972, 1974, and 1979 (USDHEW 1972, 1976,1979b) and on teenage use of cigarettes and smokeless tobacco in 1989 (Allen et al. 1991, 1993; Moss et al. 1992). These surveys are referred to collectively as the National Teen- age Tobacco Surveys. All six surveys were conducted via telephone. (In 1968, results from in-person inter- views conducted in households without telephones in- dicated that the exclusion of such households would not significantly influence the data obtained from the tele- phone sample [USDHEW 19721.) However, the 1989 survey, often referred to as the Teenage Attitudes and Practices Survey, mailed questionnaires to those persons in the sample who could not be reached by telephone (Allen et al. 1991, 1993; Moss et a1.1992). (See Table 1 for sample sizes, types of surveys, response rates, ages, and sponsoring agencies.) The response rate was reported only for the 1989 survey (82 percent) (Allen et al. 1991, 1993). Estimates from the 1968-1979 NTTS were based on unweighted data; those from the TAPS incorporated survey design and post-stratification weights. Because of differences in sampling, weighting, and interviewing procedures, the 1989 survey cannot be readily compared with the earlier surveys. TAPS is ongoing. TAPS II, which included a na- tional longitudinal component, was conducted in spring 1993; data were not available for this report. . National H_oiisehold Surveys on Drug Abuse Since 197~NIDA has conducted periodic house- hold surveys (the: NHSDA) of the civilian, non- institutionalized population of persons aged 12 and older. These surveys are now sponsored by SAMSHA. Pub- lished data are available from surveys conducted by NIDA for the years 1974, 1976, 1977, 1979, 1982, 1985, 1988,1990,.and 1991 (Abelson and Atkinson 1975; Abelson and Fishburne 1976; Fishburne, Abelson, Cisin 1980; Miller et al. 1983; USDHHS 1988a, 1990a, 1991a, 1992a). Multistage sampling designs were used to ran- domly sample households in the 48 contiguous states; the 1991 survey also included Alaska and Hawaii (USDHHS 1992a). Respondents were interviewed in their homes by trained personnel. The response rate averaged 80 percent (Gfroerer 1993), and the data were weighted to provide national estimates. For all years except 1979, "ever smokers" were defined as persons who reported having tried a cigarette, and "current smok- ers" were defined as persons who had smoked within the past month. For 1979, only persons who reported having smoked five or more packs of cigarettes in their lifetime were asked if they were current smokers; direct comparison with other NIDA surveys is thus problem- atic. The results of the 1982 survey have been used to adjust the 1979 prevalence estimates to be more compa- rable with other years. From 1974 through 1982, race information was categorized as either white or races other than white; from 1985 through 1991, this informa- tion was categorized as white, black, and other (Abelson and Atkinson 1975; Abelson and Fishburne 1976; Fishburne, Abelson, Cisin 1980; Miller et al. 1983; USDHHS 1988a, 1990a, 1991a, 1992a). Patterns of use identified by the 1991 survey are described for persons 12 through 18 years old. In addition, the initiation pat- terns of persons 30 through 39 years of age are used to estimate the percentage of people who initiate smoking after 18 years of age. Since 1988, the NHSDA has also collected data on smokeless tobacco'use. The NHSDA is conducted annually; 1992 data were not available for this report. Monitoring the Future Project Surveys The University of Michigan's ISR, under grants from NIDA, has surveyed nationally representative samples of high school seniors in the spring of each year since 1975 as part of the MTFP. In 1991 and 1992, 8th- and 10th-grade students were also surveyed. This report includes analyses from published or in-press data from 1976 through 1992 (Bachman, Johnston, O'Malley 1980a, b, 1981, 1984, 1985, 1987, 1991; Bachman et al. 1991; Johnston, Bachman, O'Malley 1980a, b,1982,1984,1986, 1991, 1992; Johnston, O'Malley, Bachman 1992a, 1992), from unpublished data for 1989 through 1992 (ISR, Uni- versity of Michigan, unpublished data), and from analy- ses of public-use computer tapes for the 1976-1989 surveys (CDC, OSH, unpublished data). The data from 1975'were not included in this report, because a com- puter tape was not available for 1975 and because the response rate was much lower and the sample size much _._ Epidemiology 105 TIMN 0138957

tiur~iun Ginir,tl', Rir-t-t Figure 1. Selected Marlboro cigarette advertisements, 1937-1992 ..-. , ,~ .cs . . .•i~ ® IVORY :Lrn.5 Pmfc et t/ie ly, 0 ARLBQR 0 . ...~..r.:.~.. ~:.kL& 0,09 ~ `>~rcrrrr ~ • r.',f't(TfI V&l~l~ //c 0 I ® 0 0 SURGEON GENERAI'S WARNING: Smoking By Pregnant Women May Result in Fetal Intury. Premature Birth. And low'Rtrth Wetght. 0 Sources: Clockwise from top left: Nezv Yorker 1937; Road & Track 1990; Road & Track 1992. In a parallel manner, advertisements for brands such as Virginia Slims appealed to feminine indepen- dence. An ad executive who headed the account for a leading female brand, and who requested anonymity, was quoted by the Wall Street Journal as stating, "We try to tap the emerging independence and self-fulfillment of women, to make smoking a badge to express that" (Waldman 1989, p. B1). Over the past few decades, many advertising cam- paigns have featured race car drivers, and many brands (such as Camel, Marlboro, and Winston) continue to sponsor racing events and teams. A commercial study of three different executions of a 1976 Viceroy adver- tisement with close-ups of "a young man in auto racing garb" found that subtle visual differences caused by the model's appearance, positioning, or other visual staging devices could greatly affect consumer reactions. Despite identical verbal copy and layout in all three advertisements, one of them more strongly suggested that smokers of Viceroy had the desirable "positive personality characteristics including courageousness, 178 Advertising and Promotion TIMN 0139030

tiiu,Xeuii e;cvirral'• Re;avt C:S DEPARTMENT OF HEALTH AND HUMAN SERVICES. Natie)nal ituu<e-hold :ureyon dntgabuse: population estimatcs 1991. Revised: November 20, 1992. US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse. DHHS Publication No. (ADM) 92-1887, 1992a. US DEPART"vtEtiT OF HEALTH, EDUCATION, AND 1h'EL- FARE. Snroku~t and health. A report of the Surteon General. US Department of Health, Education, and Welfare, Public Health Service, Office of the Assistant Secretarv for Health, Office on Smoking and Health. DHEW Publication No. (PHS) 79-50066, 1979a. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. Smokeless tobacco or health: an international perspective. Mono- graph No. 2. [;S Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute. Bethesda (MD): NIH Publication No. 92-3461, September 1992b. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. National household sun.wy on drug abuse: main findings 1991. US Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Admin- istration, Office of Applied Studies. DHHS Publication No. (SMA) 93-1980,1993. US DEPARTMENT OF HEALTH, EDUCATION, AND WEL- FARE. Teenage smoking: national patternsofcigarettesmoking,ages 12 throuKh 18, in 1968 and 1970. US Department of Health, Education, and Welfare, Health Services and Mental Health Administration, Regional Medical ProgramsServices, National Clearinghouse for Smoking and Health. DHEW Publication No. (HSM) 72-7508,1972. US DEPARTME;\;TOF HEALTH, EDUCATION, AND WEL- FARE. Teenagesmaking: natiunal patternsofcigarettesmoking,ages 12 through 18, in 1972 and 1974. US Department of Health, Education, and Welfare, Public Health Service, National Insti- tutes of Health. DHEW Publication No. (NIH) 76-931,1976. US DEPARTMENT OF HEALTH, EDUCATION, AND WEL- FARE. Teenage smoking. Immediate and long-term patterns. US Department of Health, Education, and Welfare, National Insti- tute of Education, November 1979b. VELICER WF, PROCHASKA JO, ROSSI JS, SNOW MG. As- sessing outcome in smoking cessation studies. Psycholegical Bulletin 1992;111(1):23-41. WALL MA, JOHNSON J, JACOB P, BENOWITZNL. Cotinine in the serum, saliva, and urine of nonsmokers, passive smokers, and active smokers. American Journal of Public Health 1988;78(6):699-701. WALLACE JM, BACHMAN JG. Explaining racial/ethnic dif- ferences in adolescent drug use: the impact of background and lifestyle. Social Problems 1991s38(3):333-57. WERCH CE, GORMAN DR, MARTY PJ, FORBESS J, BROWN B. Effects of the bogus-pipeline on enhancing validity of self- reported adolescent drug use measures. Jourrad of School Health 1987;57(6):232-6. ZANES A, MATSOUKAS E. Different settings, different re- sults? A comparison of school and home responses. Public Opinion Quarterly 1979;43(4):550-7. 120 Epidemiology . TIMN 0138972

Preventing Tobacco Use Among Young People Figure 3. A model of smoking initiation: cigarette advertising as a shaping force of an adolescent's ideal self-image Cigarette advertising I Images of smokers Ideal self-image 7 \ If ideal = self-image If ideal # self-image Y No change in behavior Alter behavior to be more like ideal self-image Less risk of initiation of smoking Greater risk of initiation of smoking Source: Burton, Moinuddin, Grenier (unpublished data). no more than a puff of a cigarette were asked how many of their peers and how many adults smoked. Respon- dents were aLso asked whether they had ever seen a cigarette ad and when an ad was last seen. Los Angeles youth were more likely than Helsinki youth to overestimate the prevalence of peer smoking (a 417 percent overestimate vs. a 150 percent one) and of adult smoking (319 percent vs. 173 percent). Both be- tween countries and within the Los Angeles respon- dents, reported cigarette advertising exposure was positively related to the amount of overestimation of both adult and peer smoking prevalence. Overestimates of smoking prevalence were found to be positively re- lated to intentions to smoke. Interestingly, self-reported exposure to cigarette advertising and intentions to smoke had a direct relationship beyond that mediated by misperceptions of smoking prevalence. In a recently published study of seventh-and eighth- graders, Botvin et al. (1993) found that exposure to ciga- rette advertising in periodicals and newspapers was predictive of current smoking status. Adolescents with high exposure to cigarette advertising were significantly Advertising and Promotion 193 TIMN 0139045

hreC•i•i1hnLt Tt)hA`ci~ LL•t~iUnt~ t'cOl'lt' Association) coined the expression "smokewashing" to imply that children were being brainwashed by cigarette advertising (AA 1963q). The campaign that drew the most specific criti- cism for its advertising copy was the American Tobacco Company's 1963 Lucky Strike slogan: "Luckies sepa- rate the men from the boys, but not from the girls" (AA 1963c). The television schedule stipulated use of all three networks and spot commercials on 500 stations in 90 markets (USTJ 1963b). A typical print ad showed a young man looking longingly at an accomplished, ma- ture man (such as a race car driver) who was enjoying a cigarette while receiving recognition for a feat (such as a trophy for winning a race) and being admired by an attractive woman. The President of the National Asso- ciation of Broadcasters called the campaign a "brazen, cynical flouting of the concern of millions of American parents about their children starting the smoking habit.... They well know that every boy wants to be regarded as a man" (AA 1963g, p. 1). Advertising Age joined in editorial condemnation of the campaign by stating: "It is a too-clever, too-cynical attempt.... This is advertising we can do without" (AA 1963t, p. 20). In the face of this criticism, the six major firms in the industry dropped virtually all advertising in college me- dia, football programs, magazines, and newspapers, all of which they had been supporting with up to $1 million annually (AA 1963b). This action left in place, however, other teen-targeting practices, such as R.J. Reynolds's expenditure of nearly $2.5 million (about half of its spot radio commitment) on teen radio stations during after- school hours, a practice the company claimed it discon- tinued in 1964 (AA 1964b). Advertising Age noted the political and public relations dilemma thatcigarette firms faced, since the companies were interested "in picking up new business from new, young smokers" yet did not want "to be seen reaching to the young market" (AA 1963f, p. 108). Industrv executives met in the summer of 1963 to discuss restrictions on television advertising, using the Tobacco Institute as a framework to avoid collusion charges (AA 1963v). One of the Tobacco Institute s sug- gestions was that programs "whose content is directed particularly at youthful audiences should not be spon- sored or used. Thus, good judgment in program con- tent, rather than arbitrary restriction of sponsorship to certain hours of the listening or viewing day, should be the determining factor" (AA 1963j, p. 1). Although the Tobacco Institute took pains to note that it did not monitor or regulate the advertising of its members, the chief execu- tives of all of the major firms, save Brown & Williamson, instantly endorsed the suggestions, indicating that they would display the necessary judgment and self-regula- tory restraint. The suggestions of the Tobacco Institute d rew scorn from Senator Maureen Neuberger, a leading Congres- sional critic of tobacco-marketing practices. The Senator felt that the suggestions and the entire self-regulatory process would prove to be an "exercise in futility" that was "motivated by a desire to head off government regulation" (AA 1963j, p. 8). Senator Warren Magnuson complained about sponsorship (for the Kent brand of cigarettes) of The Ed Sullivan Show for the Beatles' Ameri- can debut, which exposed millions of teens to cigarette advertising (AA 1965). In 1964, the Federal Trade Commission (FTC) noted that both the messages and the media placement seemed destined to attract the young: Whether through design or otherwise, cigarette advertising is so placed that its audience is substan- tially and not merely incidentally or insignificantly, composed of nonadults.... Whether or not the ciga- rette industry has deliberately attempted to exploit the large and vulnerable youth market, its advertis- ing, in emphatically reiterating the pleasures and attractions of smoking without disclosing°the dan- gers to health, has exercised an undue influence over the large class of youthful, immature consum- ers or potential consumers of cigarettes (FTC 1964, pp. 110-2). An analysis of the television schedule sponsored by cigarette firms in 1963 indicated that almost all firms bought air time during a large number of shows that had audiences consisting of 30 percent or more youth (i.e., persons under 21 years old). The sponsors, the shows sponsored, and the percentages of youthful audiences for the shows included the American Tobacco Com- pany-Combat (45 percent), The Jimmy Dean Show (32 percent), Monday Night Movie (30 percent), Saturday Night Movie (30 percent), and The Twilight Zone (30 percent); Liggett & Myers -The Outer Limits (46 percent), The Price Is Right (32 percent); Lorillard-The Joey Bishop Show (44 percent), Wide World of Sports (38 percent), Winter Olym- pics Preview (35 percent), The Dick Van Dyke Show (33 percent); Philip Morris-The Jackie Gleason Show (38 per- cent), The Red Skelton Show (37 percent), Route 66 (31 ' percent); and R.J. Reynolds-Glynis (44 percent), McHale's Navy (40 percent), The Beverly Hillbillies (38 percent), 77 Sunset Strip (32 percent), and Saturday Night at the Movies (32 percent) (Pollay and Compton 1992). Altogether, cigarette companies sponsored 55 shows for a total of 125 hours a week. On the assumption that the average half-hour television show involved two commercials, teenagers were exposed to more than 1,350 cigarette commercials during 1963, and younger children were exposed to over 845 commercials during that year. Analysis of the time slots most frequently Advertising and Promotion 169 TIMN 0139021

hl"c : il/tnik TJ!'Niit~ (_hC .•1Nh'11~: ~ 01U1"~ hi1'l'IC 1'IERCE JP, HATZIANDREU E. Report ot the !y8badt)lt )/.i ot hohacco sur'w. C;S Department of Health and Human Services, Public Health Service, Centers for Disease Contrcil, Office on Smoking and Health. Publication No. OM 90-2004, 1990. PIERCE JP, NAQUIN M, GILPIN E, GIOVINO G, MILLS S, MARCUS S. Smoking initiation in the United States: a role for v.'orksite and college smoking bans. Journal of the National t=ancer Institute 19N1;83( l4):1009-13. PIRIE PL, MURRAY DM, LUEPKER RV. Smoking prevalence in a cohort of adolescents, including absentees, dropouts, and transfers. American fournal of Public Health 1988;78(20):176-8. ROBERTSON JB, BRAY JT. Development of a validation test for self-reported abstinence from smokeless tobacco products: preliminary results. Prezlentire Medicine 1988;17(4):496-502. SCHINKE SP, SCHILLING RF II, GILCHRIST LD, ASHBY VIR, KITAJIMA E. Pacific Northwest Native American youth and smokeless tobacco use. International Journal of Addictions 1987;22(9):881-4. SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION. The 1991 National Household Survey on Drug Abuse. Unpublished data. TAIOLI E, WYNDER EL. Effect of the age at which smoking begins on frequency of smoking in adulthood [letter]. New En~Zland Journal of Medicine 1991;325(13):968-9. TURNER CF, LESSLER JT, DEVORE JW. Effects of mode of administration and wording on reporting of drug use. In: Turner CF, Lessler JT, Gfroerer JC, editors. Sur'ey measurement ofdrug use: rncthodolc,tical studies. US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration. Rockville (MD): nHHS Publication No. (ADM) 92-1929, 1992. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. The health consequences of sntoking for u+omen. A report of the Surgeon General. US Department of Health and Human Ser- vices, Public Health Service, Office of the Assistant Secretary for Health, Office on Smoking and Health, 1980. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. The heal th corsequencts of smoking: cancer and chronic lung d isease in the n'vrkplace. A report of the Surgeon General. US Department of Health and I-Iuman Services, Public Health Service, Office on Smoking and Health. DHHS Publication No. (PHS) 85-50207, 1985. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. The health consequences of using smokeless tobacco. A report of the adz'isory colmnittee to the Surgeon General. US Department of Health and Human Services, Public Health Service, National Institutes of Health. NIH Publication No. 86-2874,1986. LS DEl'ARTME`T OF HEALTH A\D H[:`tA\ tiF.lt% K_(`a Natioual houseltolct suminton drug ahu:,r: inuw hndiltl• 198 5. l.5 Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Admini5tra- tion, National Institute on Drug Abuse. DHHS Publication No. (ADM) 88-1586, 1988a. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. The health consequences of smoking: nicotine addiction. A report of the SurYeon General. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Health Promotion and Education, Office on Smok- ing and Health. DHHS Publication No. (CDC) 88-8-I06, 1988b. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. National household survey on drug abuse: population estinmtes: 1988. US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Ad- ministration, National Institute on Drug Abuse. DHHS Publi- cation No. (ADM) 89-1636,1989a. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. Reducingthehealthconsequencesofsrnoking: 25yearsofprogress. A report of the Surgeon General. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS Publication No. (CDC) 89-8411,1989b. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. National household sur+ey on drug abuse: main findings 1988. US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administra- tion, National Institute on Drug Abuse. DHHS Publication No. (ADM) 90-1682,1990a. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. The health benefits of smoking cessation. A report of the Surgeon General. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS Publication No. (CDC) 90-8416,1990b. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. National household survey on drug abuse: main findings 1990. US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administra- tion, National Institute on Drug Abuse. DHHS Publication No. (ADM) 91-1788,1991a. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. Strategies to control tobacco use in the United States: a blueprint for public health action in the 1990s. Monograph No. 1. US Depart- ment of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute. Bethesda (MD): NIH Publication No. 92-3316,1991b. TIMN 0138971 Epidentiology 119

Voluntary Compliance with Age-at-Sale Laws for Tobacco Model Laws to Restrict Distribution of Tobacco to Minors Warning Labels on Tobacco Products 257 Introduction 257 History of Warning Labels on Tobacco Products 257 Current Status of Warning Labels 260 Limitations of Warning Labels 261 Effectiveness of Warning Labels 261 Effect of Tobacco Taxation 263 Introduction 263 History of Tobacco Taxation 263 Federal Tobacco Taxes 263 State and Local Tobacco Taxes 265 Cigarette Tax Increases and Cigarette Prices 267 Effect of Excise Taxes on Tobacco Use 269 Aggregate Data Studies 269 Microlevel Data Studies 270 Price Responsiveness of Adolescent Smokers 271 Discussion 272 Tax Policies Under Consideration 272 Increasing Tobacco Taxes 272 Earmarking Taxes 274 Conclusions 274 References 276 254 255 TIMN 0139058

bought found that they were significantly correlated with the proportion of teenagers each time slot afforded (Pollay and Compton 1992). A similar analysis in the FTC's annual report to Congress about cigarette advertising counted 73 televi- sion programs sponsored by cigarette companies; these programs appeared collectively 296 times during Janu- arv 1968 and contained 501 advertisements. Not count- ing other sponsor identifications, this schedule likely exposed the average teenage viewer to over 60 full- length cigarette commercials per month (FTC 1968). Self-Regulatory Cigarette Advertising Codes In 1965, the tobacco industry began creating self- -regulatory cigarette advertising and promotional codes (U.S. Congress 1965). The standards related primarily to four areas: advertising appealing to the young, advertis- ing containing health representations, the provision of samples, and the distribution of promotional items to the young. The code prohibited cigarette advertising in school and college publications, testimonials from ath- letes or other celebrities perceived to appeal to the young, the use of advertising through comic books or newspa- per comics, and the distribution of samples at schools. Also prohibited were representations that smoking was essential to social success, representations that the healthi- nesss of models was.due to cigarette smoking, the use of models who were participating in physical activity, or the use of models who were younger (or appeared younger) than 25 years of age. As one observer (Baker 1968) noted, the tobacco industry did not seem to find its code particularly restric- tive: Four months after the code was formulated, Vice- roy ads featured young tennis players lighting up after a hot game. Salem showed a young couple playing giggly games alongside a waterfall.... A TV commercial producer admitted that it didn't matter how young the models looked, or how youth- ful were their actions, as long as they possessed 'over twentv-five'~ birth certificates. In fact, his quest was for old~i models who 'looked young' (p. 116; italics in original). The code also prohibited cigarette advertising on shows whose audience was "primarily" underage-that is, 45 percent or more of a show's viewers were under 21 years old (AA 1966). This decision rule allowed consider- able room for interpretation. For example, R.J. Reynolds continued to sponsor The Beverly Hillbillies even though the audiences for two selected individual shows exceeded the code requirement; a later interpretation by the to- bacco industry held that the code would be applied to two successive months of audience analyses, rather than 170 Advertising and Promotion to selected specific shows (AA 1y67b). Later that year, after monthly data showed high levels of minors, R.J. Reynolds ceased sponsoring the show (AA 1967c). The National Association of Broadcasters Code Authorit,v, which reviewed all advertisements under the self-regulatory process, noted that the volume and char- acter of cigarette advertising were likely to influence the young and were therefore still problematic. In a confi- dential report, the association expressed its concern: Despite changes which have been brought about in cigarette advertising on radio and television, the cumulative impression created by virtually all of the individual campaigns supports a finding that smoking is made to appear universally acceptable, attractive and desirable.... The difficulty in ciga- rette advertising is that commercials which have an impact upon an adult cannot be assumed to leave unaffected a young viewer, smoker or otherwise. The adult world depicted in cigarette advertising very often is a world to which the adolescent as- pires. The cowboy and the steelworker are symbols of a mature masculinity toward which he strives. Popularity, romantic attachment and success are also particularly desirable achievements for the young. To the young, smoking indeed may seem to be an important step towards, and a help in growth from adolescence to, maturity (National Associa- tion of Broadcasters 1966, pp. 30-1). Candy Cigarettes In 1967, the FTC complained to the tobacco indus- try that the industry's self-regulatory code permitting the sale of candy and bubble gum in packages that re- sembled those of actual cigarette brands amounted to "an indirect form of advertising aimed at children" (AA 1967a, p. 191). At least five U.S. candy manufacturers distributed candy cigarettes that imitated existing ciga- rette brands. The brands imitated (some by more than one candy company) were Camel, Lucky Strike, L&M, Marlboro, Pall Mall, Salem, Winston, Chesterfield, Oa- sis, Lark, and Viceroy. One type of candy cigarette came from a European source and appeared in packages stat- ing, "Made under license of Philip Morris Inc., New York, Mf, USA." The domestic candy cigarettes bore no such overt evidence of links to the tobacco industry, but one U.S. candy maker interviewed in Advertising Age stated that "no [tobacco] company had ever suggested that it might take action" for unauthorized use of trade- marks (AA 1967d, p. 97). Another said, "The companies don't object. That's the point. We've been doing it for many years. They don't care' (p. 97). The tobacco companies disclaimed any intent to lure children with candy cigarettes, but would not say TIMN 0139022

1'!'c'C'c'llt/i!ti TvNdc'ccl U,t' rllltcvlt } 01vl,~ t','vt1h' habits and interests of young people, reported that estimates of smoking rates among adolescents aged 13 through 19 had increased from 25 percent in I, 961 to 35 percent in 1963. That study also found that 44 percent of graduating seniors smoked. The Fortune article linked this reported increase to advertising: "Cigarette ads often portray and seem to be pitched directly at young people" (p. 120). Promotion Through Radio and Television Cigarette sellers were among the most enthusiastic pioneers in the use of radio network broadcasting for coast-to-coast advertising. By 1930, the American To- bacco Company, Brown & Williamson, Lorillard, and R.J. Reynolds were all buying network radio time (Dunlap 1931). The American Tobacco Company's Lucky Strike brand sponsored many radio comedies and musical shows, such as The Jack Benny Show, The Kay Kayser Kollege of Musical Knowledge, and the best-known and longest running of the popular music shows, The Lucky Strike Hit Parade. This radio show, which started in 1928 and ran into the 1950s on television, appealed to a young audience; it featured, for example, teen idol Frank Sinatra when he was launching his career (Cone 1969). So popu- lar was this show in 1938 that when its producers intro- duced a sweepstakes promotion offering free cartons of "Luckies" for correctly guessing each week's three most popular tunes, the promotion drew nearly seven million entries per week (Hettinger and Neff 1938). By the early 1930s, R.J. Reynolds was sponsoring radio programs that were popular with youth, such as the Canrel Pleasure Hour, The All Star Radio Revue, and the enduring Camel Caravan, which featured the swing mu- sic of Benny Goodman (Tilley 1985). In 1938, the Chester- field brand of Liggett & Myers signed Glenn Miller and the Andrew Sisters to replace Paul Whiteman (Marin 1980). Artie Shaw appeared for Lorillard's Old Gold cigarettes, and Tommy Dorsey appeared for Brown & Williamson's Kool and Raleigh brands (Lewine 1970). The heavily commercial nature of these shows is hard to imagine by today'sstandard. A single hour of the Raleigh Rt vieu, for example, contained 70 promotional refer- ences to Raleigh cigarettes (Fox 1984). Market research studies guided the selection of musical shows and styles that appealed to young people of various ages. For example, the market research files of the J. Walter Thompson Company, then advertising Old Golds for Lorillard, included the following market re- search studies for 1941 and 1942: Survey of Sales at Colleges, Survey of Dealers in 32 Colleges, Remembrance Check on "Apple' Campaign Among College Students, Report by Crossley on New York City Youth Interests in Radio Programs, and Radio Preferences Among Teenage Boys and Girls (Pollay 1988). The successful use of radio led the cigarette indua- try to pioneer in television advertising. By 1950, more than seven hours per week were being sponsored by cigarette sellers. An editorial in that year's United States Tobacco Journal pronounced cigarette companies "the dominant factor in television advertising sponsorship"- evidence of the companies' faith that "it is an historically demonstrated certaint,v that the more people subjected to intelligent advertising, the more people will buy the product advertised" (USTJ 1950a, p. 4). By the earl,v 1960s, tobacco companies were spending the majority of their total promotional budget on television advertising (Advertising Age [AA1 1963m, n). Their trust in the efficacy of advertising in this medium led to record- setting promotional spending (AA 1963b, 1964f), corre- sponding sales growth (AA 1963k), and increased profits (AA 1963p; LISTJ 1963c). Promotion Through Schools Promotional activities sometimes advanced into the nation's schools. In 1948, Liggett & Myers Tobacco Company provided high schools with free football pro- grams; a scorecard at the center of the program was in effect a two-page advertisement for Chesterfield ciga- rettes. Public complaints apparently led to the cancella- tion of this particular campaign, despite the fact that cigarette advertisers had previously supplied such pro- grams for football and other high school sports (Tide 1948). In 1953, plastic-coated book covers featuring school logos on the front and cigarette ads on the back were being used to promote Old Gold cigarettes to students in most of the country's 1,800 colleges and in more than a third of its 25,000 high schools (AA 1953b). College students in particular held great marketing potential for the tobacco industry in the 1950s. As Philip Morris Public Relations Director James Bowling ex- plained: "Research and experience proved that the con- sumer, at this age and experience level, is more susceptible to change, has far-reaching influence value, and is apt to retain brand habits for a longer period of time than the average consumer reached in the general market. There- fore, though the advertising cost per thousand in the college market is relatively high, the actual expenditure can be a great deal more efficient" (Gilbert 1957, p. 184). In the 1950s, the American Tobacco Company tar- geted college students with its largest ever Lucky Strike campaign, which used college newspapers, campus ra- dio stations, football programs, and extensive campus sampling and tie-in promotions (AA 1953a). A research firm specializing in young people reported that cigarette firms were spending about $5 million per year on college promotions in the 1950s. It noted that most of these college students had started smoking at earlier ages, and that "continual exposure to advertising to adults through Advertising and Promotion 167 TIMN 0139019

J06tccl' Usc'.~~Nll~llt ) oUfl/,ti Pc'oF'h' Smoking as a Risk Factor for Smokeless Tobacco Five longitudinal studies examined the prospec- ti%-c relationsllips between cigarette smoking and the onset or continued use of smokeless tobacco (Ary, Lichtenstein, Se-erson 1987; Dent et al. 1987; Murray et al. 1988; An, 1989; Sussman et al. 1989). (The relation- ship between smokeless tobacco use and subsequent cigarette smoking is reviewed later in this chapter.) In a longitudinal study of eighth graders, Dent et al. (1987) reported that smoking status at baseline predicted the onset of smokeless tobacco use one year later. Twenty- nine percent of regular smokers at baseline-but only 6 percent of those who had never smoked-reported smokeless tobacco onset at follow-up. Ary, Lichtenstein, and Severson (1987) used discriminant analvsis to iden- tify predictors of the onset of smokeless tobacco use nine months after smoking onset among 7th, 9th, and 10th graders. The discriminant function accounted for 11 percent of the variance, and having tried smoking was an important predictor, correlating at 0.64 with the dis- criminant function. In a similar study using a separate sample of 7th, 9th, and 10th graders in Oregon, smoking did not significantly predict smokeless tobacco onset at 6-month or 12-month follow-ups (Ary 1989).' Another longitudinal study found general support for the influ- ence of smoking on seventh graders who had tried smoke- less tobacco (Murray et al. 1988). Longitudinal analysis of one-year follow-up data from two other samples of seventh graders indicated that both males and females exhibited a fairly consistent relationship between the onset of smokeless tobacco use and pretest smoking (Sussman et al. 1989). Three of the longitudinal studies cited above also examined the prospective relationship between cigarette smoking and continued use of smokeless tobacco among adolescents. Arv, Lichtenstein, and Severson (1987) found that baseline smoking did not predict frequency of later smokeless tobacco use at nine-month follow-up. In a separate study, Ary (1989) examined these relationships and found that frequency of smoking was related to continued daily sinokeless tobacco use at 12-month follow-up but not~at 6-month follow-up. A 24-month follo,,ti•-up study of.. ninth graders also found general support for the influence of smoking on later use of smokeless tobacco (Murray et al. 1988). Although the findings from these three prospective studies are incon- clusive, numerous studies report significant concurrent relationships between smoking and smokeless tobacco use. The degree of statistical power exhibited by these relationships varied' widely, but every study found at least one significant association between smokeless to- bacco use and smoking. Other Adolescent Behaviors Twelve studies fairly consistently indicated that smokeless tobacco use is related to concurrent use of alcohol and marijuana (Lichtenstein et al. 1994; Arv, Lichtenstein, Severson 1987; Burke et al.1988, 19H9; Jc,nes and Moberg 1988; Murrav et al. 1988; Arv 1989; Riley, Barenie, Mvers 1989; Rouse 1989; Sussman et al. 1989; Riley et al. 1991; Stevens et a1.1991). One of these stud ies (Sussman et al. 1989) found that seventh- and eighth- grade females showed no relationship between having tried smokeless tobacco and concurrently using alcohol, but two of four samples with male subjects showed significant relationships. Only three studies examined the prospective relationships between smokeless to- bacco use and the use of alcohol and marijuana. In one study, the onset of smokeless tobacco use among those who had not used at baseline was related to marijuana use but not to alcohol use (Ary, Lichtenstein, Severson 1987). In a separate study, initial use of alcohol or mari- juana did not predict onset of smokeless tobacco use at 6- month follow-up, but initial alcohol use predicted smokeless tobacco use at 12-month follow-up (Ary 1989). In another 12-month longitudinal study, onset of smoke- less tobacco use among those who at baseline had never used smokeless tobacco was predicted by initial alcohol use in one of two samples of seventh-grade females but not in two samples of males (Sussman et a1.1989). Taken together, there is some evidence that prior use of either alcohol or marijuana is related to subsequent onset of smokeless tobacco use and to continued use of smokeless tobacco among daily users. Several studies suggest that adolescents who use smokeless tobacco are more likely to use multiple drugs than are adolescents who do not use smokeless tobacco. Ary, Lichtenstein, and Severson (1987) found that among male adolescents who reported use of smokeless to- bacco, cigarettes, alcohol, or marijuana in the week pre- ceding the survey, 43 percent (47 percent in Ary's separate study [19891) indicated that they used more than one of these substances during that week. The percentage of daily users of smokeless tobacco who reported use of alcohol during the preceding week was particularly high (76 percent in Ary, Lichtenstein, and Severson's study [19871 and 74 percent in Arv's separate study [19891). Among daily smokeless tobacco users, 83 percent in Ary, Lichtenstein, and Seversori s study (1987) (80 percent in Ary's 1989 study) also reported using a drug other than alcohol, a fact suggesting that daily smokeless to- bacco users are particularly likely to be multiple drug users. TIMN 0138995 Psycliosocial Risk Factors 143

Preventing Tobacco Use Among Young People psychosocial risk factors-having a low self-image, attributing positive meanings or benefits to smoking, and perceiving smoking as prevalent and norma- tive-strongly predict smoking intentions and smok- ing onset. In several countries, concern about the health con- sequences of smoking and the potential influence of advertising on consumption has prompted a nationwide ban on tobacco advertising (UK Department of Health 1992). In 1975, Norway banned all tobacco advertising, sponsorship, and indirect tobacco advertising. In 1977, Finland banned all forms of tobacco advertising. Canada introduced a ban in 1989 on all tobacco advertising, sponsorship, and indirect advertising of Canadian ori- gin. New Zealand introduced a ban in December 1990 on Condusions 1. Young people continue to be a strategically impor- tant market for the tobacco industry. 2. Young people are currently exposed to cigarette messages through print media (including outdoor billboards) and through promotional activities, such as sponsorship of sporting events and public e.nter- tainment, point-of-sale displays, and distribution of specialty items. 3. Cigarette advertising uses images rather than infor- mation to portray the attractiveness and function of smoking. Human models and cartoon characters in cigarette advertising convey independence, health- fulness; adventure-seeking, and youthful activities- themes correlated with psychosocial factors that appeal to young people. advertising in print media originating in New Zealand, on advertising in posters, and on sponsorship of sports. Although the bans in Canada and New Zealand have been relatively recent, the current evidence indicates that these actions have had a significant effect on consump- tion in each of the four countries dUK Department of Health 1992). In each case, the banning of advertising was followed by a decrease in smoking rates that per- sisted even when controlled by changes in other factors, such as price. These studies focused on total cigarette consumption; although the bans appear to have influ- enced smoking rates among young people in Canada and Norway, more specific data concerning young people are forthcoming. 4. Cigarette advertisements capitalize on the disparity between an ideal and actual self-image and imply that smoking may close the gap. 5. Cigarette advertising appears to affect young people's perceptions of the pervasiveness, image, and func- tion of smoking. Since misperceptions in these areas constitute psychosocial risk factors for the initiation of smoking, cigarette advertising appears to increase young people's risk of smoking. Advertising and Prombtion 195 TIMN 0139047

tiilr~Co 11 Ge'Ne'/'dl '-; Re'{h irt MAXWELL JC JR. The Maxu~ell consumer reFx>rt: 1991 year-end mles estinmtes for the cigarette industry. Richmond (VA): Wheat First Sect: rities. 1992. NATIONAL CENTER FOR HEALTH STATISTICS. Ad%ance report of final mortality statistics, 1989. MonH/ly Vifal Stati~tvc> Report 1992a;40(8). MCNEILL AD. The development of dependence on smoking in children. Briti:h Journal of the Addictions 1991;86(5):589-92. MCNEILL AD, JARVIS MJ, WEST RJ. Subjective effects of cigarette smoking in adolescents. Psychopharmacology 1987;92(1):115-•7. MCNEILL AD, WEST RJ, JARVIS MJ, JACKSON P, BRYANT A. Cigarette withdrawal symptoms in adolescent smokers. Psychopimrmacolog_y 1986;90(4):533-6. MILLERRG. Beyondanova: basics ofapplied statistics. NewYork: John Wiley & Sons, Inc., 1986. MILLER JD, CISIN IH, GARDNER-KEATON H, HARRELL AV, WIRTZ PW, ABELSON HI, ET AL. National survey on drug abuse: main findings: 1982. US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Instituteon Drug Abuse. Bethesda (MD): DHHS Publication No. (ADM) 83- 1263, 1983. MOSS AJ, ALLEN KF, GIOVINOGA, MILLS SL. Recenttrends in adolescer1t smoking, smoking-uptake correlates, and expec- tations about the future. Advance Data. US Department of Health and Human Services, Public Health Service, Centers for Disease Cowh'ol and Prevention, National Center for Health Statistics. No. 221, 1992. MURRAY DM, PERRY CL. The measurement of substance use among adolescents: when is the 'bogus pipeline' method needed? Addictive Behaviors 1987;12(3):225-33. NATIONAL CENTER FOR HEALTH STATISTICS. The statis- tical design of the Health Household-Interview Survey. By staff of the US National Health Survey and the Bureau of the Census. Health Statistics. US Department of Health, Education, and Welfare, Public Health Service. PHS Publication No. 584 A2, Washington (DC): US-Governunent Printing Office, 1958. NATIONAL CENTER FOR HEALTH STATISTICS. Changes in cigarette smoking habits between 1955 and 1966. Vital and Health Statistics. Series 10, No. 59. US Department of Health, Education, and Welfare, Public Health Service, Health Services and Mental Health Administration. PHS Publication No.1000, 1970. NATIONAL CENTER FOR HEALTH STATISTICS. Health interview survey procedures, 1957-1974. Vital and Health Sta- tistics. Series 1, No. 11. US Department of Health, Education, and Welfare, Public Health Service, Health Resources Admin- istration, National Center for Health Statistics. DHEW Publica- tion No. (HRA) 75-1311,1975. 118 Epidemiology NATIONAL CENTER FOR HEALTH STATISTICS, VENTURA SJ. Advance report of new data from the 1989 birth certificate. Monthly Vital Statistics Report 1992b;40(12). NATIONAL CENTER FOR HEALTH STATISTICS. Health United States, 1992. Hyattsville (MD): Public Health Service. DHHS Publication No. (PHS) 93-1232, 1993. NATIONAL CENTER FOR HEALTH STATISTICS, KOVAR MG, POE GS. The National Health Interview Survey design, 1973-84, and procedures, 1975-83. Vital and Health Statistics. Seriesl,No.18. US Departmentof Healthand HumanServices, Public Health Service, National Center for Health Statistics. DHHS Publication No. (PHS) 85-1320,1985. NATIONAL CENTER FOR HEALTH STATISTICS, MASSEY JT, MOORE TF, PARSONS VL, TADROS W. Design and Estimation for the National Health Interview Survey,1985-94. Vital and Health Statistics. Series 2, No. 110. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics. DHHS Publication No. (PHS) 89-1384,1989. NATIONAL CENTER FOR HEALTH STATISTICS, SCHOENBORN CA. Health promotion and disease preven- tion: United States, 1985. Vital and Health Statistics. Series 10, No.163. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics. DHHS Publication No. (PHS) 88-1591, 1988a. NATIONAL CENTER FOR HEALTH STATISTICS, SCHOENBORN CA, MARANO M. Current estimates from the National Health Interview Survey, United States, 1987. Vital and Health Statistics. Series 10, No. 166. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics. DHHS Publication No. (PHS) 88-1594,1988b. NOLAND MP, KRYSCIO RJ, RIGGS RS, LINVILLE LH, PERRfiT LJ, TUCKER TC. Saliva cotinine and thiocyanate: chemical indicators of smokeless tobacco and cigarette use in adolescents. Journal of Behavioral Medicine 1988;11(5):423-33. PIERCE JP, FARKAS A, EVANS N, BERRY C, CHUI W, ROSBROOK B, ET AL. Tobacco use in California. A focus on preventing uptake in adolescents. Sacramento (CA): California Department of Health Services, 1993. PIERCE JP, GILPIN E, BURNS DM, WHALEN E, ROSBROOK B, SHOPLAND D, ET AL. Does tobacco advertising target young people to start smoking? Evidence from California. Journal of the American Medical Association 1991;266(22):3154-8. ,rIT41s4 0138970

tiurXCuri LOuw•11l', RCF10n•t ads," the authors concluded, "are clearly violating the industry's voluntary code that requires models not to 'appear to be less than twenty-five years of age"' (Mazis et al. 19y2, p. 35). Ads That Target Women The history of campaigns that target women has been reviewed by discussing specific campaigns and generating data for advertising intensities (i.e., the num- bers of ads appearing in each magazine) for 1971 through 1984 (Ernster 1985). Tabulation of the number of ads in Better Homes and Gardens, Ladies Home Journal, and McCall's revealed that ad intensity grew steadily during the 1970s, peaked in 1979, and declined thereafter. iVonetheless, in 1984, an average of more than 10 cigarette ads appeared in each issue of these magazines and of Cosmopolitan, Family Circle, Glamour, Harper's Bazaar, Mademoiselle, Redbook, Vogue, and Woman's Day. A similar report (Howe 1984) on the history of women and cigarette advertising included graphs of the frequency of cigarette ads showing women smoking that appeared in Life (for the period 1936-1972) and Ebony (for 1945-1980). These ads peaked in the mid-1960s, and again in the early 1970s. The report observed that in these peak years, the ads generally focused on "women jogging, biking, backpacking and playing tennis, all while smoking a cigarette, too. It would be difficult to argue that these positive images are not influential on young, image-conscious teenagers" (p. 8). Ads That Target Blacks The cigarette ads targeting blacks in Ebony from 1950 through 1965 were studied by Pollay, Lee, and Carter-Whitney (1992). When the full census of cigarette ads from Ebony (N = 540) were compared with cigar- ette ads from a matching sample of Life issues, the inves- tigators found that the ads targeting blacks were significantly more likely to use athletes and were two to three years tardy in announcing to black consumers new products with tar- and nicotine-reducing filters. Further- more, cigarette advertising was initially more prevalent in Life than in Ebony, but after 1960, Ebony issues carried more cigarette ads. The cigarette industry's greater intensity in target- ing blacks through advertising has also been observed in more contemporary studies. In 1985, a comparison of advertising in selected magazines directed at white and black audiences (Cummings, Giovino, Mendicino 1987) found that the magazines targeting blacks had signifi- cantly more cigarette advertising and more ads for men- thol brands, which are preferred by a much higher proportion of blacks than whites (see "Cigarette Brand Preference" in Chapter 3). This racial disparity may mark the cigarette industry's reaction to the notable de- cline in black adolescent smokers during the past decade (see "Trends in Cigarette Smoking" in Chapter 3). A review of cigarette promotional practices in 1985 noted the diversity of methods for reaching black audiences, including the growing use of sponsorships of athletic, cultural, civic, fashion, and entertainment events. Espe- cially noteworthy was the intensive use of smaller bill- boards in black communities; these ads accounted fot, 37 percent of all billboards, and most featured menthol brands. In contrast to the larger highway billboards, smaller billboards are usually placed low and close to the street-and thus visible to passersby of all ages. Recently, R.J. Reynolds attempted to introduce a new brand of cigarettes, Uptown, to the black community in Philadelphia (Robinson et al. 1992). Through the efforts of black leaders, who mobilized their communities, the Uptown Coalition emerged. The Philadelphia commu- nity created the agenda rather than allowing the tobacco industry to dictate it. Media messages were carefully framed,and UptownCoalition spokespersonsweregiven clearly prescribed roles. In 1990, RJ. Reynolds abruptly canceled the launch of Uptown. The Uptown Coalition was historic because it represented the first community- based initiative that succeeded in getting the tobacco industry to take a cigarette out of production. 184 Advertising and Promotion TIMN 0139036

Surgeon General's Report Figure 4. A model of smoking initiation: effect of cigarette advertising on perceptions of smoking prevalence among adults and peers Perceived percentage of adult smokers Exposure to cigarette advertising Intentions to smoke Perceived percentage of peer smokers Source: Burton et al. (unpublished data). more likely to be current, past-day, past-week, or past- month smokers than were those with low exposure to cigarette advertising. Significant associations were also found between exposure to cigarette advertising and students' estimates of smoking prevalence among their peers and among adults. Studies have been equivocal concerning the rela- tive importance of overestimates of peer smoking com- pared with overestimates of adult smoking. The general interpretation is that normative influences are operative in both cases; that is, smoking is more or less misperceived to be a usual and appropriate behavior. It also has been suggested that overes~n~abes of adult smoking serve to increase the symbolism of smoking as a desired, adult behavior; smoking therefore acquires greater meaning to an adolescent in transition to adulthood. Discussion Even though the tobacco industry asserts that the sole purpose of advertising and promotional activities is to maintain and potentially increase market shares of adult consumers, it appears that some young people are recruited to smoking by brand advertising. Two sources of epidemiologic data support this assertion. Adolescents consistently smoke the most advertised brands of cigarettes, both in the United States and else- where (McCarthy and Gritz 1984; Baker et al. 1987; DiFranza et al. 1991). Moreover, following the intro- duction of advertisements that appeal to young people, the prevalence of use of those brands-or even the prevalence of smoking altogether-increases. This as- sociation was seen among adolescent females after the 1968 introduction of the Virginia Slims brand; smoking prevalence among adolescent females nearly doubled between 1968 (8 percent) and 1974 (15 percent) (USDHHS 1980). A similar associated increase was seen for smokeless tobacco use among adolescent males after a major advertising and promotional campaign in the 1970s focused on "beginners" (Tye, Warner, Glantz 1987). More recently, Camel's Old Joe advertising cam- paign appears to have substantially increased the brand's market share among persons less than 18 years old (DiFranza et a1..1991). Advertising and promotional activities also appear to influence risk factors for adolescent tobacco use, even if this is not the intention of the tobacco industry. These 194 Advertising and Promotion TIMN 0139046

tiitr~rwr C;irto-al" !:t•pw; perceive that their peers are smokers. The shift from social to more personal reasons for smoking is associated with increasing nicotine dependence and addiction. Several other factors that influence smoking initiation are not covered in this chapter. First, the com- bined influence of tobacco advertising and promotion represents a powerful environmental risk factor (see Chapter 5). Second, cultural or community-level re- search on the causes of smoking onset is decidedly lim- ited. ln particular, the effect of taxation, of restrictions to public smoking, of vending machine regulations, and of limiting access to tobacco for underage buyers needs to be addressed prospectively (Chapman and Bloch 1992; Sweanor et al. 1992; see Chapter 6). Third, even at the school level, smoking prevalence rates have been shown to be partly attributable to attendance at a particular school and to school smoking policies (Best et al. 1984; Semmer, Lippert, et a1.1987; Pentz et a1.1989; Santi et al. Initiation of Smokeless Tobacco Use 1990-91; see "Smoking Restrictions in the ScnooY" in Chapter 6). Still, which aspects of schools contribute to smoking onset-whether their rules, consistency of rule enforcement, grade structure, or discipline procedures- need to be studied. These distal environmental factors partly determine the meaning for, and acceptability of, cigarette use at a community level, determine the ease or difficulty with which adolescents can obtain tobacco, and reinforce or inhibit the continuation of use into adult- hood. Proximal factors are strong determinants of use once the meaning of smoking is established and access to cigarettes is possible. Therefore, the more distal risk factors might be considered the proper targets of in- tervention research efforts, which should test the po- tency of these factors and provide the clear community-level message that cigarette smoking among the young is unacceptable. Compared with the research literature on smoking initiation, the knowledge base on smokeless tobacco initiation is modest. Far fewer longitudinal stud- ies have been conducted. For the most part, research efforts on smokeless tobacco have been cross-sectional; a few have also been guided by behavioral theory. None- theless, a number of methodologically sound studies provide knowledge about the risk factors associated with the initiation of smokeless tobacco use. In parallel with the research on cigarette smoking among young people, sociodemographic, environmental, behavioral, and per- sonall factors have all been explored as correlates of smoke- less tobacco use. With only a few exceptions, the consistency of the findings with those found for cigarette smoking suggests that both smoking and the use of smokeless tobacco prtxinctss share a common causality as well as' similar fuitictions and meanings for young people. Sociodemographic Factors in the Initiation of Smokeless Tobacco Use National survey data on the demographics of smokeless tobacco use are presented in detail in Chapter 3 (see "Recent Patterns of Smokeless Tobacco Use") and are only summarized here. These data clearly indicate that smokeless tobacco use among young people is par- ticularly prevalent among non-Hispanic white males. 140 Psychosocial Risk Factors The three youth surveys that assessed smokeless tobacco prevalence (that is, use during the month preceding the survey) also found that males were 10 to 15 times more likely than females to use smokeless tobacco. Although nationally representative data on American Indian and Alaskan Native youth are not available, community- level studies of these populations have reported high rates of weekly smokeless tobacco use among both males (43 percent) and females (34 percent), even at very young ages (Schinke et a1.1987,1989; Bruerd 1990). The Monitoring the Future Project survey, a na- tional survey of high school seniors, indicated that 54 percent of males had used smokeless tobacco. Among those, 23 percent first used smokeless tobacco before or during the sixth grade, and over 53 percent first used it before or during the eighth grade (see "Grade When Smokeless Tobacco Use Begins" in Chapter 3). Data from a number of other recent surveys suggest that early adolescence is the peak age for first using smokeless tobacco (Schaefer et al. 1985; US Department of Health and Human Services [USDHHS] 1986; Ary, Lichtenstein, Severson 1987; Ary et al. 1989; Riley, Barenie, Myers 1989; Brownson et a1.1990; Riley et a1.1990,1991). Limited evidence suggests that the following sociodemographic factors may also be related to higher rates of smokeless tobacco use among youth: one or no parents in the household (Jones and Moberg 1988; Murray et al. 1988; see "Sociodemographic Risk Facto'rs for . TIMN 0138992

Chapter 6 Efforts to Prevent Tobacco Use Among Young People Introduction 209 Public Opinion About Preventing Tobacco Use Among Young People Introduction 210 Public Opinion About Tobacco Education 210 Restrictions on Smoking in Schools 210 Restrictions on Tobacco Advertising and Promotion 211 Restrictions on the Sale of Tobacco Products to Minors 213 Taxes on Tobacco Products 214 Educational Efforts to Prevent Tobacco Use Among Young People 216 School-Based Smoking-Prevention Programs 216 Introduction 216 Early Approaches to Smoking Education and Prevention 216 Information Deficit Model 217 Affective Education Model 217 Correlates of Adolescent Smoking Behavior 217 Instilling Skills for Resisting Social Influences to Smoke 218 Intervention Objectives .218 Overall Program Structure 218 Curriculum Format 219 Exemplary Programs for Resisting Social Influences 220 Social Inoculation 220 Project CLASP 220 Life Skills Training 221 The SODAS Model 222 The Waterloo Smoking-Prevention Program 222 The Minnesota Smoking-Prevention Program 222 International Research on Smoking-Prevention Programs 224 Western Australia 224 Nor~1Karelia Youth Project 224 Uni~d.;IEingdom 224 Meta ~yses of School-Based Smoking Prevention 225 Discussion 225 Preventing Smokeless Tobacco Use 226 Introduction 226 Evaluation of School-Based Efforts 226 The Oregon Research Institute Program 226 Toward No Tobacco Use 227 Project SHOUT 227 Programs for Native American Populations 227 210 TIMN 0139056

Smoking Cessation 227 Introduction 227 Convenience Samples of Adolescents Who Try to Quit Smoking 228 Effect of Smoking-Prevention Programs on Cessation 228 Cessation Interventions in the School 228 Cessation Interventions Based Outside the School 229 Discussion 230 : Smokeless Tobacco Cessation 230 Introduction 230 Clinical Studies 230 School-Based Efforts 230 Smokeless Tobacco and Cigarettes 231 Research and Programmatic Challenges 231 Clinical Interventions to Prevent Tobacco Use 232 Introduction 232 Recommendations to Clinicians Who Care for Children and Adolescents 232 Role of Health Professionals in the School, in the Community, and in Policy Formation 233 Community Programs to Discourage Tobacco Use 233 Introduction 233 Communitywide Research Trials on Smoking Prevention 234 State and Federal Tobacco-Control Efforts at the Local Level 235 Community Organizations for Preventing Tobacco Use 236 Prevention Programs Initiated by the Tobacco Industry 237 Prevention Programs Sponsored by Health-Related Organizations 238 Tobacco-Control Advocacy Organizations 238 Role of the Mass Media in Reducing Tobacco Use 239 Introduction 239 Programmatic Use of Mass Media to Reduce Adolescent Tobacco Use 239 Theory and Research on Using Mass Media to Reduce Adolescent Drug Use 242 Effective Designs for Mass-Media Campaigns 244 Public Policies to Prevent Tobacco Use Among Young People 245 Effect of General-Public Smoking Restrictions on Young People 245 Introduction 245 History of Public Smoking Restrictions 245 Smoking Restrictions in the School 246 Other Public Smoking Restrictions That Affect Youth 247 Effect of Smoking Restrictions on Adolescent Tobacco Use 248 Restrictions on Minors' Access to Tobacco 248 Introduction 248 Tobacco Sources for Youth 248 Studies of Young People's Access to Tobacco 249 State and Local Laws Regarding Tobacco Distribution to Minors 249 Enforcement of Tobacco-Distribution Laws 254 TIIVIN 0139057

Preventing Tobacco Use Among Young People Introduction This chapter examines the range and effectiveness of efforts to prevent tobacco use among young people. The first section provides data on recent public opinion of strategies to reduce tobacco use among young people. The second set of sections focuses on educational efforts to reduce cigarette smoking and smokeless tobacco use among young people, including school-based, clinic, and communitywide programs. The third set of sections examines the impact of social conditions and public poli- cies, including the effects of mass media programming, legal restrictions, warning labels, and tobacco taxation. Together, these efforts can inoculate against the psychosocial risk factors discussed in Chapters 4 and 5, as shown in Figure 1. Figure 1. Efforts to prevent tobacco use among young people, by stage of initiation Never Smoker ! Mass media programming Counteradvertising Communitywide programs Social influences programs Taxation and cost Restricting sales to minors bo- Nonsmoker Social influences programs Taxation and cost ~.- Nonsmoker Regutar Use Restrictions on smoking at school Cessation programs 410- Quit Addiction Source: Adapted from U.S. Department of Health and Human Services (1991). Prevention 209 TIMN 0139059

11ITtic" !1 (~c'~ft'~'.lr • ~\c~h ~ Personality Traits ~~~.~~, Some studies have examined relationships beutween smokeless tobacco use and a number of personality traits. A positive association was found with anger (Jacobs et al. 1988), anxiety (Jacobs et al. 1988), assertiveness (Botvin, Baker, Tortu 1989), depression (Jones and Moberg 1988; Rouse 1989), and locus of control (Dignan et al. 1986). A negative association was found with anxiety, curiosity (Jacobs et al. 1988), and self-concept (Dignan et al. 1985). Smokeless Tobacco Use as a Risk Factor for Continued Use Intentions to Use Smokeless Tobacco Consistent with data on youth smoking, the re- search indicates a strong relationship between concur- rent smokeless tobacco use and intention to use in the future. Brubaker and Loftin (1987) found that reported intention to use smokeless tobacco in the week after the survey was strongly related to current smokeless to- bacco use in a small sample of fifth- through eighth- grade males. Intention to use in the next two weeks was also related to current-use status (Gerber, Newman, Mar- tin 1988). No studies were found, however, that exam- ined the prospective relationship between intention to use smokeless tobacco and the initiation or continuation of use. Current Use of Smokeless Tobacco Ary, Lichtenstein, and Severson (1987) prospec- tively examined the predictors of frequency of smoke- less tobacco use at a nine-month follow-up for their sample of daily users of smokeless tobacco. Current use of smokeless tobacco was the best predictor of later use; the initial rate of use was highly correlated with the rate of use nine months later and accounted for 33 percent of the variance. This finding suggests that the successful reduction of smokeless tobacco use will re- quire eariy intervention before the development of physi- ological addiction. Summary of Psychosocial Risk Factors for Smokeless Tobacco Use The major factors associated with the initiation and development of smokeless tobacco use found in this review are shown in Table 1. With the exception of adequate knowledge of' the health consequences of smokeless tobacco use and the social acceptance af- forded by smokeless tobacco use, these factors are nearly identical .to those found for the onset of smoking. Al- though most youth perceive that smokeless tobacco use can be harmful to health, most smokeless tobacco users do not perceive the risk to be great, particularlv to themselves, and particularly compared with the health risk of cigarette smoking. Peer modeling of smokeless tobacco use seems to be strongly and consistently re- lated to the onset and continued use of smokeless to- bacco. Smokeless tobacco use serves social functions within the peer group that may support experimental and continued use. The evidence is less conclusive for modeling by parents and siblings. Peer and, notably, parental acceptance of smokeless tobacco use is much higher than for cigarette smoking. Fairly consistent evidence indicates that smokeless tobacco use is related to concurrent use of cigarettes, alcohol, and marijuana. Findings from prospective stud- ies suggest that the use of smokeless tobacco may pre- cede the use of these other substances and occurs earl,v in a sequence of drug use by some adolescents. Prospective evidence shows that smoking and the use of alcohol and marijuana are also related to the onset and continued use of smokeless tobacco. Engaging in risk-taking behavior and having poor academic performance also appear to be related to smokeless tobacco use (see "Smokeless Tobacco Use and Other Health-Related Behaviors"'and "Sociodemographic Risk Factors for Smokeless Tobacco Use" in Chapter 3). There is mixed evidence that smoke- less tobacco use is associated with youthful athletic par- ticipation; nonetheless, some professional athletes have promoted its use both indirectly (through visible per- sonal use) and directly (through advertising). Finally, there is evidence of concurrent relation- ships (but no prospective evidence) between smokeless tobacco use and health beliefs/knowledge, attitudes, ex- pectancies, and social image. The perception that smoke- less tobacco use may be a healthier choice than cigarette smoking consistently emerges in the data and indicates the need for prevention programs that stress the health consequences of smokeless tobacco use. Smokeless tobacco use, then, appears to be a function of the social world of young people, who see this "adult" behavior as an aid-a generally accessible one-in improving their individual social image. More- over, perhaps because even among adults the health consequences of smokeless tobacco use are not widely understood, adults lack consensus on whether smoke- less tobacco use should be actively discouraged. Peer use of smokeless tobacco thus becomes a strong motiva- tor for initiation and continued use. These misperceptions on the part of adolescents and adults alike are of serious concern, given the health- compromising, addictive aspects of smokeless tobacco use. More strikingly, smokeless tobacco use is associated strongly with other drug use and may serve as an entry behavior to the use of cigarettes, alcohol, and illegal substances. 146 Psychosocial Risk Factors TIMN 0138998

hYtit'/ltlNX Toh/7iit/ Ll;t'.4IH0il~ ~~ll(fh{ ht'Ol1li References ,ABELSON HI, ATKINSON RB, Public experience with psychoactive substances: a nationwide study among adults and vouth. Princeton (.NJ): Response Analysis Corporation, 1975. ABELSON HI, FISHBURNE PM. Nonmedical use of psychoactive substances: 1975/6 nationwide study among youth and adults. Princeton (NJ): Response Analysis Corpora- tion, 1976. ALLEN K, MOSS A, BOTMAN S, WINN D, GIOVINO G, PIERCE J. Teenage attitudes and practices survey (TAPS): methodology and response rate. Paper presented at the 119th annual meeting of the American Public Health Association, 1991. ALLEN K, MOSS A, GIOVINO GA, SHOPLAND DR, PIERCE JP. Teenage tobacco use data. Estimates from the teenage attitudes and practices survey, United States, 1989. Advance Data. US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Health Statistics. No. 224,1993. BACHMAN JG, JOHNSTON LD, O'y1ALLEY PM. Monitor- ing the future: questionnaire responses from the nation's high school seniors 1976. Ann Arbor (MI): Institute for Social Research, University of Michigan, 1980a. BACHMAN JG, JOHNSTON LD, O'MALLEY PM.. Monitor- ing the future: questionnaire responses from the nation's high school seniors 1978. Ann Arbor (Ml): Institute for Social Research, University of Michigan, 1980b. BACHMAN JG, JOHNSTON LD, O'MALLEY PM. Monitor- ing the future: questionnaire responses from the nation's high school seniors 1980. Ann Arbor (MI): Institute for Social Research, University of Michigan, 1981. BACHMAN JG, JOHNSTON LD, O'MALLEY PM. Monitor- ing the future: questionnaire responses from the nation's high school seniors 1981K' Ann Arbor (MI): Institute for Social Research, University of Michigan,1984. BACHMAN JG, JOHNSTON LD, O'MALLEY PM. Monitor- ing the future: questionnaire responses from the nation's high school seniors 1984. Ann Arbor (MI): Institute for Social Research, L'niversity of Michigan, 1985. BACHMAN JG, JOHNSTON LD, O'MALLEY PM. Monitor- ing the future: questionnaire responses from the nation's high school seniors 1986. Ann Arbor (MI): Institute for Social Research, University of Michigan, 1987. BACHMAN JG, JOHNSTON LD, O'MALLEY PM. Monitor- ing the future: questionnaire responses from the nation's high school seniors 1988. Ann Arbor (Ml): Institute for Social Research, University of Michigan, 1991. BACHMAN JG, WALLACE JM, O'MALLEY PM, JOHNSTON LD,KURTHCL,tiEIGHBORSHW. Racial /ethnic differences in smoking, drinking, and illicit drug use among American high school seniors, 1976-89. American Journal of Pllhli.c Health 1991;81(3):372-7. BAUMAN KE, KOCH GG, BRYAN ES, HALEY NJ, DOWNTON MI, ORLANDI MA. On the measurement of tobacco use by adolescents. Validity of self-reports of smoke- less tobacco use and validity of cotinine as an indicator of cigarette smoking. American Journal of Epidemiology 1989;130(2):327-7. BIGLAN A, GALLISON C, ARY D, THOMPSON R. Expired air carbon monoxide and saliva thiocyanate: relationships to self-reports of marijuana and cigarette smoking. Addictive Behaviors 1985;10(2):137-44. CAMPANELLI PC, DIELMAN TE, SHOPE JT. Validity of adolescents' self-reports of alcohol use and misuse using a bogus pipeline procedure. Adolescence 1987 Spring; XXII(85):7-22. CENTERS FOR DISEASE CONTROL. Smokeless tobacco use in rural Alaska. Morbidity and Mortality Weekly Report 1987;36(10):140-3. CENTERS FOR DISEASE CONTROL. Prevalence of oral le- sions and smokeless tobacco use in Northern Plains Indians. Morbidity and Mortality Weekly Report 1988;37(39):608-11. CE .~~~OR DISEASE CONTROL. Cigarette smoking among youth-United States, 1989. Morbidity and Mortality Weekly Report 1991a;40(41):712-5. CENTERS FOR DISEASE CONTROL. Differences in the age of smoking initiation between blacks and whites-United States. Morbidity and Mortality Weekly Report 1991b;40(44):754-7. CENTERS FOR DISEASE CONTROL. Cigarette smoking among adults-United States, 1990. Morbidity and Mortality Weekly Report 1992a;41(20):354-5. CENTERS FOR DISEASE CONTROL. Comparison of the cigarette brand preferences of adult and teenaged smokers- United States, 1989, and 10 U.S. communities, 1988 and 1990. Morbidit_yand Mortality Weekly Report 1992b;41(10)169-81. Epidemiology 115 TIMN 0138967

I"•c';'cvlt1lIN 7t 'hk c0 LL c' .\un01~ 1 uut\~ I'c'nldr adolescent's smoking or approval of the adolescent's refusing to smoke, together with two other drug-related variables, indirectly predicted low levels of use. Chassin et al. (1986) evaluated perceptions of parental strictness; their findings support the need for interventions tailored to different age groups of adolescents. Among the young- est subjects (10 through 12 years old), those who per- ceived that their parents were more strict than other parents were actually more likely to begin smoking over a one-vear inten.'al. Among the oldest subjects (14 through 16 years old), however, those who perceived that they had stricter parents were less likely to begin to smoke. Those aged 12 through 14 years were not af- fected by parental strictness. Other researchers have further noted that extremes of parental strictness, from inadequate restraint to overcontrol, are associated with problem behaviors (Pandina and Schuele 1983). Adult Discrepancy Shean (1991) developed the concept of adult dis- crepancy-the discrepancy between the "adult" behav- iors in which an adolescent wants to participate at age 14 (such as going to a nightclub) and what was actually done by his or her parents when they were age 14. Those adolescents with high discrepancy were more likely to be smokers as young adults than those with low discrep- ancy, which may suggest that adolescents with high discrepancy tend to make the transition to an adulthood not modeled by parents. The adult discrepancy factor, in addition to peer, sibling, and parental smoking, inten- tions to smoke, and effects of cigarette advertisements, predicted young adult smoking over an eight-year interval. This study points to the strong effect of the social environment on the onset and maintenance of adolescent smoking. Behavioral Factors in the Initiation of Smoking Behavioral factors involve patterns of behaviors that are directly related to cigarette use, such as aca- demic achievement, health-compromising and health- enhancing behaviors, and smoking-related skills. These associated behavior patterns may increase the risk of smoking by providing opportunities to view smoking as functional or appropriate. Academic Achievement The onset of smoking has been shown repeatedly to be related to poor academic achievement (see Table 6 in Chapter 3). Relevant indicators of students' achieve- ment include scholastic performance (grades), high school graduation, truancy rates, and future professional or educational aspirations. Borland ~ind flu1.luiph 1 lu77) examined the relative predictability of xhulastic pvr- formance, parental smoking, and socioeconomic ~tatu', among 1,814 high school students in L'ennsvlvania. The strongest correlate to smoking was scholastit: performance; those with the highest grades were found to smoke less than those with the lowest grades. Thiti finding is consistent with Brunswick and Messeri's (1984) research among young, urban black adolescents in Harlem, New York, as well as the Sussman et al. (1987) research with Hispanic and Asian adolescents in south- ein California. Students who disliked school and feared school failure were more likely to begin smoking in earh• adolescence than those who liked school and had expec- tations of school success (Ahigren et al. 1982). In two well-designed studies, adolescents who had limited ex- pectations of academic achievement increased their smok- ing levels over time (Gerber and Newman 1989; Chassin, Presson, Sherman 1990). Still, among inner-city black seventh-grade students, Botvin et al. (1992) found that academic achievement was not a significant predictor of current smoking or intentions to smoke. Conrad, Flay, and Hill (1992) found that 80'percent of the prospective studies on the onset of smoking indi- cated a positive relationship between low academic achievement (and other school-related factors) and smok- ing onset. In a longitudinal study of 739 junior high students (66 percent white, 15 percent black, 10 percent Hispanic) in Los Angeles, the research team of Newcomb, McCarthy, and Bentler (1989) concluded that an adolescent's "academic lifestyle orientation" (measured by grades, educational aspirations, personal and profes- sion plans, and expectations) was the central organizing influence on teenage smoking behavior, teenage emo- tional well-being, social relationships with smokers, and adult smoking behavior. This centrality emerged even when emotional well-being, self-efficacy, personal ambi- tion, and friends' smoking behavior were considered. Other Adolescent Behaviors The association between smoking and other ado- lescent behaviors has been examined as an extension of Jessor and Jessor's (1977) concept of the covariation of problem behaviors, including both unconventional be- haviors (such as alcohol and drug use) and conventional behaviors (such as academic achievement and church attendance). Cigarette use among adolescents has been studied as "problem:' behavior; that is, studies have ex- amined its association with alcohol and drug use, risk- taking behaviors, proneness to deviance, early antisocial behavior, and group membership, as well as its associa- tion with constructive or health-enhancing behaviors. Some adolescents see problem behaviors as a way to Psychosocial Risk Factors 133 TIMN 4138-985

hre'.'e'1lf71i,~ Tciht7Ct:o (.be' .-INIoUIL Yelilflg he'U14t' visible smoke, and after 1976 not a single instance of smoke was found in this sample. The imagery in those ads was increasingly, and apparently deliberately, becoming more pristine by eliminating smoke from ads. The balance between the verbal and visual elements of the ads was measured in this study, as was the degree of health focus. Ads that relied more heavily on words than on pictotial images were judged as trying to convey a health message. Both the health focus and the balance between verbal and visual elements were found to be episodic; ads tended to verbally emphasize health themes during the years of major smoking and health events. Such ads often emphasized a health-related prod- uct innovation, such as scientifically designed filters. This general pattern seemed to end in 1964, the year of the first Surgeon General's report, during and after which ads became more visual. Warner (1985b) notes, "Industry advertising directors may have concluded that the most effective contemporary response to health concerns is an indirect one: conveying visual images of vibrant, physi- cally fit, successful, sociable, and sexy people in physically active or glamorous settings, in other words, associating smoking with people who are the proverbial 'picture of health"' (p. 125). Similar observations were made by Rogers and Gopal (1987), who studied an unspecified number of ads from three issues of Time and Life maga- zines each year, at five-year intervals from 1938 to 1986. They noted that over time, positive health appeals were displaced by claims of having "less harmful" products, and that these in turn were displaced by "more and more lifestyle advertising ... brand imaging ... using more poster style layouts and color spreads ... with very little body copy" (pp. 262, 266). Other researchers have noted the episodic nature of cigarette advertising history but attribute the changes not to industry strategy or sophistication, but to the effects of regulation and self-regulation, such as FTC activity or industry self-regulatory codes. Ringold and Calfee (1989) report on the verbal content of 568 ads d rawn primarily from Time magazine from 1926 through 1986. This sample is both longitudinal (N = 348), expand- ing on the sample of one ad per year for various brands reported earlier (Ringold 1987), and cross-sectional, us- ing a sample of 25 ads each for the seven mid-decade years 1926, 1936,1946, 1956, 1966, 1976, and 1986. The ads were coded along 27 general ad characteristics and 51 claim categories. The coding, described by the authors as conservative, treated all mildness claims as claims about taste that were irrelevant to health and treated all claims about filter innovations as claims about product quality, not about health. Nonetheless, results of the longitudinal sample show that 27 percent of all claims were health claims, making it the most common category, primarily because ads since 1963 were required to cam tar and nicotine disclosures (See "Warning Labels on Tobacco Products" in Chapter 6). Voluntary health claims were anywhere from 17 percent to 29 percent of total claims before 1954 but had nearly disappeared after that year. In the longitudinal analysis, action-oriented ads- those depicting competitive sports, adventurous pur- suits, or leisure behaviors-were more than twice as common (42 percent of all ads) as those showing all other types of activity, such as working, eating, or shopping (17 percent of all ads). Almost identical results were found for the cross-sectional sample of 220 ads. No data were reported for how the frequencies of these images of activities changed over time. Advertising That Targets Youthful Audiences Albright et al. (1988) studied cigarette ads in maga- zines that reach young readers (Rolling Stone, Cycle World), female readers (Ladies Home Journal, Mademoi- selle), or general adult readers (Time, TV Guide, Ebony, Popidar Science). All cigarette ads in one issue for every year from the 1960s through 1985 were coded, yielding 778 ads for analysis. Like other analysts, Albright et al. found that the volume of magazine advertising increased dramatically during this period, stabilizing after 1977 at six to seven ads.per issue. Within this study sample, the proportion of total ads appearing in the magazines reaching younger audiences grew significantly over time to become 36 percent of the total. The analysts concluded that although these data may not fully repre- sent the overall market trends, "women and adolescent magazine readers are exposed to a large quantity of cigarette ads, regardless of the advertisers' intent" (Albright et a1.1988, p. 232). Altman et al. (1987) analyzed the themes and im- ages employed in this same sample of magazines. The study focused on the ads (78 percent of the total sample) that showed a setting or had a model present. These were coded for elements of the act of smoking, the pres- ence of a low-tar or low-nicotine theme, and suggestions of the "vitality of smoking." The latter concept was measured with subcategories of adventure/risk (e.g., rock climbing, sailing, racing cars), recreation (e.g., play- ing tennis, surfing), and romantic/erotic appeal (e.g., scantily dressed models, moonlit settings). Images of risk and adventure, recreation, and erotic or romantic display in youth magazines increased sig- nificantly over this period (1960s to 1985). Ads in youth magazines were significantly more likely than ads in other magazines to depict images of adventure or risk, Advertising and Promotion 181 TIMN 0139033

uI C O tw•,I 1"' "rt Smokeless Tobacco Use as a Risk Factor for Smoking, Alcohol, and Other Drug Use Although the known literature indicates that the use of cigarettes and other drugs is a risk factor for smokeless tobacco use, several studies also indicate that the converse is true; that is, smokeless tobacco use is a risk factor for the onset and maintenance of cigarette smoking and for the use of alcohol and marijuana (see "Smokeless Tobacco Use and Other Drug Use" in Chap- ter 3). Ary, Lichtenstein, and Severson (1987) examined the prospective relationship between smokeless tobacco use and the onset of the use of cigarettes, alcohol, and marijuana at nine-month follow-up. Smokeless tobacco users were found to be more likely than nonusers to begin using cigarettes (22 percent vs. 7 percent), alcohol (18 percent vs. 7 percent), and marijuana (37 percent vs. 18 percent). These findings were replicated in Ary's (1989) 12-month follow-up study of a separate sample. Smokeless tobacco users were significantly more likely than nonusers to report smoking cigarettes (6 percent vs. 0.5. percent), drinking alcohol (29 percent vs. 12 percent), and smoking marijuana (12 percent vs. 2 percent). Similarly, smokeless tobacco users were more likely than nonusers to increase their use of other drugs. A greater proportion of smokeless tobacco users than of nonusers reported increased use (in the week preceding the survey) of cigarettes (18 percent vs. 8 percent), alco- hol (34 percent vs. 20 percent), and marijuana (20 percent vs. 8 percent) (Ary, Lichtenstein, Severson. 1987). The 1989 study replicated these findings for each substance: cigarettes (7 percent vs. 2 percent), alcohol (25 percent vs. 13 percent), and marijuana (15 percent vs. 2 percent) (Ary 1989). Several studies provide additional evidence for the progression from smokeless tobacco to other drugs. In one, decreases in smokeless tobacco use were accompanied by increases in cigarette smoking (Hunter et al. 1986). In a different longitudinal study, smokeless tobacco users were more likely to report cigarette smok- ing at a two-year folldw-up (67 percent) than were non- users (14 percent) (Schinke et al. 1986). A study of undergraduates founa that switching from smokeless tobacco to cigarettes was a more likely progression than the converse (Glover, Laflin, Edwards 1989). Risk Taking and Rebelliousness Although smoking is associated with rebellious- ness and unconventionality, several' studies have found no such association for smokeless tobacco use. A signifi- cant but modest relationship has been found between smokeless tobacco use and risk taking. In one of the few longitudinal studies of smokeless tobacco use, Dent et al. (1987) found that among eighth graders, current risk taking predicted the onset of smokeless tobacco use one year later. - In another study, a significant relationship was reported between seventh-grade students' smoke- less tobacco use and risk taking (Botvin, Baker, Tortu 1989). Studies with high school students found that risk taking was related to trying smokeless tobacco but not to the level of smokeless tobacco use (Riley, Barenie, Myers 1989; Riley et al. 1991). In two of eight replication samples in another study, risk taking was a significant correlate of trying smokeless tobacco (Sussman et al. 1989). Participation in Athletics Given the_number of professional athletes who use smokeless tobacco, and given the associated advertising efforts by smokeless tobacco companies, youth who par- ticipate in athletics would seem likely to be at greater risk of using smokeless tobacco than nonparticipants. Cur- rent studies have mixed findings about this possible relationship. Although 28 percent of predominantly white Little League baseball players (aged 12 or less, N = 1,141) in southeast Texas believed that more than half of profes- sional baseball players use smokeless tobacco, this belief was not strongly associated with use of smokeless to- bacco among these youth (Evans, Raines, Getz 1992). Similar findings on a stratified random sample of rural and urban youth in grades one, three, five, and seven were reported in North Carolina (Lisnerski et al. 1991). In a one-year longitudinal study of seventh graders, . sports participation did not predict onset of smokeless tobacco use in two samples of males and in one of two samples of females (Sussman et al. 1989); for the other sample of seventh-grade females, the relationship was positive but modest. Sussman et al. (1990) reported that self-identified "dirts" (i.e., "heavy metal" music enthusi- asts and marijuana users) and "skaters" (i.e., skateboard- ers and surfers) were more likely to be currently using smokeless tobacco than were "jocks/athletes." Another study of high school students yielded inconclusive re- sults (Riley, Barenie, Myers 1989). On the other hand, Ringwalt (1989) found that 11th-and 12th-grade athletes (students who played on school teams) were more likely than nonathletes to have used smokeless tobacco, to have used smokeless tobacco in the preceding 30 days, and to perceive fewer (if any) health risks for smokeless tobacco use. Jones and Moberg (1988) found that fre- quency of smokeless tobacco use was related to partici- pation in team sports. Glover et al. (1989) found that smokeless tobacco use among U.S. college students was related to participation in organized sports. Takeri to-• gether, the current evidence is inconclusive and war- rants further investigation that might consider team rules regarding smokeless tobacco use, coaches' use of smoke- less tobacco or attitude toward team members' use, and parents' degree of involvement in the team. 144 . Psychosocial Risk Factors TIMN 0138996

1') t~ (,'IW L .,' il-, l:,r,'f:; .,':i I;•; , Personal Factors in the Initiation of Smokeless Tobacco Use Knowledge of Long-Term Health Consequences BeciuSe the long-term health consequences of smokeles,; tobacco use have not been as widely commu- nicated as those of smoking, knowledge of these conse- quences is potentially an important predictive factor for smokeless tobacco use. Most youth appear to be aware that smokeless tobacco use can be harmful to health, but most smokeless tobacco users do not perceive their own risk to be great. In interviews with smokeless tobacco users, 80 percent of junior high school and 92 percent of senior high school users acknowledged that smokeless tobacco use can be harmful, but about 60 percent of the junior high users and 40 percent of the senior high users believed that there was no risk or onlv slight risk in regular smokeless tobacco use (USDHHS 1986). A study of 7th- through 10th-graders found that 31 percent of daily users of smokeless tobacco believed that there was verv little health risk associated with this use (Arv, Lichtenstein, Severson 1987). Similarly, only 40 percent of 7th- through 12th-grade students in another sample perceived smokeless tobacco use as very harmful (Schaefer et al. 1985). Vtartv, McDermott, and Williams (1986) reported that 35 percent of high school students who use smokeless tobacco beljeved that such use had little or no effect on their health. Many youth appear to believe that smokeless to- bacco use is much safer than cigarette use. Schaefer et al. (1985) found that 77 percent of smokeless tobacco users perceived smoking to be very harmful, whereas only 40 percent perceived smokeless tobacco use as verv harmful. Another study reported that 86 percent of fifth- and sixth-grade smokeless tobacco users be- lieved that smoking would hurt their health, but only 33 percent believed this of smokeless tobacco use (Schinke et al. 19K6). Arv et al. (1989) found that when smokeless tobacco users were asked why they pre- ferred smokeless tobacco to cigarettes, they most often gave "lower health;risk" as the reason. Users of smoke- less tobacco are more- likely than nonusers to perceive that smokeless tobaqco is a comparatively safe alterna- tive to cigarette use (Chassin et al. 1985; McDermott and Martv 1986; Bovle 1989; Glover, Laflin, Edwards 1989; Brownson, DiLorenzo, Van Tui.nen 1990; Brownson et al. 1990; Lisnerski et al. 1991). A number of studies have examined the relation- ship between concurrent smokeless tobacco use and health knowledge and, beliefs about smokeless tobacco, but none of these studies have examined the prospective relationship. Most of these studies show that youth with more health knowledge of, or greater beliefs in, the risks of !,tnukt'I«~, tub,tcru uSC 'tr(2 inJeL'd IC11 likCk ti) ti• • ~-moktless tobacco. ThretN studit!N reported that h,it, in~ tried smokeletis tobacco was related to lau•k ot hc,ilth knowledge and beliefs (Cohen et al. 1987; Rilev, Barcnie, Vivers 1989; Rilev et al. 1991); onlv one studv that evam- ined this possible link failed to find such a relaticm<hip, and that study involved very young subjects (fir-4t through seventh graders) (Lisnerski et al. 19y1). tiple studies have reported that health knon.•ledge and beliefs were significantly related to various categorie~ of smokeless tobacco use (Bovle 1989; Polcvn et 11. 1yy1), current smokeless tobacco use (Chassin et al. 1985; Colborn, Cummings, Michalek 1989; Glover, Latlin, Edwards 1989; Marty, McDermott, Williams 1986), level or amount of smokeless tobacco use (Rilev, Barenie, Mvers 1989; Rilev et al. 1991), or dailv smokeless tobacco use (Arv, Lichtenstein, Severson 1987). In onlv two studies was no relationship found between health knowledge and beliefs and smokeless tobacco use (Brownson et al. 1990; Lisnerski et al. 1991). Functional Meanings In a study of seventh- and eighth-grade sEudents, favorable personal attitudes toward smokelesss tobacco use were significantly related to concurrent use ofsmoke- less tobacco (Polcyn et al. 1991). In another study, 8th- through 11th-grade students' expectancy and beliefs about the positive attributes of smokeless tobacco use (e.g., tastes good, is relaxing, helps concentration) were related to current smokeless tobacco use (Colborn, Cummings, Michalek 1989). Negative attributes of smokeless tobacco use (i.e., gives bad breath, stains teeth) were negatively related to current smokeless tobacco use (Colborn, Cummings, Michalek 1989). No prospective studies were found. Social Image Other research suggests that smokeless tobacco use has a more positive social image than smoking (Chassin et a1.1985; Chassin and Presson 1988). One study of high school students found that students were more likelv to have used smokeless tobacco during the past month and that nonusers were more likely to have intentions of using if the students' real and ideal self-concepts were similar to their perceived image of smokeless tobacco users (Chassin et a1.1985). This finding suggests that youth may take up smokeless tobacco as a method of attaining a valued social image. Positive social attributes expected from smokeless tobacco use (e.g., increases attractiveness, brings more friends, makes one become more "macho") were also shown to be significantly related to concurrent use of smokeless tobacco (Colborn, Cummings, Michiilek 1 q89). No prospective research was found. Psychosocial Risk Factors 145 TIMN 0138997

achieve-and signal to others-the precocious transition to independence and autonomy. The association of cigarette smoking and illegal drug use suggests that cigarettes may be an entry-level or gateway drug in a sequence of progressive drug use (see "Smoking as a Risk Factor for Other Drug Use" in Chapter 2 and "Smoking and Other Drug Use" in Chap- ter 3). The suggestion here is not that smoking causes illegal drug use, but that those who use illegal drugs have most likely smoked cigarettes previously. In the following studies, smoking is considered a gateway drug, since the decision to smoke appears to facilitate the deci- sion to use other drugs. Scheier and Newcomb (1991) studied 717 junior high school students in northern California. They con- cluded that early cigarette use predicted illegal drug use during the two-year study period. This finding comple- ments the work of Fleming et al. (1989) and IVewcomb and Bentler (1986), who emphasized the crucial role of cigarette smoking in the progression to marijuana and hard drug use, even without the mediating impact of alcohol use. Those authors concluded that these sub- stances are reciprocally influential over time, with in- creased use of cigarettes associated with increased use of illegal drugs. By young adulthood, a clear correlation seems to exist between cigarette smoking and illegal drug use. For example, in Brunswick and Messeri s (1983) 6- to 8-year prospective study of 536 blacks aged 11 through 13 in Harlem, IVew York, at follow- up (aged 18 through 23), 56 percent of males and 59 percent of females who had used illegal drugs smoked cigarettes, whereas 24 percent of males and 35 percent of females who had not used illegal drugs smoked cigarettes. Risk Taking, Rebelliousness, and Deviant Behaviors Risk taking, rebelliousness, and deviant behaviors are generally those behaviors that are considered uncon- ventional, antisocial, or alienated from traditional insti- tutions. The resear.ch literature has repeatedly characterized adolescent drug use as one manifestation of rebelliousness anc!'deviance (Jessor and Jessor 1977; Chassin, Presson, Sherman 1989). By testing Jessor and Jessor's (1977) model, Chassin et al. (1984) found that proneness to deviance significantly predicted smoking onset in a longitudinal study of secondary students, al- though not for those who had already experimented with cigarettes. In a subsequent study of high school students, Chassin, Presson, and Sherman (1989) found that in some instances, deviance was associated with independence and personal control; whether psycho- logically constructive or not, however, deviance was a significant predictor of cigarette smoking. A risk-taking 134 Psychosocial Risk Factors orientation (that is, an inclination toward excitement and chance taking) was similarly associated with trying a cigarette for the first or second time (Leventhal, Fleming, Glynn 1988). Risk taking was also a significant predictor of smoking initiation in the Collins et al. (1987) study of 11- and 12-year-olds in Los Angeles. In the Sussman et al. (1987) study of southern California adolescents, risk taking predicted smoking among blacks, but the associa- tion was not significant for whites, Hispanics, or Asians. Conrad, Flay, and Hill's (1992) review of prospective research on smoking initiation cited five studies that associated rebelliousness, risk taking, and proneness to deviance with smoking onset (see "Cigarette Smoking and Other Health-Related Behaviors" in Chapter 3). Peer Groups During the past two decades, the relative impor- tance of adolescent bonding with peers has increased, while the importance of bonding with parents has de- clined (Perry, Kelder, Komro 1993). This shift has al- lowed more time, opportunity, and social support for dysfunctional behaviors, such as cigarette use. Adoles- cent females who spent most of their free time with•their. families, for example, were less likely to begin smoking than those who spent little free time with their families (Brunswick and Messeri 1984). As Flay (1993) notes, "youth alienated from conventional culture have more opportunities than others to observe substance use and its positive functions.... They are also,more likely to overestimate the proportion of their peers who use these substances-because they are likely to be associating with groups who actually do use ....[andl deviant cul-• tures reinforce these youth when they do use, for ex- ample, by acceptance into groups" (p. 369). Leventhal et al. (1991) observe that parents, teach- ers, and other adults seldom discuss with youth the intense biological and social changes that occur in ado- lescence: "When such a dialogue is absent ... the peer group becomes the predominant influence integrating and shaping the adolescents' vague yet pressing internal states" (p. 586). Participation in Athletics and Other Health-Enhancing Behaviors Health-enhancing behaviors, such as sports involve- ment, might moderate a high-risk environment (Rantakallio 1983). Swan, Creeser, and Murray (1990) found that girls were significantly less likely to begin smoking if they were involved in an organized sport, but were significantly more likely to begin smoking if they participated in organized social activities. Involvement in sports did not appear to affect boys' rate of smoking TIMN 0138986

til/!",`Cll/f (.rt'/h'11ll- Rt'pl'v: described a typical Marlboro ad and noted that "the significant meanings are coming from the illustration. The copy logic is strictly after-the-fact" (p. 19). ` He disputed the conventional wisdom that the illustrations are merely attention-getting devices: "This is nonsense. The other meanings [from the visuals] can be totally unrelated to copy logic-and far more important" (p. 19). Consequences of Image Advertising As an article in the trade journal Printers' Ink ob- served, the "grim messages ... from the health-scare days [of the early 1950s] gave way to pleasant, almost 'Pollyanna' prose. . . . The 1955 comeback ... [taught ad- vertising to] stick to cajoling the smokerwith soft,'gentle' phrases and oh-so-gay jingles" (Day 1955, p. 15). A few years later, the same journal noted that "once more the industry is back to its traditional and usually successful course - advertising flavor, taste and pleasure against a backdrop of beaches, ski slopes and languid lakes. It is a formula that works, as all-time high sales show" (Print- ers' Ink 1960, p. 37). As Fortune (1963) summarized, "Nowadays, all allusions to the health question are mod- els of indirection" (p. 125). In 1981, the FTC reviewed the changes that had occurred in cigarette advertising since the 1964 Surgeon General's report and noted the continuing glamorization of cigarette smoking. The FTC noted that in the last sixteen years: There has been little change.... Ads have contin- ued to attempt to allay anxieties about the hazards of smoking and to associate smoking with good health, youthful vigor, social and professional suc- cess ... Thus, the cigarette is portrayed as an inte- gral part of youth, happiness, attractiveness, personal success and an active, vigorous, strenu- ous lifestyle....[The ads are] rich in thematic imagery associating smoking with, among other things, outdoor activities, athletics, individualism and achievement. They are frequently filled with rugged, vigorous, attractive, healthy-looking people living energetic lives full of success and athletic achievem%""t , free from any health haz- ards" (FTC 1981, pp; 2-_2, 2-8). Conveying Male and Female Images One of the early consequences of motivation re- search was to help the industry give brands of cigarettes distinctly male or female identities (Burnett 1958; Cheskin 1967). Probably no brand more dramatically demon- strated this strategy than Marlboro, which in 1956 was converted, through an enormously successful advertis- ing campaign, from a previous, stereotypically "female" advertising image to a stereotypically "male" image that culminated in the Marlboro cowboy. (The particulars of this marketing transformation are discussed later in this chapter.) Leo Burnett (1961), the man who created the Marlboro cowboy, described how the campaign touched a motivational chord in consumers: "We have been able to get under [the consumers'] skins a bit and find out what they really think about a product or the presenta- tion of it and can't or won't express in words" (p. 63). Research for the campaign was done, in part, by the Home Testing Institute and the Color Research Institute for association testing (Cheskin 1967). Intensive field interviews were used to pretest the selling promotion and advertising techniques (Weissman 1955). Large advertising spending in all media brought the campaign to a vast audience. Leo Burnett (1961) described outdoor advertising as a vital factor in the success of Marlboro; the medium's low cost per expo- sure allowed for the use of enough signs to achieve what Burnett called "the No. 1 factor in building confidence ... the plain old fashioned matter of friendly familiarity" (p. 217; italics in original). This success with advertising the Marlboro brand led Philip Morris to launch another brand, Virginia Slims, with stereotyped female characteristics (Weinstein 1970). The successand durability of both these campaigns evidence the power of nonverbal imagery to communicate subjective values such as independence, masculinity, and femininity and to attract and retain consumers. Historical Perspectives on the Effectiveness of Cigarette Advertising The role of cigarette advertising in attracting new smokers was easier to recognize in the days when the rate of recruitment exceeded the rate of death and quit- ting so that total cigarette sales grew. Comments from diverse sources credited cigarette advertising for expand- ing sales and accelerating market broadening social trends, such as smoking among women. This acknowl- edgment of cigarette advertising's effects on demand and onset was commented on in articles by academic analysts, advertising agents and journals, the tobacco trade press, and tobacco executives themselves. Academic and Industry Analyses "In the 1920s," a recent analyst noted, "advertising sold the cigarette habit to the American Public-surely the industry's most regrettable achievement of the de- cade" (Fox 1984, p.114). Commenting during the 1940s on the diminution of the medical, moral, and religious reservations about smoking previously held by consum- ers, a Harvard Business School professor wrote, "The campaigns of testimonials featuring well-known person- ages and the picturing of the 'right' kind of people 172 Advertising and Promotion TIMN 0139024

tit0Nt'i1i1 Ln910'd/ - Xi!'O! BOTVIN EM, BOTVIN GJ, BAKER E. DevelopmentalchanKes in attitudes toward cigarette smokers during early adoles- cence. Psycholo,~~ical Reports 1983;53(2):547-53. CENTERS FOR DISEASE CONTROL. Acces~,ibilit< < t ciga- rettes to vouths aged 12-17 vears-Lnited States, 1989. ,~v1ur- !}urituanui Murtality Wrt'kly Rrport 1992;41(27):-183-8. BOYLE R. Adolescent knowledge of smokeless tobacco's health consequences. Health Education 1989;20(4):35-8. BROWNSON RC, DILORENZO TM; VAN TUINEN M. Smokeless tobacco use among Missouri youth. Missouri Medi- cine 19y0;87(6):35i---1. BROWNSON RC, DILORENZO TM, VAN TUINEN M, FINGER WW. Patterns of cigarette and smokeless tobacco use among children and adolescents. Preventive Medicine 1990;19(2):170-80. BRUBAKER RG, LOFTIN TL. Smokeless tobacco use by middle school males: a preliminary test of the reasoned action theory. Journal of School Health 1987;57(2):64-7. BRUERD B. Smokeless tobacco use among Native American school children. Pnblic Health Reports 1990;105(2):196-201. BRUNSWICK AF, MESSERI PA. Causal factors in onset of adolescents' cigarette smoking: a prospective study of urban black youth. Adeurnces in Alcohol and Substance Abnse 1983; 30-2):35-32. BRUNSWICK AF, MESSERI PA. Origins of cigarette smoking in academic achievement, stress and social expectations: does gender make a difference? Jonrnal of Early Adolescence 1984;-1(4):353-70. BURKE GL, HUNTER SM, CROFT JB, CRESANTA JL, BERENSON GS. The interaction of alcohol and tobacco use in adolescents and young adults: Bogalusa heart study. Addic- tire Behavion; 1988;13(4):387-93. BURKE JA, ARBOGAST R, BECKER SL, NAUGHTON M, LAUER R.M. Prevalence and predictors of smokeless tobacco use: Iowa's program against smoking. In: National Cancer Institute. Snnokeless tobacco use in the United States. Monograph tio. 8. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute. Bethesda (MD~~NIH Publication No. 89-3055,1989, 71-7. : CAMP DE, KLESGES RC, RELYEA G. The relationship be- tween body weight concerns and adolescent smoking. Health PsycholoRy 1993;12(1):24-32. . CASTRO FG, MADDAHIAN E, NEWCOMB MD, BENTLER PM. A multivariate model of the determinants of cigarette smoking among adolescents. Journal of Health and Social Behavior 1987;28(3):273-89. 150 Psychosocial Risk Factors CENTERS FOR DISEASE CONTROL AND PREVENTION. Minors' access to tobacco-Missouri, 1992, and Texas, 1993. Morbidity and Mortality Weekly Report 1993;42(7):12-5-8. CHAPMAN S, BLOCH M, editors. [Prefacel. Tobacco Control 1992;(1 Suppl) September:S2-S3. CHARLTON A, BLAIR V. Predicting the onset of smoking in boys and girls. Social Science and Medicine 1989;29(7):813-8. CHASSIN L, PRESSON CC. The social image of smokeless tobacco use in three different types of teenagers. Addictire Behaviors 1988;13(l):107-12. CHASSIN L, PRESSON CC, SHERMAN SJ. Family correlates of adolescent smokeless tobacco use in relation to cigarette smoking. International Journal of Family Psychiatry 1988;9(1): 49-66. CHASSIN L, PRESSON CC, SHERMAN SJ. "Constructive" vs. "destructive" deviance in adolescent health-related behav- iors. Journal of Youth and Adolescence 1989;18(3):245-62. CHASSIN L, PRESSON CC, SHERMAN SJ. Social psycho- logical contributions to the understanding and prevention of adolescent cigarette smoking. Personality and Social Psychole ~vj Bulletin 1990;16(1):133-.i1. CHASSIN L, PRESSON CC, SHERMAN SJ, CORTY E, OLSHAVSKY RW. Predicting the onset of cigarette smoking in adolescents: a longitudinal study. Journal of Applied Social Psychology 1984;14(3):224-43. CHASSIN L, PRESSON CC, SHERMAN SJ, EDWARDS DA. Four pathways to young-adult smoking status: adolescent social-psychological antecedents in a midwestern community sample. Health Psychology 1991;10(6):409-18. CHASSIN L, PRESSON CC, SHERMAN SJ, MCGREW J. The changing smoking environment for middle and high school students: 1980-1983. Journal of Behavioral Medicine 1987;10(6):581-93. CHASSIN L, PRESSON CC, SHERMAN SJ, MCLAUGHLIN L, GIOIA D. Psychosocial correlates of adolescent smokeless tobacco use. Addictive Behaviors 1985;10(4):431-5. CHASSIN L, PRESSON CC, SHERMAN SJ, MONTELLO D, MCGREW J. Changes in peer and parent influence during adolescence: longitudinal versus cross-sectional perspectives on smoking initiation. Developmental Psychology 1986;22(3): 327-34. WVIN 0139002

Preventing Tobacco Use Among Young People and brand were masked, and subjects were asked whether the,v had ever seen the ad and what product and brand were being advertised. They were then shown six other Old Joe ads, one at a time, and asked to rate the appeal of these ads. The high school students were more likely than adults to recognize and correctly identify Old Joe (98 vs. 73 percent), to think the ads looked "cool" (58 vs. 40 percent), to think the ads were interesting (74 vs. 55 percent), to think that Old Joe is cool (43 vs. 26 percent), and to report that they would like to have Old Joe as a friend (35 vs. 14 percent). Data on brand preference collected from the high school students who smoked were compared with corresponding data from seven surveys completed before the kick-off of the Old Joe campaign early in 1988. The authors reported that in the three-year duration of the Old Joe campaign, the pro- portion of smokers under 18 years old who preferred Camel cigarettes over other brands rose from 0.5 percent to 33 percent. Pierce et al. (1991) analyzed data from the Califor- nia Tobacco Survey, a 1990 random-digit-dialed tele- phone survey of 24,296 adults aged 18 and over and 5,040 adolescents aged 12 through 17. Respondents were asked to "think back to the cigarette advertisements ... recently seen on billboards or in magazines. What brand of cigarette was advertised the most?" Thirty-four percent of the adults named Marlboro as the most-advertised brand; 14 percent of the adults named Camel cigarettes. Among the adolescents, 42 percent identified Marlboro and 30 percent identified Camel as the most advertised brand. No more than 3 percent of either the adult or teenage respondents named any other single brand. The percentage of respondents who named Marlboro increased with age among the adolescents, peaking at 48 percent among 16- and 17-year-olds before declining among adults. The percentage of respondents who named Camel was inversely related to age, ranging from 23 percent for 16- and 17-year-olds, to 20 percent for 18- through 24-year-olds, to 10 percent for respondents aged 45 years and older. Similar results were found by Pierce et al. (1993) and by a Gallup (1992) survey, al- though Camel advertisements were identified as the most pervasive ads according to McCan's (1992) analysis of the 1992 California Tobacco Survey. It is not surprising, given these results, that Marlboro and Camel cigarettes are used by up to 70 percent of adolescent smokers (Gallup 1992; CDC 1992). A study conducted by Fischer et al. (1991) sug gested that even very young children were aware of the Joe Camel campaign. In this study, three- through six- year-old children were asked to match each of 22 brand logos on cards to one of 12 products pictured on a game board. Ten of the logos were from children's products, seven from adult products, and five from cigarette brands. The recognition rate for Old Joe ranged from 30 percent for three-year-olds to 91 percent for six-year-olds. By the age of six, the face of Old Joe and the silhouette of Mickey Mouse (the logo for the Disney Channel on cable televi- sion) were equally well recognized. Young People's Self-Image and Implications for Tobacco Use Intention to smoke is one of the strongest predic- tors of trying cigarettes and of becoming a smoker (Conrad, Flay, Hill 1992). Chassin et al. (1981) found that 9th- and 10th-grade students whose reported image of smokers correlated with their reported self-image, ideal- date image, and certain attributes of ideal self-image were likely to report that they intended to smoke. The attributes of ideal self-image that correlated with at- tributes of smokers' image were "tough," "foolish," "act big," "disobedient " and "interested in the opposite sex." A positive relationship of self-image and ideal-date im- age with smokers' image was also found to differentiate students who were already smokers from nonsmokers. Bowen et al. (1991) found that even among preadoles- cent, fifth-grade boys, reported images of smokers were more likely to match advertising images of smokers among those who had tried a cigarette than among those who had never tried cigarettes. Barton et al. (1982) asked'6th- and 10th-grade stu- dents to evaluate slides of peer models posed with and without cigarettes. Children in both age groups rated smoking models as being less healthy, more foolish, tougher, poorer at schoolwork, more sociable, more os- tentatious, and more disobedient than nonsmoking mod- els. Grube et al. (1984) subsequently reported that both smokers and youth who intended to smoke were more likely than nonsmokers to have self-images like the im- ages they attributed to smokers. McCarthy and Gritz (1984) found that among 6th ; 9th-, and 12th-grade boys and among 12th-grade girls, a correlation of ideal self- image to advertising images of smokers was associated with intentions to smoke. Students in 11 seventh-grade classes in a working- class area of Pasadena participated in a study (Burton et a1.1989) that investigated attributes of four categories of images: self, ideal self, smoker, and cigarette ad. A random sample of 122 students were asked to use a six- point scale to rate four attributes (healthy, wise, tough, and interested in the opposite sex) in responding to four questions: (1) "What sort of person are you?"; (2) "What sort of person would you like to be?"; (3) "What sort of person is a smoker?"; and (4) "In billboards, magazines and other advertisements, smokers are made out to be Advertising and Promotion 191 TIMN 0139043

Preventing Tobacco Use Among Yotuig People Promotional Efforts of the Tobacco Industry Introduction Whereas the role of advertising is primarily cogni- tive and affective (affecting consumers' knowledge, be- liefs, and attitudes), the role of promotional efforts indudes a substantial conative (action-affecting) component (Kotler 1991). A cigarette advertisement, regardless of how compelling, is unable to put a cigarette into a consumer's hands. At best it can create desire or an interest in smoking. Cigarette promotion, however, can use sam- pling to put a cigarette into a consumer's hand-along with, in some instances, the lighter to ignite it. Promotion can also target a product to those specific consumers most likely to respond to a manufacturer's appeals (Rossiter and Percy 1987). Cigarette marketers use several of the major cat- egories of promotion to facilitate both the entrance of new smokers to the market and their development of brand loyalty. Because of the rapid growth in cigarette promotional expenditures (FTC 1992) and the impor- tance of these expenditures in potentially recruiting new smokers, the following discussion will analyze each of these major categories of cigarette promotion. The recency of this growth, however, limits the amount of research this report can draw upon. Public Entertainment The cigarette industry uses the sponsorship of pub- lic entertainment events to bypass broadcast advertising bans and self-regulatory constraints. Sponsorship is an efficient way for an advertiser to have its brand name and logo achieve the equivalent effect of broadcast ad- vertising without having to include any government- mandated warnings. Thus, cigarette manufacturers sponsor a wide array of sporting events (e.g., the Virginia Slims Tennis Touirmament, the Winston Cup series, and auto racing in g°,etteralthrough sponsoring particularcars and drivers) anc(;'• •otlter forms of public entertainment (e.g., the Kool Jazz C~oncert). The association of the brand name with the event is an advertising association for the brand. For example, through racing events and race cars bearing the Winston and Camel brand names, R.J. Reynolds has become the leading sponsor of automobile and motorcycle racing in the United States (Blum 1991). The association between events and cigarettes is so clear that in some markets, when ads selling tickets for a sponsored event (such as the Virginia Slims Tennis Tour- nament in Newport, Rhode Island) are run in local newspapers, the ads carry the mandated cigarette health warnings. Sponsorship can also preempt opposition to cigarettes among those who view sponsorship as neces- sary for the funding of an event. Despite the stated health threat, the association of the cigarette brand name with the event continues unabated on broadcast media, and event programming continues to feature cigarette brand logos. In the 1989 Marlboro Grand Prix telecast, for example, the Marlboro logo could be seen for over 46 of the 94 total minutes of broadcast time (Blum 1991). Such sponsorship is clearly viewed as delivering a brand message by the marketer. Event sponsorship also provides access to youth markets of potential smokers (Buchanan and Lev 1990). Because youth do not predominantly compose the atten- dance or viewership of such sponsored events, however, cigarette advertisers can argue that they are not:actively targeting youth. Yet given the heavy concentrations of young people in these audiences, and given the limited venues available to cigarette advertisers to present their images to children, sponsored events may be among the most cost-effective promotional mechanisms. Two studies conducted with children and adoles- cents support the observations that cigarette industry sponsorship reaches young people. Aitken, Leathar, and Squair (1986) conducted a study to determine children's awareness of cigarette brand sponsorship of sports and games in the United Kingdom. Young people from ages 10 through 17 years old were asked what they under- stood by the term "sponsorship" and whether they could recall any cigarette brands that sponsored sports. The authors found that 13 percent of 10- and 11-year-old children and 43 percent of 16- and 17-year-olds men- tioned that sports sponsorship entailed both a company's financial sponsorship of sporting events and its opportu- nity to advertise its products; 80 percent of 16- and 17- year-olds mentioned at least one of these two components of sponsorship. More than half of those 12 years old and older correctly associated at least one sponsored sport and the brand of the sponsoring cigarette company. Even children younger than age 11 identified the sponsored sports as activities linked with excitement. These find- ings supported those of Ledwith (1984), who also found that many 12- through 17-year-old schoolchildren were able to correctly identify sponsored sports and the spon- soring cigarette brand. A secondary effect of sponsoring sports events is that the brand names become closely associated with the Advertising and Promotion 185 TIMN 0139037

IOhdt1t'U•t'.l'F1( 'ti~ ft~Ilt11 I Y01 '/t' onset in this study. Nv4cCau1 et al. (1982) found no asso- ciation between boys' smoking and participation in ex- tracurricular activities. Among urban black females in Brunswick and Messeri's (1y84) study, those who re- ported minimal concern about their health and those who reported a larger appetite were more likely to begin smoking; in contrast, black males who had the greatest number of health-related activities and were of normal bodv weight were more likely to begin smoking than other black males (Brunswick and Messeri 1983). Sussman et al. (1993) found that among youth at the highest risk of smoking, those who did not smoke re- ported that they valued their health. Finally, in Kelder's (1992) longitudinal study of secondary school students in the north-central United States, cigarette smoking was found to be related to poor food choices and less exercise after the eighth grade; the correlation between these behaviors was stronger with increasing age. Behavioral Skills The final set of behavioral factors comprises the behavioral skills that are necessary to begin smoking, those that are necessary to resist influences to smoke, and those that are necessary to cope with other social situations that might indirectly encourage cigarette use. Hahn et al. (1990) found that 42 percent of smoking experimenters had asked for their first cigarette. In the Sussman et al. (1987) studv in southern California, diffi- culty in refusing offers to smoke predicted onset for all four ethnic groups, particularly for whites and blacks, for whom it was the strongest predictive factor found in the studv. This difficultv in refusing an offered cigarette appears to be strongly influenced by the offering friend's attitudes and behaviors (e.g., being persistent or critical if refused), particularly for high-risk adolescents (Salomon et al. 1984; Lawrance and Rubinson 1986; Reardon, Sussman, Flay 1989). Conrad, Flay, and Hill (1992) re- viewed three prospective studies and found that refusal or resistance skills against smoking were associated with lower rates of onset. Generally, cjjarette use can be viewed as a coping mechanism-a ;skilled, response designed to close the gap between an _ olescent's current position and goals g,. (Leventhal et aI. 1991). Smoking serves as a coping response if it brings the adolescent closer to a valued goal, such as acceptance in a peer group. Smoking may also serve as a coping response to stress or distress (Wills and Shiffman 1985; Castro et al. 1987). These studies suggest that youth need more general social skills, such as being able to cope with various kinds of stress or social pressures, to help them manage.the many devel- opmental demands of adolescence (Franzkowiak 1987). A more comprehensive concept of skills that has been used in prevention efforts is aiscusned in Chapter h (•t2c2 "lnstilling Skills for Resisting Social Intluences to Smoke" and "Exemplary Programs for Resisting Social Intluenct.-.," ). Personal Factors in the Initiation of Smoking Personal factors are those that are inherent in the individual; they include cognitive processes, values, per- sonality constructs, and psychological well-being. These factors can be considered the personal filters through which sociodemographic and environmental factors pass as they influence behavior. Personal risk factors also explain differences in behavior among individuals ex- posed to the same or similar environments. The per- sonal factors that have been examined in the research literature include levels of knowledge about the health consequences of smoking, the functions or meanings of cigarette use among adolescents, the subjective expected utility (SEU) of smoking, self-esteem, self-image, self- efficacy in refusing offers of cigarettes, personality vari- ables, and emotional well-being. Knowledge of Long-Term Health Consequences Knowledge of the long-term health consequences of smoking has not been a strong predictor of adolescent onset (Collins et a1.1987; Krohn, Naughton, Latier 1987; Sussman et al. 1987; Conrad, Flay, Hil11992; Royal Col- lege of Physicians of London 1992), perhaps because virtually all U.S. adolescents-smokers and nonsmokers alike-are aware of the long-term health effects of smok- ing and because many adolescents feel inherently invul- nerable in their characteristically short-term view (Gerber and Newman 1989). Belief that smoking has short-term effects on health appears to be a more powerful influence than knowledge of long-term health effects (Krohn, Naughton, Lauer 1987; McNeill et al. 1988). Similarly, belief in personally relevant negative social consequences of smoking has been associated with a decline in smok- ing prevalence among secondary school students (Chassin et a1.1987). Botvin et al. (1992) found that lack of concern about the harmful effects of smoking was associated with intentions to smoke among young, inner-city black adolescents. Similarly, dismissing or minimizing the health consequences of smoking has been associated with both initiation of cigarette use and adult smoking levels (Mittelmark et al. 1987; Swan, Creeser, Murray 1990). Krohn, Naughton, and Lauer (1987) found that smoking behavior predicted beliefs about the health effects of smoking more than beliefs predicted future cigarette use. Knowledge of the health consequences of smoking may or may not deter some adolescents from beginning to smoke; beginning to smoke appears to ac- centuate adolescents' denial of the health consequences. Psychosocial Risk Factors 135 TIMN 0138987

Surgeon General's Report NORDBERG A, WAHLSTROM G, ARNELO U, LARSSON C. Effect of long-term nicotine treatment on ('H) nicotine binding sites in the rats brain. Drug and Alcohol Dependence 1985; 16(l):9-17. POLLARD RB, MELTON LJ 111, HOEFFLER DF, SPRINGER GL, SCHEINER EF. Smoking and respiratory illness in military recruits. Archives of Environmental Health 1975; 30(11):533-7. O'DONNELL JA, CLAYTON RR. The stepping-stone hy- pothesis-marijuana, heroin, and causality. Chemical Depen- dencies: Behavioral and Biomedical Issues 1982;4(3):229-41. OECHSLI FW, SELTZER CC, VAN DEN BERG BJ. Adoles- cent smoking and early respiratory disease: a longitudinal study. Annals of Allergy 1987;59(2):135-40. OFFENBACHER S, WEATHERS DR. Effects of smokeless tobacco on the periodontal, mucosal and caries status of ado- lescent males. Journal of Oral Pathology 1985;14(2):169-81. PALMER KJ, BUCKLET MM, FAULDS D. Transdermal nico- tine: a review of its pharmacodynamic and pharmacokinetic properties, and therapeutic efficacy as an aid to smoking ces- sation. Drugs 1992;44(3):498-529. PARNELL JL, ANDERSON DO, KIMVIS C. Cigarette smok- ing and respiratory infections in a class of student nurses. New England Journal of Medicine 1966;274(18):979-84. PATHOBIOLOGICAL DETERMINANTS OF ATHERO- SCLEROSIS IN YOUTH (PDAY) RESEARCH GROUP. Rela- tionship of atherosclerosis in young men to serum lipoprotein cholesterol concentrations and smoking. Journal of the Ameri- can Medical Association 1990;264(23):3018-24. PETERS JM, FERRIS BG. Smoking, pulmonary function and respiratory symptoms in a college-age group. American Re- view of Respiratory Disease 1967;95(5):774-82. PETO R. Epidemiology, multistage models, and short-term mutagenicity tests. In: Hiatt HH, Watson JD, Winsten JA, editors. Origins of human cancer, book C, human risk assess- ment. Vol. 4. Cold Spring Harbor (NY): Cold Spring Harbor Laboratory, 1977. PICKWORTH WB, HERNING RI, HENNINGFIELD JE. Spontaneous EEG changes- during tobacco abstinence and nicotine substitution hiit~tvolunteers. Journal of Pharma- cology and Experimental Tl>~rppeutics 1989;251(3) 976-82 ;,,~~~~, . PIERCE JP, FIORE MC, NOVOTNY TE, HATZIANDREU EJ, DAVIS RM. Trends in cigarette smoking in the United States: projections to the year 2000. Journal of the American Medical Association 1989;261(1):61-5. PINDBORG JJ. Oral cancer and precancer. Bristol (England): John Wright & Sons, Ltd., 1980. PINDBORG JJ. Oral precancer. In: Barnes L, editor. Surgical pathology of the head and neck. New York Dekker, 1985. 48 Health Consequences POMERLEAU OF, POMERLEAU CS. Neuroregulators and the reinforcement of smoking: toward a biobehavioral explanation. Neuroscience and Biobehavioral Reviews 1984;8(4):503-13. PUBLIC HEALTH SERVICE. Smoking and health. Report of the advisory committee to the Surgeon General of the Public Health Service. US Department of Health, Education, and Welfare, Public Health Service. PHS Publication No. 1103,1964. RIMPELA AH, RIMPELA MK. Increased risk of respiratory symptoms in young smokers of low tar cigarettes. British Medical Journal 1985;290(6480):1461-3. ROYAL COLLEGE OF PHYSICIANS OF LONDON. Smoking and the you ,:,~. London: The Lavenham Press, Ltd., 1992. RUSH D. Respiratory symptoms in a group of American secondary school students: the overwhelming association with cigarette smoking. International Journal of Epidemiology 1974;3(2):153-65. RUSSELL MAH. The nicotine addiction trap: a 40-year sen- tence for four cigarettes. British Journal of Addiction 1990;85(2):293. RUSSELL MAH, JARVIS MJ, FEYERABEND C. A new age for snuff? Lancet 1980;1(8166):474-5. SACHS DPL. Pharmacologic, neuroendocrine, and biobehavioral basis for tobacco dependence. In: Simmons DH, editor. Current pulmonology. Vol. 8. Chicago: Year Book Medical Publishers, 1987. SAMET JM. A historical and epidemiological perspective on respiratory symptoms questionnaires. American Journal of Epi- demio,logy 1978;108(6):435-46. SAMET JM, CAIN WS, LEADERER BP. Environmental to- bacco smoke. In: Samet JM, Spengler JD, editors. Indoor air pollution. A health perspectim Baltimore (MD): Johns Hopkins University Press, 1991. SAMET JM, TAGER IB, SPEIZER FE. The relationship be- tween respiratory illness in childhood and chronic air-flow obstruction in adulthood. American Review of Respiratory Dis- ease 1983;127(4):508-23. SCHENKER MB, SAMET JM, SPEIZER FE. Effect of cigarette tar content and smoking habits on respiratory symptoms in women. American Review of Respiratory Disease 1982;125(6):684-90. TIMN 0138901

Preventing Tobacco Use Among Young People In the United Kingdom, Aitken, Leathar, and O'Hagan (1985) followed a procedure similar to that used by Chapman and Fitzgerald. They showed ciga- rette advertisements, interspersed among advertisements for other products, to groups of male and female school- children (aged 6 through 16 years) from Glasgow's in- ner-city areas (most of whose residents were of lower socioeconomic status) and suburban areas (most of whose residents were of higher socioeconomic status). Chapman and Fitzgerald's findings that large proportions of chil- dren were aware of cigarette advertisements were sup- ported in this study and were extended to include younger children. Among some of the 12-year-olds and most of the 14- and 16-year-olds in the Glasgow study, the adver- tising images elicited comments that indicated the young people's perceiving implicit, supposedly adult themes, such as independence, sex appeal, and success. In a separate study, Aitken et al. (1987) showed nine color photographs of different cigarette advertise- ments to 12- through 17-year-olds. When the young people were asked if they had seen any of the advertise- ments before, 83 percent of the 6- and 7-year-olds and 91 percent of the 16- and 17-year-olds recalled seeing the same ad. When asked to match the various ads to brief verbal descriptions of the ads, the study subjects in the three oldest age groups (those 12 through 17 years old) succeeded at a level greater than chance. Together, the results from these studies show that even relatively young children are aware of cigarette advertising and are able to recall particular advertise- ments. Older adolescents are moreover capable of inter- preting the advertisements in imagistic terms related to attractive features of adult life. Opinions on Cigarette Advertising and Smoking Behaviors O'Connell et al. (1981) surveyed more than 6,000 students aged 10 through 12 who were drawn from a sample of 88 primary schools in New South Wales, Australia. Logistic regression was used to determine the relative importance of various personal and social environmental factors in relation to the proportion of children who reported smoking one or more times per week. The factors included friends' smoking, approval of tobacco advertising, siblings' smoking, the amount of money available to spend weekly, gender, age, and par- ents' smoking. As part of the same study, Alexander et al. (1983) identified factors associated with change in smoking status (both beginning and ceasing to smoke) over the 12 months between the baseline and follow-up surveys. Of the children who reported not smoking during the month preceding the baseline survey, significantly more of those who at baseline approved of cigarette advertising reported smoking during the month preceding the follow-up survey than did those who disapproved of cigarette advertising. Similar re- sults were found for the children who reported smok- ing during the month preceding the baseline survey. The study thus found a positive relationship between approving of advertising and subsequently taking up smoking, and between disapproving of advertising and quitting smoking. Armstrong et al. (1990) conducted a large random- ized trial among seventh-grade students (13 years old) in Western Australia in which peer-led and teacher-led programs concerning social influences were evaluated. When the students were resurveyed one year and two years after the intervention, the results identified factors associated with beginning to smoke. Both boys and girls who at baseline reported that cigarette advertisements made them think they would like to smoke a cigarette were significantly more likely to have adopted smoking at the one-year and two-year follow-up surveys than those who did not report feeling this way. . Aitken and Eadie (1990) examined whether the awareness and appreciation of cigarette advertisements were independent of other predictors of adolescent smok- ing. In this study, 868 Glasgow adolescents between the ages of 11 and 14 years were selected at random and interviewed privately in their homes. Older adolescents, boys, and current smokers in the sample tended to ap- prove of cigarette advertisements and were also more likely to correctly identify cigarette advertisemeiits that carried no brand identification. In general, smokers were more successful than nonsmokers at identifying cigarette advertisements, were more likely to have siblings who smoked, tended to be more approving of cigarette adver- tisements, and were less likely to perceive that their parents strongly opposed smoking. These findings sug- gest that advertising may reinforce the habit of smoking, even among new, young smokers. Young People's Responses to Different Types of Cigarette Advertisements - Huang et al. (1992) reported on the preferences of seventh- and eighth-grade children (average age 14) con- cerning three categories of cigarette advertisement: ads with cartoons, those picturing human models, and those with only the cigarette package and words (tombstone ads). The study was a cross-sectional survey conducted in April 1991 among 243 students in two junior high schools in Chicago. Seventy percent of the students were black, 22 percent white, 3 percent Hispanic, 2 per- cent Native American, 1 percent Asian, and 2 percent from other races. Analyses were limited to responses of the black and white subjects. The subjects first were Advertising and Promotion 189 TIMN 0139041

Pre';'e'Ittll~~ Tol'de1o Ll-e'.'lllle~ll~~ ~e'IIN~: l'e't'pJe' References AHLGREN A. NOREM AA, HOCHHAC;SER Vl, GARVIN J. .~ntecedent< ut ~,moking among pre-adolescents. Jountal of Drug Ettl/cwhw/ I yti?;1'_(-I):323-I0. ALEXANDER H`L CALLCOTT R, DOBSON AJ, HARDES GR, LLOYD D!vl, O'CONNELL DL, ET AL. Cigarette smok- ing and drug use in schoolchildren: [V-factors associated with changes in smoking behaviour. Gtterrtational Journal of EpidentioloSnt 1983;12(1):59-66. AMERICAN SCHOOL HEALTH ASSOCIATION, ASSOCIA- TION FOR THE ADVA,tiCEMENT OF HEALTH EDUCA- TION, SOCIETY FOR PUBLIC HEALTH EDUCATION, INC., US DEPARTMENT OF HEALTH AND HUMAN SERVICES. The national adolescent health sttrz'etl: a report on the health of Americlz': uouth. Oakland (CA): Third Party Publishing, 1989. ARY DV. Use of smokeless tobacco among male adolescents: concurrent and prospective relationships. In: National Cancer Institute. S(ttokeless tobacco use in the United States. Monograph No. 8. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute. Bethesda (MD): NIH Publication No. 89-3055, 1989, 49-55. ARY DV, B[GLAN A. Longitudinal changes in adolescent cigarette smoking beh ivior: onset and cessation. Journal of Behar'ivntl :41edictnc lyK8;l 1(-1):361-82. ARY DV, BIGLAN A, NAUTEL CL, WEISSMAN W, SEVERSON HH. Longitudinal prediction of the onset and change in rate of adolescent smoking. In: Forbes WF, Frecker RC, Nostbakken D, editors. Proceedinqs of the Fifth World c'onferetlce orr Sumkirtg lrud Health, Vol. 1., 1983; Winnipeg. Ottawa (Canada): Canadian Council on Smoking and Health, 1983. ARY DV, LICHTENSTEIN E, SEVERSON HH. Smokeless tobacco use among:inale adolescents: patterns, correlates, predictors, and theuse of other drugs. Preventive Medicine 1987 :16(3):38.5--I01:'-- ARY DV, LICHTENSTEIN E, SEVERSON H, WEISSMAN W, SEELEY JR. An in-depth analysis of male adolescent smoke- less tobacco users: interviews with users and their fathers. Journul of Brltat'iontl Medicirte 1989;12(5):449-67. BACHMA.ti' JG, WALLACE JM,O'MALLEY PM, JOHNSTON LD, KL;RTH CL, NEIGHBORS HW. Racial/ethnic differ- ences in smoking, drinking, and illicit drug use among Ameri- can high school seniors, 1976-89. Antericnn Journal of Public Health 1991;81(3):372-7. BANDURA A, editor. Social learning theorti. Englewood Cliff,, (NJ): Prentice Hall, 1977. BANDURA A, editor. Social foutdatioll+ of thought Mtd actio/l. A ulcial cogrtitive tlteorlt. Englewood Cliffs (NJ): Prentice Hall, 1986. BAROVICH M, SUSSMAN S, DENT CW, BURTON D, FLAY BR. Availability of tobacco products at stores located near public schools. International Journal of Addictions 1991;26(8): 837-50. BAUMAN KE, FISHER LA. Subjective expected utility, locus of control, and behavior. Journal of Applied Social Psyclwlogy 1985;15(7):606-21. BAUMAN KE, FISHER LA, BRYAN ES, CHENOWETH RL. Antecedents, subjective expected utility, and behavior: a panel study of adolescent cigarette smoking. Addictive Behaviors 1984;9(2):121-36. BAUMAN KE, FOSHEE VA, LINZER MA, KOCH GG. Effect of parental smoking classification on the association between parental and adolescent smoking. Addictive Behaviors 1990;15(5):413-22. BAUMAN KE, KOCH GG, LENTZ GM. Parent characteris- tics, perceived health risk, and smokeless tobacco use among white adolescent males. In: National Cancer Institute. Suoke- less tobacco use in the United States. Monograph No. 8. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Insti- tute. Bethesda (MD): NIH Publication No. 89-3055,1989, 43-8. BEST JA, FLAY BR, TOWSON SMJ, RYAN KB, PERRY CL, BROWN KS, ET AL. Smoking prevention and the concept of risk. Journal of Applied Social Psychology 1984;14(3):257-73. BORLAND BL, RUDOLPH JP. Relative effects of low socio- economic status, parental smoking and poor scholastic perfor- mance on smoking among high school students. Social Science and Medicine 1975;9(l):27-30. BOTVIN GJ, BAKER E, GOLDBERG CJ, DUSENBURY L, BOTVIN EM. Correlates and predictors of smoking among black adolescents. Addictive Behaviors 1992;17(2):97-103. BOTVIN GJ, BAKER E, TORTU S. Smokeless tobacco use among adolescents: correlates and concurrent predictors. Jour- lml of Dezvelopnlental and Behavioral Pediatrics 1989;10(4):181-6. TIMN 0139001 Psychosocial Risk Factors 149

tillY~c( )ii C,0 lt'Pd I " kc'{,i,~ ` Table 4. Smokeless tobacco sales and advertising expenditures, 1985 -1991 Sales Year Total pounds sold Revenues (U.S. $) Advertising and promotion expenditures (U.S. $) 1985 121,449,115 730,618,970 80,068,229 1986 118,778,334 797,777,885 76,676,706 1987 116,540,281 852,717,347 67,777,044 1988 114,435,233 901,654,382 68,223,671 1989 116,437,890 981,637,304 81,200,611 1990 117,415,326 1,091,170,201 90,101,355 1991 120,110,686 1,237,961,670 104,004,042 Source: Federal Trade Commission (1993). outrage at the attempt to encourage women to smoke, yet prompted the envy and emulation of many other cigarette marketers (Wood 1958). Later, various cigarette campaigns targeted and featured women, including Hollywood movie stars, winners of the Miss America beauty pageant, women in heroic World War II roles, mothers (for Mother's Day), and brides (Howe 1984; Ernster 1985). Some of these campaigns explicitly por- trayed cigarette smoking as appropriate for the young. For example, a Lorillard campaign that showed a woman running on the beach encouraged viewers to "Light an Old Gold for young ideas." Ads Targeting Young People From the time of the earliest marketing campaigns, parents, educators, and policy makers worried about the exposure-intentional or not, it was inevitable-of young people to cigarette advertising. These concerns were not misplaced. For example, one variant of the American Tobacco Company's campaign for Lucky Strike in the 1920s depicted a young woman and a very young man "breaking the chains of the past" to reach for opportunity and an open pack of cigdrettes (Anderson 1929). In 1929, a Senate proponent of amendments to the Pure Food and Drug Act declared, "Not since the days when the vendor of harmful nostrums was swept from our streets, has this country witnessed such an orgy of buncombe, quackery and downright falsehood and fraud as now marks the current campaign promoted by certain cigarette manu- facturers to create a vast woman and child market" (Schudson 1984, pp. 194-5). Such protests had little effect on the tobacco industry's marketing plans. Despite the increased over- all number of smokers in the 1920s, 1930s, and 1940s, the industry considered it strategically important to continue efforts to recruit more young consumers. In 1950, for example, a tobacco industry trade journaLre- ported the following industry perception: "A massive potential market still exists among women and young adults, cigarette industry leaders agreed, acknowledging that recruitment of these millions of prospective smokers comprises the major objective for the immediate future and on a long term basis as well" (United States Tobacco Journal [USTJj 1950b,p.1). Andata 1955pressconference announcing redesigned brand packaging, the president of the Philip MorrisCompanies made it clear that appeal- ing to the young was a deliberate, strategic focus for the company: "We wanted a new, bright package that would appeal to a younger market" (Tide 1955, p. 31). The company's ad director was even more explicit: "Our ads are now aimed at young people and emphasize gentle- ness" (i.e., ease of smoking) (Tide 1955, p. 31). A few years later, Philip Morris launched a comic strip campaign featuring a "handsome, rough and ready" adventure hero, "Duke Handy." The comic strip was placed in the Sunday color comic sections of 40 newspapers in a na- tional network. Behind this comic strip was a "heavy promotionalcampaign" that included "stories and ads in major newspapers on the schedule, Duke Handy cam- paign buttons, truck posters, newspaper display cards, newsboy competitions and supporting publicity and pro- motional activities" (USTJ 1958a, p. 7). These youth-oriented marketing strategies pre- vailed even in the face of increasing reports from scien- tists warning of the health risks of smoking. In 1963, Fortune magazine observed that "several recent studies show that teenagers have not been much impressed by any anti-smoking campaigns" (Fortune 1963, p. 101). In one of the studies discussed in this Fortune article, Gilbert Research, a firm specializing in research on the 166 Advertising and Promotion ~ TIMN 0139018

1'rt'n';thltS TA41tt't) U,;t' rllNC'1!~ l~t~fll/L ('t'O14t' decades of awareness of the dangers of tobacco use, media managers are reluctant to turn away the rev- enue enjoyed from cigarette advertising (Kessler 1989; Tve 1990). . Smokeless Tobacco Advertising and Promotional Expenditures In 1986, a report of the Advisory Committee to the Surgeon General concluded that use of smokeless to- bacco represents a significant health risk, is not a safe substitute for cigarette smoking, can cause oral cancers, and can lead to nicotine addiction and dependence (USDHHS 1986). In the same Vear, Congress passed the Comprehensive Smokeless Tobacco Health Education Act (CSTHEA) of 1986 (Public Law 99-252). The act required that (1) the public be informed of any health dangers of smokeless tobacco use, (2) smokeless tobacco advertising and packaging include three rotated warn- ing labels (except on outdoor billboards, which could bear any one of the three warning labels), and (3) smoke- less tobacco advertising be restricted from radio and television. The CSTHEA also encouraged legislation to make age 18 the minimum age to purchase smokeless tobacco; by 1993, all 50 states and the District of Colum- bia had passed such legislation (CDC, Office on Smoking and Health, unpublished data). The 1986 Advisory Committee Report to the Sur- geon General and the 1986 CSTHEA were responses to increasing evidence both that smokeless tobacco use com- promised health and that increasing numbers of Ameri- cans apparently perceived smokeless tobacco as a safe alternative to cigarette smoking; annual U.S. consump- tion of smokeless tobacco had increased substantially between 1972 and 1985 (USDHHS 1986). Although the amount (in pounds) of smokeless tobacco sold declined from 1985 through 1988, amounts increased during the following three years (Table 4). By 1991, annual con- sumption of smokeless tobacco products in the United States had returned to its 1985 level of over 1-20 million pounds (FTC 1993). The increases-in the use of smokeless tobacco from the 1970s to the mid-1980s can be attributed to more aggressive marketiitg by the smokeless tobacco industry, new smokeless tobacco products, the teaming of smoke- less tobacco with well-known sports and entertainment personalities, the increased accessibility of smokeless to- bacco products, and a growing market of young males (Christen 1980; Glover, Christen, Henderson 1981; USDHHS 1992a, b; see "Environmental Factors in the Initiation of Smokeless Tobacco Use" in Chapter 4). One of the primary aims of advertising and promotional ac- tivities during the past two decades was to attract people to try smokeless tobacco (Glover, Christen, Hmderscm 1981; Tye, Warner, Glantz 1987). The strategy was evi- dently a success. In 1970, men over the age of »(pre- sumably longtime users) were the heaviest users of moist snuff; by 1985, the usage rate was two times higher among males aged 16 through 19 than among older men (USDHHS 1992b). In 1991, the United States Tobacco Company, one of five major tobacco companies that produce smokeless tobacco products in the United States, produced 87 per- cent of the moist snuff consumed (USDHHS 1992b). The company's most popular products, Copenhagen and Skoal, were also the most popular among adolescent users. Advertisements for these products have stressed that smokeless tobacco is easy to use, that it is convenient "in places where you can't light up," and that "a pinch is . all it takes: " By providing explicit instructions for use (sometimes delivered by well-known professional ath- letes) and by suggesting that the product could be used without adult detection, smokeless tobacco advertise- ments have appeared to target male adolescents (Chris- ten 1980; USDHHS 1992b). Promotional activities for smokeless tobacco have gained increasing importance since the CSTHEA of 1986, in part because radio and television advertising were banned by the act. Advertising and promotional expen- ditures for smokeless tobacco decreased each vear from 1985 through 1987, then increased yearly from 1988 through 1991,. along, with yearly smokeless tobacco sales figures (Table 4). Of these expenditures, public enter- tainment sponsorship was the largest single advertising and promotional spending category from 1986 through 1990; over $21 million was allocated in 1991 (FTC 1993). In 1991, expenditures to provide consumers with cents- off coupons and retail value-added promotions, such as buy-one-get-one-free offers or specialty advertising gifts given at points of sale, became the largest spending category (over $23 million allocated). Public entertain- ment sponsorship and specialty advertising gifts appear to particularly appeal to male adolescents, even if the smokeless tobacco industry does not explicitly target teens (USDHHS 1992b). Of particular note is the use of product sampling of smokeless tobacco products. In 1978, the United States Tobacco Company ran advertisements in Sports Illus- trated for free samples of fruit-flavored, low-nicotine snuff products for beginners (Tye, Warner, Glantz 1987); the samples were accompanied by instructions on how to use smokeless tobacco. Currently, the smokeless tobacco industry's voluntary code on sampling prohibits sam- pling to those under 18 years old (Davis and Jason 1988); this restriction nonetheless permits the marketing of smokeless tobacco on college campuses. Advertising and Promotion 163 TIMN 0139015

Preventing Tobacco Use Among Yoeing People especially for health and educational programs (Gallup Organization 1993), such as those aimed at preventing children from smoking or from using drugs. A 1989 national survey sponsored by the Associated Press (Asso- ciated Press / Media Genera11989) found that 75 percent of adults supported increasing the federal excise tax on cigarettes to pay for an expanded federal antidrug pro- gram. The same questions asked in 1990 found that 77 percent supported raising cigarette taxes (Associated Press/Media General 1990). The 1989 SAVES (Marcus et al., in press) found that about two-thirds of adults favored using an extra tax on tobacco to cover the cost of Table 3. Public opinion about increasing tobacco taxes, United States, 1989-1990 Source and year of survey Description of survey Gallup Organization National personal 1989 interview survey with 2,048 adults (aged ~ 18 years) Gallup Organization National telephone 1990b survey of 1,255 adults (aged 2- 18 years) Hart Research National telephone Associates and survey of a random Robert Teeter sample of registered 1990a, b, c voters (January survey N =1,510; May survey N =1,007; July survey N = 1,555) Yankelovich, Clancy, Shulman 1990a, b National telephone survey of adults (aged > 18 years) (May survey N =1,000; October survey N=500) Associated Press/ Media General 1989,1990 National telephone survey of adults (aged _ 18 years) (September 1989 survey N = 1,071; May 1990 survey N = 1,143) Questions Taking into account the amount each (tax) would raise, and your opinion about these taxes, which, if any, would you favor as a means of reducing the federal budget deficit? deficit? • If taxes were raised to reduce the deficit, which one of the following would be your first choice to help reduce the Let us suppose the government needed to raise taxes. Do you favor or oppose raising alcohol and tobacco taxes? Do you favor or oppose raising taxes on cigarettes to reduce the federal budget deficit? To pay for a bigger federal antidrug program, would you support or oppose higher federal taxes on cigarettes? Responses 64% favored raising ciga- rette taxes by 16 cents per pack; the only other tax measure mentioned more frequently was raising the tax on alcohol (69%) First choice of largest . proportion of respondents (42%) was raising taxes on cigarettes and alcohol January 1990: 78% favor May 1990: 83% favor July 1990: 78% favor May 1990: 72% favor October 1990: 71% favor September 1989: 75% favor May 1990: 77% favor Prevention 215 TIMN 0139065

Surgeon Genera['; Repurt Research on the Effects of Cigarette Advertising and Promotional Activities on Young People Introduction A substantial and growing body of scientific litera- ture has reported on young people's awareness of, and attitudes about, cigarette advertising and promotional activities.' Research has also focused on the effects of these activities on psychosocial risk factors for beginning to smoke. Considered together, these studies offer a compelling argument for the mediated relationship of cigarette advertising and adolescent smoking. To date, however, no longitudinal study of the direct relationship of cigarette advertising to smoking initiation has been reported in the literature. This lack of definitive litera- ture does not imply that a causal relationship does not exist; rather, better quantification of exposure, effect, and etiology is needed. Important data from research con- ducted for the tobacco industry are not available; such information would add considerably to our knowledge. A definitive study, such as a randomized control trial with young people exposed and not exposed to cigarette advertising, is both practically and ethically impossible. What is possible and needed is research that is longitudi- nal and multivariate, that takes advantage of recent statistical modeling methods, and that uses large samples of children and young adolescents who have not tried smoking and who have had relatively little exposure to cigarette advertising. The issue of causality is addressed in this section by examining the effect of cigarette advertising and promo- tional activities on the known psychosocial risk factors (discussed in detail in Chapter 4) for the initiation of smoking. If advertising and promotional activities con sistently affect these factors-factors such as self-image, the functional meanings of smoking, normative expecta- tions, and intentions to smoke-then these activities may also affect smoking~oitset. This mechanism is especially plausible in the Unibed States, where cigarette advertis- ing and promotiona! activities are pervasive. During an unusual historical period, July 1, 1967, through December 31,1970, antismoking messages were widely aired on television and radio as part of the FTC's Fairness Doctrine. These messages were aired until a 'Recent evidence of the effects of tobacco advertising on adult tobacco consumption can be found in the United Kingdom Department of Health document, Effect of Tobacco Advertising on Tobacco Consumption: A Discussion Document Reviewing'the Evidence (UK Department of Health 1992). complete ban on prosmoking advertising on radio and television took effect on January 1, 1971. For those three and one-half years, the American public was exposed to both prosmoking and antismoking messages on radio and television. A carefully designed study of nearly 7,000 adolescents (Lewit, Coate, Grossman 1981) found that having both sets of messages on radio and television had the effect of reducing adolescent smoking rates; the impact was strongest during the first year of the anti- smoking messages. These study findings suggest that a nationwide, well-funded antismoking campaign could effectively counter the effects of cigarette advertising in its currently permitted media forms. Young People's Exposure to Cigarette Advertising Several research studies show that young people are aware of, and respond to, cigarette advertising. In a recent Gallup (1992) study, 87 percent of the 1,125 adoles- cents surveyed nationwide could recall recently seeing one or more tobacco company advertisements,. Simi- larly, Pierce et al. (1993) found in their study of nearly 7,000 California adolescents that over 90 percent of the 12- and 13-year-olds could name a brand they had seen advertised. Half of the adolescents in the Gallup survey could identify the cigarette brand name associated with at least one of four cigarette slogans (Gallup 1992). Chapman and Fitzgerald (1982) tried to determine the level of awareness of cigarette advertisements among 11- through 14-year-olds in Australia and the possibility of a relationship between awareness of advertisements and smoking behavior. Data were collected on smoking prevalence and preferred brands. Participants were asked to identify the cigarette brands advertised in photographs of eight print-media cigarette advertisements that had been edited to remove any identifying writing. The children were also asked to complete edited advertising slogans. Children who reported smoking in the last four weeks were almost two times more likely to correctly identify the advertisements and complete the slogans than were children who reported that they had not smoked during that period. Smokers' pre- ferred brands generally corresponded with the adver- tisements and slogans most often correctly recognized. Of the 130 brands of cigarettes available on the market at the time of the study (1981), just four brands accounted for cigarettes smoked by nearly 80 percent of these ado- lescent smokers. 188 Advertising and Promotion TIMN 0139040

lllrgt'lI ll Gt'1(t'1'.!l " !lt'l4'rt G[I-CHRIST LD,SCHI`KESP, tiURIUS P. Rewiucingonsetuf habitual smoking among women. Prevrrttive Medicine [ LItiy: I ti('-):? 3 5--ki. HUNTER SM, VIZELBERG [A, BERENSON GS. Identtfytn); mechanisms of adoption of tobacco and alcohol use among youth: the Bogalusa heart study. Social Netsorks 1y91;13( I):, 91-104. GLOVER ED, LAFLIN M, EDWARDS SW. Age of initiation and ~.witchin); patterns bevxeen smokeless tobacco and ciga- retce> amonK collel;e ~tudents in the United States. American lom'Itdl of Pttblic Health lc)ti9;790:207-t3. GLOVER ED, LAFLIN M, FLANNERY D, ALBRITTON DL. Smokeless tobacco use among American college students. Jour- lull vr Arncricnn Collcge Health 1989;38(2):81-5. GODDARD E. Whu children start srrroking. London (UK): Her Majesty's Stationery Office, 1990. GRITZ ER. Cigarette smoking by adolescent females: impli- cations for health and behavior. Women and Health 1984; 9(2-3):103-15. GRITZ ER, CRANE LA. Use of diet pills and amphetamines to lose weight among smoking and nonsmoking high school seniors. Health Psycholoyy 1991;10(5):330-5. GRUNBERG NE, WINDERS SE, WEWERS NIE. Gender dif- ferences in tobacco use. Health Psycholc>gif 1991;10(2):143-53. HAHN G, CHARLIN VL, SUSSMAN S, DENT CW, MANZI J, STACY AW, ET AL. Adolescents' first and most recent use situations ot smokeless tobacco and cigarettes: similarities and ditferences. ,-lridictivc Behaviors 1990;15(5):439-48. HALL RL. DEXTER D. Smokeless tobacco use and attitudes towara smukele~~ tobacco among Native Americans and other adolescents in the Northwest. Arncrican Journal of Public Health I 48h;7 !i(1? ):15i1()-ti. HANSEN WB, GRAHAM JW, SOBEL JL, SHELTON DR, FLAY BR, JOH `SO:~ CA. The consistency of peer and parent influences on tobacco, alcohol, and marijuana useamong young adolescents. lournal of Behavioral Medicine 1987;10(6):559-79. HOOKER K. Developmental tasks. In: Lerner Rlbt, Petersen AC, Brooks-Gunn J, editiirs, Encuclupedia of Adolescence. Vol. I. New York: Garland Publishing,1991:228-231. Hl: NTER SM, CROFT JB, BURKE GL, PARKER FC, WEBBER LS, BERENSON GS. Longitudinal patterns of cigarette smok- ing and smokeless tobacco use in youth: the Bogalusa heart studv. American lcltrnral of Public Health 1986;76(2):193-5. HUNTER S.ML CROFT JB, VIZI;LBERG IA, BERENSON GS. Psychosocial influences on cigarette smoking among youth in a southern community: 'the Bogalusa heart study. Morbidity and Mortnlittt Weekfht Relxrrt 1987;36(4 Suppl):17S-25S. 152 Psychosocitrl Risk Factors ISOHANNI M, MOILANEN I, RANTAKALLIO P. Determi- nants of teenage smoking, with special reference to non- standard family background. British Jotrrnal of Addiction 1991;86(4):391-8. JACOBS GA, NEUFELD VA, SAYERS S, SPIELBERGER CD, WEINBERG H. Personalitv and smokeless tobacco use. Ad- dictive Behaviors 1988;13(4):311-8. JESSOR R, JESSOR SL. Problem behaz,ior and psyclwlogical detcl- opment: a longitudinal study of youth. New York: Academic Press, 1977. JOHNSTON LD, O'MALLEY RM, BACHMAN JG. Smoking, drinking, and illicit drug use among American secondary school students, college students, and young adults, 1975-1991. Volume I. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Insti- tute on Drug Abuse. Bethesda (MD): NIH Publication No. 93-3480, 1992. JONES RB, MOBERG DP. Correlates of smokeless tobacco use in a male adolescent population. American Journal of Pub- lic Health 1988;78(1):61-3. KANDEL DB, LOGAN JA. Patterns of drug use from adoles- cence to young adulthood: I. Periods of risk for initiation, continued use, and discontinuation. American Journal of Ptridic Heal tl: 1984;74(7):660-6. KAPLAN SL, LANDA B, WEINHOLD C, SHENKER IR. Ad- verse health behaviors and depressive symptomatology in adolescents. Journal of the American Academy of Child Psychiatry 1984;23(5):595-601. KELDER, SH. Youth cardiovascular disease risk and preven- tion: The Minnesota heart health program and the class of 1989 study (dissertationl. Minneapolis (MN): University of Minnesota, 1992. KELLAM SG, ENSMINGER ME, SIMON MB. Mental health in first grade and teenage drug, alcohol, and cigarette use. Drug and Alcohol Dependence 1980;5(4):273-304. KLEPP K-1, HALPER A, PERRY CL. The efficacy of peer leaders in drug abuse prevention. Journal of School Health 1986;56(9):407-11. KONOPKA G. Adolescence, concept of, and requirements for a healthy development. In: Lerner RM, Petersen AC, Brooks- Gunn J, editors. Encyclopedia of Adolexence. Vol. 1. New York: Garland Publishing, 1991. TIMN 0139004

Surgeon General's Report Table 1. Public opinion about restricting or banning different types of tobacco advertising and promotions, United States,1487-1991 Source and year of survey Description of survey Questions or statements Responses University of Telephone survey of a Minnesota 1987 random sample of adults: (Forster et a1.1991) (aged 18-74 years) in seven communities in Minnesota (N = 821) American Cancer Telephone survey of a Society 1989 random sample of adults (Marcus et al., in (aged ? 18 years) in four press) states: Arizona (N = 294), Pennsylvania (N = 291), Texas (N = 303), and Michigan (N = 98) National Cancer Telephone survey of a Institute 1989 random sample of 300 to (Centers for Disease 400 adults (aged 25-64 Contro11991b) years) in each of 10 U.S. COMMTT* intervention communities California Telephone survey of a Department random sample of adults of Health (aged - 18 years) in Services 1990 California (N = 6,600) (California Department of Health Services' 1991) Do you favor or oppose prohibiting tobacco signs and billboards? Do you favor or oppose prohibiting tobacco advertising in magazines and newspapers? Advertising of cigarettes should be banned in newspapers, magazines, and outdoor posters or billboards. Tobacco companies should be prohibited from distributing free tobacco samples on public property or through the mail. Tobacco companies should be prohibited from sponsoring sports events or advertising their products at these events. Tobacco companies should not be allowed to sponsor sporting and cultural events. Do you think advertising of tobacco products on outdoor billboards should be allowed or banned? Do you think advertising of tobacco products through newspapers and magazines should be allowed or banned? Do you think sponsorship of sporting or cultural events by tobacco companies should be allowed or banned? Do you think that distribution of free cigarettes and tobacco products on public property should be allowed orbanned? Do you think that distribution of free tobacco samples or coupons to obtain free samples by mail should be allowed or banned? *COMMIT = Community Intervention Trial for Smoking Cessation. 73% favored a prohibition 70% favored a prohibition Agreement across the four states sampled: 61%-69% 73%-81% 49%-59% Agreement across the 10 communities sampled: 31%-56% 54% favored a ban (42% smokers; 62% nonsmokers) 49% favored a ban (38% smokers; 57% nonsmokers) 52% favored a ban (39% smokers; 61% nonsmokers) 75% favored a ban (62% smokers; 84% nonsmokers) 67% favored a ban (52% smokers; 78% nonsmokers) 212 Prevention TIMN 0139062

checkout stands). Coupons reduce the price a consumer pays for products and thereby reduce the consumer's cost-sensitivity, which may be a substantial barrier to making a purchase (McCarthy and Perreault 1993). Pre- miums (e.g., including a cigarette lighter in the purchase price or even within the actual packaging of a box or carton of cigarettes) reduce cost-sensitivity by increasing (or appearing to increase) the value of a purchase. Free samples do away with cost-sensitivity altogether and actually give consumers an opportunity to try something new (Popper 1986; Davis and Jason 1988). Promotional devices such as these are more likely than advertising alone to lead consumers to purchase a product more than once-a pattern sought by all manufacturers. Cigarette Advertising and Promotional Expenditures In 1990, cigarette advertising and promotional expenditures grew to almost $4 billion (see Table 1), making cigarettes the second most promoted consumer products (after automobiles) in the United States. These expenditures occurred at a time when domestic sales of cigarettes and adult per-capita consumption were at rela- tively low levels although domestic revenues continued to increase (Table 2). Advertising and promotional ex- penditures account for 10 to 12 percent of the revenue generated by the tobacco industry in the United States. More than three quarters of these expenditures were for promotional activities, which had steadily increased to over $3 billion, while advertising expenditures for ciga- rettes dropped to $887 million (Federal Trade Commis- sion [FTC] 1992). The decline in cigarette advertising came principally from reductions in print advertising (a 14 percent drop in magazine advertising and a 7 percent drop in newspaper advertising) to their lowest level (in constant 1990 dollars) since the ban on broadcast adver- tising came into effect in January 1971 and the tobacco industry focused advertising attention on print media. In 1990, expenditures for outdoor advertising and transit posters for cigarettes were at an all-time high of 5435 million (see Tabte 3). The largest category of ciga- rette promotion that*year was that of coupon use and retail value-added promotions, which at $1.2 billion rep- resented nearly 30 percent of all cigarette advertising and promotionalexpenditures. The cigarette companies spent just over $1 billion on promotional allowances, which included the money that cigarette companies paid to retailers for shelf space (slotting allowances), cooperative advertising allowances, and trade (wholesaler) allow- ances. Cigarette companies spent over $300 million on point-of-purchase materials in 1990. These expenditures for displays were roughly equivalent (within 10 per- cent) to cigarette company expenditures on magazine 160 Advertising and Promotion advertising. The substantial increases in retail-oriented expenditures reflect an aggressive cigarette marketplace in which companies vie for larger shares of decreasing numbers of cigarette smokers. In 1990, the cigarette companies also expended over $125 million on public entertainment (including sponsorship of sporting events and concerts). Total ad- vertising and prornotional expenditures for cigarettes included over $108 million for sports and sporting events alone. The cigarette companies reported no expendi- tures in 1990 for endorsements or testimonials or for having their brand names or tobacco products appear in any motion picture or television shows (FTC 1992). In contrast, movies in the 1980s were sometimes used to promote specific brands of cigarettes and other products (Magnus 1985). Cigarettes continue to be one of the most heavily advertised products in print media (Centers for Disease Control [CDC] 1990). In 1988, cigarettes ranked first among products advertised in outdoor media, second in magazines, and sixth in newspapers. When advertising expenditures for these three print media are combined, cigarettes were the second most heavily advertised prod- uct after passenger cars (CDC 1990). These expenditures for cigarette advertising represent a drop, however, from the total advertising expenditures in these media in 1985 and are consistent with the cigarette industry's shift in emphasis to promotional activities. One of the indirect consequences of advertising and promotional spending is that the media, reluctant to jeopardize the income that accompanies cigarette adver- tising, are inhibited in their coverage of the health risks of smoking. Warner, Goldenhar, and McLaughlin (1992) examined 99 magazines published in the United States from 1959 through 1969 and from 1973 through 1986 to assess the probability that the number of articles a maga- zine published on the health consequences of smoking would reflect whether they carried cigarette advertise- ments and what proportion of their revenues were de- rived from cigarette advertisements. Magazines that did not carry cigarette advertisements were more than 40 percent more likely to cover the health consequences of smoking than were magazines that carried such adver- tising. For women's magazines, the likelihood increased to 230 percent; a 1 percent increase in the share of adver- tising revenue derived from cigarette advertisements was found to decrease by nearly 2 percent the probability of these magazines' carrying articles on the risksofsmok- ings Numerous other studies and reports on this aspect of cigarette advertising were discussed in the 1989 Sur- geon General's report on smoking and health (U.S. De- partment of Health and Human Services [USDHHS] 1989) and reinforce the general conclusion that despite TIMN 0139012

S::rgeon Geitcral'> Report Table 2. Public opinion about different legislative actions to prevent minors' access to tobacco, United States,1987-1991 Source and year of survey C Description of survey Questions or statements Responses University of Minnesota 1987 (Forster et al. 1991) American Cancer Society 1989 (Marcus et al., in press) National Cancer Institute 1989 (Centers for Disease Contro11991b) California Department of Health Services (California Department of Health„- ; Services 1991) Telephone survey of a random sample of adults (aged 18-74 years) in seven communities in Minnesota (N = 821) Telephone survey of a random sample of adults (aged ? 18 years) in four states: Arizona (N = 294), Pennsylvania (N = 291), Texas (N = 303), and Michigan (N = 98) • Telephone survey of a random sample of 300 to 400 adults (aged 25-64 years) in each of 10 U.S. COMMTT* intervention communities Telephone survey of a random sample of adults (aged -> 18 years) in California (N = 6,600) Do you favor or oppose . 75% favored suspending suspending a retailer's the license tobacco license for sale to minors? Do you favor or oppose 57% favored eliminating the eliminating all cigarette machines vending machines? Do you favor or oppose 80% favored eliminating the eliminating cigarette machines vending machines where teenagers gather? Do you think there should Support for a ban across be laws to ban the sale of the four states sampled: cigarettes through vending 60%-68% machines? Tobacco products should be' Agreement across the 10 as strictly controlled as communities sampled: alcohol products. 51%-75%a Merchants who sell tobacco 77%-93% to minors should be fined. Cigarette vending machines 76%-89% should be eliminated in places where teens gather. Do you think cigarette 82% favored a ban (74% vending machines that are smokers; 87% nonsmokers) accessible to minors should be allowed or banned? "COMMIT = Communi'ty Intervention Trial for Smoking Cessation. machines should be eliminated in places where teens gather." Taxes on Tobacco Products Public opinion surveys consistently show that most people would support an increase in tobacco taxes over other taxes (such as income tax, sales tax, or gasoline tax) (Gallup Organization 1989, 1990a, 1993; Hart Research 214 Prevention Associates and Robert Teeter 1990a, b, c;. Yankelovich, Clancy, Shulman 1990a, b; ACS 1992; IQeine 1993). Sur- veys conducted between 1989 and 1993 show strong support for raising taxes on tobacco and alcohol as a way of reducing the federal budget deficit or to pay for health care ndorm (Toner 1993) fTabk 3). Support for raising tobacco taxes tends to increase when tax revenue is earmarked for specific purposes, TIMN 0139064

Y )it C,t'tn'r1tl" Rt';4op't Functional Meanings of Adolescent Smoking The question of why adolescents begin to smoke has led to multiple examinations of the meanings of cigarette use, the utility of smoking, and the functions that smoking serves in an adolescent's life (Leventhal and Cleary 1980; PPerry, Murray, Klepp 1987). Examin- ing smoking from the perspective of the adolescent is a departure from viewing the onset of smoking exclu- sively as a response to the social environment or as capricious, arbitrary behavior. Since knowledge of the harmful consequences of cigarettes does not appear to deter onset, researchers are examining the social reasons and purposes of smoking. Adolescents who begin to smoke perceive a more functional purpose of smoking than those who are nonsmokers (Gerber and Newman 1,989). Adolescent smokers are more likely to view smoking as a way to act mature, be accepted by a peer group, have fun, cope with personal problems and boredom, or be rebellious (Perry, Murray, Klepp 1987). Cigarette smoking has also been shown to be a coping behavior for adolescents who are dealing with disruptive and stressful family events (Castro et al. 1987). Hunter et al. (1987) found that adolescent smokers were significantly more likely than nonsmokers to believe that smoking has psychological and physiological benefits. They were also less likely to believe that others smoked for negative reasons, such as to "show off." In the research of Hahn et al. (1990), regular smok- ers were asked why they first had tried cigarettes and why they had most recently smoked. Sixty percent re- ported that curiosity was the reason for their first try, 13 percent said that they wanted to fit in with a group> and 10 percent reported that they were pressured into it For most recent use, 27 percent reported that they smoked for pleasure, 20 percent out of dependence, 17 percent because they were curious, and 10 percent to fit in with the group. These findings are consistent with Chassin et al. (1984), who sugg W-_ that positive attitudes toward smoking, such as the' ~thatsmoking is fun or pleasur- able, are a better r of the transition to regular smoking than theyat~:fi~r~~experinlentation..~t~:fi~r~~experinlentation. In gen- eral, these investigators found that positive attitudes to- ward smoking may increase as a function of age. Botvin, Botvin, and Baker (1983) found'that independent of the smoking status of friends, students in the eighth grade (13-,and 14-year-olds) were more likely to have a posi- tive social image of smoking than students in the seventh grade (11- and 12-year-olds). Subjective Expected Utility , Bauman et al. (1984) have examined the SEU of smoking for adolescents in a longitudinal study in North Carolina. SEU is defined as the extent to which an individual expects the overall consequences of a behav- ior, such as smoking, to be positive or negative. Fishbein (1980) found that behavioral intentions to smoke were related to whether more positive or negative conse- quences were expected from smoking. SEU was found to be predictive of the onset of smoking over a one-year interval and of increased smoking levels among baseline smokers (Bauman et al. 1984). In a second studv, SEU was found to be mediated by the adolescent's perception of personal control; current smokers with the highest scores for internal locus of control (that is, the belief that they have control over what occurs to them) were more likely to have been influenced by SEU (Bauman and Fisher 1985). Therefore, regular smoking appears more likely to be motivated by internal processes than are initiation and trying, which may primarily be products of exposure to a high-risk social environment. Self-Esteem The process of individuation and identity foitha- tion is inherent to adolescence. The adolescent's sense of self evolves as she or he interacts with parents, school, and peers and considers options for the future. Self- esteem, or an individual's qualitative self-evaluation, emerges from these contexts (Young and Werch 1990). In several studies, the onset of smoking has been associ- ated with lower self-esteem. Young and Werch (1990) found that young nonsmokers and those with no inten- tion of smoking in the future had higher self-esteem relative to family, school, and peers than frequent users or those who intended to use in the future. Ahlgren et al. (1982) found that low self-esteem within family or school contexts was associated with initiation and continuance of smoking. Self-esteem concerning school predicted intentions to smoke among young, inner-city black ado- lescents (Botvin et al. 1992) but did not predict actual smoking. Stacy et al. (1992) found that general low self- esteem directly predicted smoking onset in a multiracial, southern California sample yet did not significantly mediate friends' social influences. In their review of prospective research, Conrad, Flay, and Hill (1992) conclude, "Self-esteem received fairly consistent support [as a predictor of initiation] from the reviewed longitudi- nal studies. This is better than we would have ex- pected from our reading of previous cross-sectional studies" (p. 20). Self-Image Some adolescents may smoke cigarettes to enhance their low self-esteem byy improving their. external im- age-that is, by appearing mature or. "cool." Smoking onset was seen as a way to improve self-image among 136 Psychosocial Risk Factors TIMN 0138988

tiur~rwt GL'urntl', RL'iaWt scenes, sports paraphernalia, etc.). Using market data from leading national advertisers and the index of ad- vertising listed by manufacturer, the analysis revealed that,a firm's "share of voice" was almost perfectly corre- lated with its market shares; that is, all tobacco compa- nies included in this study sample of print media were advertising their products in near-exact proportion to their market share. Becoming Pictures of Health Verbally explicit health claims, a prominent feature of early cigarette advertising, have been replaced by claims about filter effectiveness, mildness, and the mandatory warnings and disclosures. As scientific evi- dence of the health risks of smoking became increasingly known to the general public in the 1950s and 1960s, the pseudoscientific claims made by cigarette advertising in earlier decades (claims that using a given brand, for instance, would protect against "smoker's cough") were replaced by unadorned statements of filter effectiveness against tar and nicotine. These later health claims tacitly allowed that smoking was harmful, but they also strongly suggested that smoking a particular brand was signifi- cantly less harmful. Such health claims thus have the primary purpose of promoting sales for a separate prod- uct category: that of "low-tar, low-nicotine" cigarettes. Verbal health claims in advertising have otherwise been ,replaced by visual, connotative imagery-what can be called pictures of health. Ringold (1987) reported on the verbal content of 211 cigarette ads drawn primarily from Time magazine from 1926 to 1985, partially supplementing the sample, as needed, with ads drawn from the New Yorker, the Saturday Evening Post, and Life, in that order. Although inexplicably omitting any Philip Morris brands, this sample sought one ad each for six brands: Camel, Ches- terfield, Kent, Lucky Strike, Old Gold, and Viceroy. De- tailed coding was done on the verbal content in headlines, subheads, and body copy. Even though all "mildness" assertions were treated as taste claims only, health claims were the most frequipndy made type of claim for the period before 1954. Pbt the overall 1926-1985 study period, health claims were the third most frequent type of claim, representing 18 percent of all claims. This finding was true for five out of the six brands studied, and there was "little to distinguish the various brands in terms of the health claims frequently used" (Ringold 1987). A study of the words and images of a11567 ads from 108 issues of Li fe (1938-1983) and Look (1962-1971) included the ads for 57 brands (Pollay 1991); 14 major brands accounted for 75 percent of the total sample. Multiple judges coded these ads for 12 major and independent thematic dimensions. Three of these di- mensions were postulated to communicate healthiness: (1) "health/safety" made verbal claims about positive physical effects, medical use or endorsements, or re- duced symptoms and risks, including filter-effectiveness claims (unless the text linked effectiveness to product taste); (2) "bold/lively behavior" provided images of active, athletic, or risk-taking behavior; and (3) "pure scenes" provided images of nature associated with whole- someness, cleanliness, and purity, such as glaciers, moun- tain streams, or new-fallen snow. Other themes measured included "well made" (product quality), "good deal" (value for money), "enjoy" (pleasure and satisfaction), "female, male, glamour/luxury" (celebrities, status, wealth), "relax" (peace of mind), and "official" (tested or endorsed by authorities). Judges found one or more of the healthiness themes in 60 percent of the studied ads, images of bold and lively behavior in 20 percent, and pure scenes in 30 percent. Some stereotypical differentiation of men and women was evident: ads featuring men were significantly more likely to use images of bold and lively behavior, whereas the ads featuring women were significantly more likely to use images of glamour and luxury. Warner (1985b) studied 716 cigarette ads from Time for selected years from 1929 through 1984. Various visual, verbal, and thematic elements of the ads were coded: the presence or absence of smoke, the manner in which cigarettes were held, the nature of models employed, the degree of prominence given to health messages, and the types of themes not focused on health, such as humor, rugged individualism, and romance. Data were not reported for individualism, emancipation, or other themes of independence. Data were grouped according to their proximity to periods of intense publicconsideration of the health consequences of smoking-such as the health concerns raised in the early 1950s (particularly since increased promotion and supply of cigarettes during World War II had contributed to a larger population of young adult smokers [Blake 19851), the first (1964) Sur- geon General's report on smoking and health, and the Fairness Doctrine that required broadcast cigarette ads to carry health-risk messages during the period 1%7-1970. Resultsshowevidenceofthedramatiegrowth in magazine advertising over the 56-year study period: the average number of cigarette ads per issue rose steadily from less than one per issue for the 1929-1952 period to over eight per issue for 1974-1981(after the ban on radio and television had gone into effect). During the last two decades studied, the images in these ads had the notable characteristic of showing virtually no smoke. Although visible smoke appeared in half of the ads before 1964, after 1964 only 5 percent of lit cigarettes appeared to emit 180 Advertising and Promotion TIMN 0139032

Suryeorr General's Report sports they sponsor. Ledwith (1984), for example, found that the likelihood of linking a sport with a brand of cigarette was directly related to the time spent watching that sport. The study also found that brand awareness increased substantially following the televised broadcast of a major sporting event sponsored by that brand. Thus, Marlboro and Winston have become associated with auto and sports car racing, and Virginia Slims has be- come associated with tennis; both brands also have be- come associated with the self-image messages these sports convey. Cigarette smoking may thus appear to receive an implied endorsement from race car drivers, whose expertise is associated with their ability to thoughtfully assess risks, and from tennis players, whose success partly depends on their physical endurance-a trait medically proven to be undermined by cigarette smoking. Tobacco company sponsorship has not been lim- ited to cigarettes. Connolly, Orleans, and Blum (1992) reported that in 1991, Skoal and Copenhagen, the two smokeless tobacco brands preferred by adolescents, were promoted on national television through their sponsor- ship of professional rodeo, hunting, formula car racing, "monster" truck racing, drag racing, sprint car racing, and stock car racing. The investigators conduded that "the harmful effects of tobacco are camouflaged against the backdrop and thrill of athletic victory" (p. 353). Sponsored athletic and entertainment events also provide a venue for product sampling. In areas in which cigarette sampling is legal, free cigarettes and other spe- cialty items can be distributed at these events. Sampling and Specialty Items Distribution of free samples is one of the most powerful devices available to marketers. It allows a company to put its product into the hands of possible consumers in circumstances where consumers are more likely to try it (e.g., outside of work or school). In the case of cigarettes, the power of sampling may be especially great (Popper 1986), because these are free samples of an addictive product. ', Although the cigarette manufactur- ers argue that samphn are not intended for nonusers or minors, there is littt"e evidence of distribution control (U.S. Congresa 198-E`i~ I3a.vis and Jason 1988). The power of sampling in the cigarette market- place is reflected by industry growth. Expenses for dis- tributing samples increased from just under $25 million in 1975 to over $100 million in 1990 (FTC 1992). The tobacco industry agrees, however, that samples should not be given to anyone under age 21 or on school, college, or university campuses (Tobacco Institute 1986). Even more notable is the growth (from $10 million in 1975 to over $300 million in 1990) in the distribution of specialty or premium items (FTC 1992). These items are not sim- ply ielated to tobacco products by bearing a brand name. Cigarette lighters, for example, are frequently provided with a sample cigarette. The lighter both facilitates trial of the cigarette sample and provides a brand-name re- minder once the sample has been consumed. Premium items also convey an advertising mes- sage without an appropriate associated warning. Figure 2 displays two pages of a 1993 Camel Cash Catalog. Pre- mium and specialty items from this catalog can be ob- tained by sending in the listed number of "C-notes," which can be collected from packs of Camel cigarettes. Although a promotional package will often include a health warning along with a specialty item (such as a T- shirt or thong sandal), the warning does not appear on the item (Slade 1992). Since many specialty items include the imaginative content of the cigarette brand's advertis- ing campaign, they provide ongoing advertising without any required health warnings. In a recent George H. Gallup International Institute survey of 1,125 adolescents nationwide, about half of the adolescent smokers re- ported that they had received promotional items from tobacco companies, as had one in four nonsmoking ado- lescents (Gallup 1992). Other Promotional Expenditures In 1990, three out of every four advertising and promotional dollars spent by the cigarette industry were devoted to promotional allowances, amounting to a total of over $3 billion. Though this amount indudes coopera- tive advertising and payments to wholesalers, its pri mary function is to pay retailers to continue to display and vend cigarettes from prominent locations in their store. The over $300 million spent by the tobacco indus- try on point-of-sale advertising in 1990 (only 10 percent less than the $328 million spent on cigarette advertising in magazines that year) is intended to bring the images of cigarette enjoyment to consumers at the store. For a brand-loyal smoker, the reminder value of a point-of- sale display is low. Therefore, to the-extent that these displays focus on brand image, they may not only en- courage experienced smokers to switch brands but also encourage new smokers to experiment with a particular brand (and with its associated brand image). The $1.3 billion spent on promotional allowances and point-of- sale displays combined are thus funds potentially di rected at new, youthful smokers. Retail value-added promotion consists of those ac- tivities (coupons, special price offers, 25-cigarette packs, etc.) that effectively reduce the cost of cigarettes. The industry argues that this promotion is clearly interbrand 186 Advertising and Promotion TjMN 0139038

Surgeon General's Report asked to use five-point scales to rate how much they would like to embody the following 19 characteristics: athletic, good-looking, kind, slim, macho, smart, sexy, average, fun, special, independent, cool, afraid, over- weight, underweight, tough, important, mature, and im- mature. They were then shown slides of 13 current cigarette ads representing nine brands taken from nine magazines obtained at a local supermarket newsstand. The students were asked to indicate how much they liked each ad and how likely they would be to buy the brand of cigarettes advertised. For each ad with either cartoon or human models, students were asked to rate the models on the same 19 characteristics used to de- scribe their ideal self-image. Students preferred advertisements with cartoons; ads with human models were the next most popular, and tombstone ads were liked least. Specifically, both black and white students ranked the two advertisements fea- turing Camel cigarettes' cartoon camel mascot Old Joe first and second; this preference was more marked among white students. Advertisements with black models were more appealing to black students than to whites, and ads featuring the Marlboro cowboy (who is white) were more appealing to white students than to blacks. Among students who smoked, the buying preferences for all brands closely paralleled the reported ad appeal. A factor analysis based on the 19 rated attributes identified five groupings of the advertisements. Female models were seen as predominantly "slim" and "good- looking." Joe Camel was "cool" and "fun," as were the two black models in a Salem ad. The Marlboro man was perceived as "tough" and "macho." On the other hand, a Montclair model was ascribed no positive attributes, but was predominantly rated as "not sexy" and "not good-looking." All of the positive attributes reported for the cigarette ad images also were described as positive attributes for the students' ideal self-images. Uutela et aL (unpublished data) compared how chil- dren in Los Angeles and Helsinki perceived advertisements for cigarettes, beer, liquor, and cars. AI though Finland does rn*pernnit advertising for either to- bacco or liquor, theautliassnotedthatCamelbootads were allowed in the country, aa were ads for the Philip Morris Company depicting the Marlboro cowboy. A total of 592 Los Angeles students and 660 Helsinki students between the ages of 8 and 17 years were asked the open-ended question, "What kinds of pictures come to your mind when you think of how a cigarette/beer/lfquor/car ad might look?" Their responses were coded into 11 categories.. In Los Angeles, the dominant ad images reported for cigarettes, beer, and liquor all were images of "happy/ fun/partying," whereas the ad images for cars were more likely to be in the "outdoors/sports" category. In Helsinki, however, the dominant ad images reported for cigarettes and for beer were "tough/macho;" for liquor, "rich/status/success," and for cars, "glamorous/ sexy/ attractive." The authors concluded that young people in Helsinki perceived cigarette advertising as portraying themes that represent the "traditional man's role," whereas the perceived themes in Los Angeles were less gender specific. Finland is one of the few western coun- tries where smoking continues to be significantly higher among boys than among girls. Humor in Advertising Nelson and While (1992) provided evidence for the role of humor in advertisements that appealed to youth in a study of 7,047 students aged 11 through 16 years old from 10 schools in the north, south, and midlands of England. Students first were asked two open-ended questions: "What is your favorite advertisement?" and "Why do you like it?" Ninety-one percent of the stu- dents reported a favorite ad; 53 percent of these students reported that humor was their main reason for liking their favorite advertisements. Boys (especially those¢13 through 16 years old) were significantly more likely than girls to choose an ad because of its humor. Girls (espe- cially those 15 and 16 years old) were more likely than boys to say they liked the personality appearing in their favorite ad. Children who chose ads for alcohol and tobacco products as their favorites were more likely than other respondents to cite humor as their reason for pre- ferring these ads. Several research studies have demon- strated that adults, as well as children, prefer advertisements with humor (Gelb and Pickett 1983). Nonetheless, cartoons with talking animals are generally considered to appeal more to children than to adults; Joe Camel and Willy Penguin (the cartoon mascot for Kool) would be highly atypical examples of advertising humor if the ads that feature them were meant only for an adult audience. Responses to Advertisements for the Camel and Marlboro Brands A few recent studies (DiFranza et a1.1991; Pierce et al. 1991; McCan 1992) have compared the responses of children and adults to Camel cigarettes' Old Joe cam- paign. The subjects in the DiFranza et al. (1991) study were 1,055 high school students in grades 9 through 12 from five regions of the United States and 345 subjects 21 years of age and older from Massachusetts. The adult subjects were. recruited from drivers renewing their licenses at the department of motor vehides office. Seven different advertisements from Camel's Old Joe campaign were used as stimuli. In the first ad, dues to the product 190 Advertising and Promotion TIMN 0139042

Preventing Tobacco Use Among Young People UNITED STATES TOBACCO JOURNAL. American Tobacco uses a new theme for Lucky Strike. United States Tobacco Journal 1963b;182(7):14. UNITED STATES TOBACCO JOURNAL. A justified faith [editorial]. United States Tobacco Journal 1963c;179(22):4. UUTELA A, VARTIAINEN E, BURTON D, JOHNSON CA. Perceived exposure to advertisements for cigarettes, beer, li- quor and cars among youth in Helsinki and Los Angeles. Unpublished data. WALDMAN P. Tobacco firms try soft, feminine sell. Wall Street Journal 1989 December 19; Sect B1. WARD S. Testimony in Tobacco Issues (Part 2). Hearings before Committee on Energy and Commerce, House of Repre- sentatives, 1989, Serial No. 101-126:302-308. WARNER KE. Cigarette advertising and media coverage of smoking and health. New England Journal of Medicine 1985a;312(6):384-8. WARNER KE. Tobacco industry response to public health concern: a content analysis of cigarette ads. Health Education Quarterly 1985b;12(2):115-27. WARNER KE, GOLDENHAR LM. Targeting of cigarette advertising in US magazines, 1959-1986. Tobacco Control 1992;1(1):25-30. WARNER KE, GOLDENHAR LM, MCLAUGHLIN CG. ' Cigarette advertising and magazine coverage of the hazards of smoking: a statistical analysis. New England Journal of Medicine 1992;32b(5):305-9. WEINBERGER MC, CAMPBELL L, DUGRENIER :=D. Ciga- rette advertising: tactical changes in the pre- and post- broadcast era. In: Hunt HK, editor. Advertising in a new aSe. Proceedings of the Annual Conference of the American Academy of Advertising, 1981. Provo (UT): American Academy of Adver- tising, 1981. WEINSTEIN H. How an agency builds a brand-the Virginia Slims story. Papers from the 1969 A.A.A.A. region conventions. 1969 October 28-29; New York. New York: American Associa- tion of Advertising Agencies, 1970. WEISSMAN G. Marlboro-from research to success. In: Brenner H, editor. Marketing research pays of f. Pleasantville (NY): Printers' Ink Books, 1955. WELD LDH. Advertising and tobacco. Printers' Ink 1937;181(1):70-6. WELLS W, BURNETT J, MORIARTY S. Advertising: principles and practice. Englewood Cliffs (NJ): Prentice Hall, 1989. WOOD JP. The story of advertising. New York: Ronald Press, 1958. WOOTTEN HM. Cigarettes' high ceiling. Printers' Ink 1941;42(2):5-8. Advertising and Promotion 203 TIMN 0139055

/'ren•,rtnr,~ Toh,<<0 U,c .-1„m,,g lo,r,tg I'OTlC independence, adventurousness and aggressiveness" (Schwartz 1976, p. 75). The sponsorship of racing car events bv Marlboro (see Figure 1) mav seem inconsistent with the cowboy character, but it is not. The company's Vice President of Marketing Senices, Ellen Merlo, explained: 'We perceive Formula One and Indy car racing as adding, if VOui will, a modern-day dimension to the Marlboro Man. The image of Marlboro is very rugged, individualistic, heroic. And so is this style of auto racing. From an image standpoint, the fit is good" (Business of Racing 1989, p. 5A). Historical Content Analyses of Cigarette Advertising Introduction The social sciences afford a variety of approaches for describing and analyzing the content of communica- tions of all kinds, whether in the form of speeches, con- versations, newspaper articles, signs, or advertisements. Specific communications, such as a single ad or the co- herent set of ads that constitutes a campaign, can be examined in detail. Tvpically, in-depth approaches, such as semiotics, are discursive descriptions that deconstruct the message and its meaning through detailed consider- ation of the elements of the ad (e.g., words, symbols, images), their structure (e.g., layout and prominence of visuals, rhetorical devices, and emphasis), and the cul- tural context in which these appear (e.g., the meanings traditionally attached to the ad elements, alone or in combination). These methods describe in sophisticated, analytical terms the probable meaning of the message to the average audience member. The term "content analvsis" is also used to describe a formal set of sampling and coding techniques, whose intent is to produce objective numerical data descriptive of a set of communications, such as a collection of ads. These systematic methods code and count both the overt and latent content of ads by observing the verbal and visual elements within a set of predetermined defini- tions. The definitions can be coded for events at various levels of observation, from broad themes to specific mi- nutiae. These definitions are employed by trained cod- ers, who apply them to a systematically drawn sample of ads. The reliability of this coding task is usually measured and reported and depends upon how clear are the communications under study, how complex the defi- nitions of interest, how difficult the coding task, how attentive the coders, and other factors. The sample can be either cross-sectional (representing many brands' advertising), longitudinal (tracing evolution of advertis- ing over time), or both. Like other sampling, the repre- sentativeness of the sample studied and the resulting potential to generalize from the results are a function of the sampling strategy (e.g., drawn from certain sources, seasonally or randomly determined, a complete census). The simultaneous pursuit of objectivity in content- analysis coding and meaningful observation often in- volves methodological judgment to weigh the various trade-offs and compromises. Some analysts (e.g., Ringold and Calfee 1989) deliberately limit their efforts primarily to the verbal content of the ads, analyzing the words in painstaking detail. The limitations of this careful but restricted focus and the inferences that can be appropri- ately drawn from it have been the subject of a sustained debate (Cohen 1989, 1992; Pollay 1989a; Ringold and Calfee 1990). The next sections of this chapter discuss the more formal content analyses of historical samples of cigarette ads and focus on the more fundamental results, general tendencies, and broader conclusions. Within the limits of the noted sampling for each study, these analyses de- scribe the universe of cigarette advertising for multiple brands, or of cigarette advertising in general, rather than for specific brands and their campaigns. In some studies, the content-analysis data descriptive of cigarette adver- tising are related to other information, such as product features, market shares, audience characteristics, or his- torical events. Increase in Visual and Vivid Advertising The first published report analyzing the content of cigarette advertising (Weinberger, Campbell, DuGrenier 1981) studied 251 cigarette ads found in the issues of Newsweek, Sports Illustrated, and the La- dies Home Journal during the years 1957, 1967, and 1977. The report noted an eightfold increase in the volume of cigarette magazine ads between 1957 and 1977, as the industry left broadcast media. The inves- tigators found significant increases, as well, in the proportion of ads in color, at premium locations (e.g., on the back or inside covers of magazines), and with multiple pages. Both explicit and implied health claims were also found to have increased signifi- cantly; almost all ads for lower-tar products adver- tised in 1977 were "tombstone" ads (i.e., consisting of text and package display only-no models, nature Advertising and PromotionY 179 TIMN 0139031

limited ability to conceptualize their future) was the most important psychogenic predictor of initiation. Adolescent Smoking Behavior as a Risk Factor for Subsequent Smoking Intentions to Smoke Since intentions are viewed as proximal to perfor- mance, the research on smoking behavior as a predictive factor of smoking includes behavioral intentions to smoke. In several studies, intentions to smoke have been associ- ated with both the onset and continuation of smoking. Sussman et al. (1987) found in their longitudinal study in southern California that the intention to start smoking was one of only three factors that predicted onset among all ethnic groups. McNeill et al. (1988) found that future intentions to smoke increased the odds of starting to smoke by a factor of 2.44 and was the strongest predictor of change in smoking status after current behavior (hav- ing tried smoking) and gender were entered into the analysis. In the Chassin et al. (1984). longitudinal study, behavioral intentions were "significant predictors of fu- ture smoking transition in all subgroups, accounting for between 1.9 percent and 10.2 percent of the variance in transition.... In fact, behavioral intentions were typi- cally the most important single predictor of future tran- sition" (p. 237). Intentions to smoke appear to be a particularly strong predictor of future smoking for those who have already tried smoking. Shean (1991) found that inten- tions to smoke a "next cigarette" among 14-year-old Western Australians predicted smoking eight years later. Conrad, Flay, and Hill (1992) found that in eight of nine prospective studies of young adolescents, the intention to smoke was significantly associated with onset. Be- cause of the strength of this association, several research- ers have used intentions to smoke as an outcome measure in their studies, especially in populations (such as pre- adolescents) where scnoking prevalence is low relative to adolescents' intentions to smoke. Intentions to begin smoking seem a much more reliable predictor of future behavior than do°R inten.tions to quit smoking (see "Adult Implications of Adolescent Smoking" in Chapter 3). Present Smoking Status Any cigarette use places an adolescent at higher risk for subsequent use and for further progression through the stages of smoking behavior. Conrad, Flay, and Hill (1992) document seven prospective studies in which prior experience with, or exposure to, smoking predicted tobacco use. McNeill et al. (1988) found that 138 Psychosocial Risk Factors the act of having tried smoking was the most predictive factor in initiation and that it more than quadrupled their study participants' odds of taking up smoking. Collins et al. (1987) found that prior smoking behavior was the most important predictor of future smoking over a 2.i- year interval. Even though the physiological effects of the first tries are mostly adverse (unpleasant taste, cough- ing, headache, nausea, dizziness) (Hahn et a1.1990), those who persist report increasingly positive reactions (pleas- ant taste, euphoria, alertness, relaxation, curbing of ap- petite) and develop tolerance (experience fewer unpleasant sensations) (Flay 1993). Stein, Newcomb, and Bentler (unpublished data) reported a more estab- lished pattern of cigarette use among young adults than among adolescents. In their study, the standardized regression coefficient of prior smoking for smoking be- havior between Year 1 and Year 5 (youth in junior high and high school age groups) was 0.43, yet from Year 9 to Year 13 (young adulthood) it was 0.82. The authors suggest that in early adolescence, some cigarette triers never fully develop a pattern of smoking, but by late adolescence, the addictive properties of cigarette . use figure prominently in behavior formation. These find- ings underscore the need for antismoking efforts to focus on preventing initial tries, on discouraging transitions to more regular smoking, and on encouraging early cessa- tion (Leventhal, Fleming, Glynn 1988; Kelder 1992). Summary of Psychosocial Risk Factors for Cigarette Smoking Some clear convergence of research findings emerges from this review, a summary of which is high- lighted in Table 1. Table 3 provides a second summary of supportive and unsupportive findings from the Conrad, Flay, and HiIl (1992) review of 27 prospective studies; for the most part, this summary table is consis- tent with Table 1. Among the sociodemographic factors, age is the risk factor consistently linked with onset in early adolescence; ages 11 through 15 (seventh through ninth grades) are the peak age group for first trial and experimentation. Cigarette smoking clearly has social meanings that are attractive to many young and vulner- able identity-seeking adolescents. This age factor is even more pronounced when linked with SES, another im- portant sociodemographic risk factor for smoking onset. Alternative health-enhancing avenues for independence and identity may be less readily available to adolescents from lower SES families, especially those adolescents who live in a single-parent home. Limited by fewer opportunities for healthy development and parental su- pervision, lower-SES youth are generally at greater risk to begin smoking. The gender difference, another major factor, is no longer evident, although the meanings of TIMN 0138990

l'ri:•iNtut,%~ Tohrrcci, Ust.Ai»i'n,~ 1`0tn1,1~ PCroplC smoking have undoubtedly had an influence in breaking down such prejudices.... Advertising undoubtedly has played a part in speeding up social acceptance of women's smoking" (Borden 1942, pp. 223, 227). One analyst who annually evaluated the cigarette industry noted that the industry is a "glowing testimo- nial to the power of advertising.... These particular com- panies have not only out-spent but also have out-earned any other[s] ....[TJhe tobacco tycoons ... are loudest in their praise for the part that advertising has played." (Wootten 1941, p. 5). Business Week (1953a) commented that "cigarettes offer the classic case ... of how a mass- production industry is built on advertising" (p. 66). Advertising Professionals Printers' Ink, the leading advertising trade journal of its day, noted in 1930 that sales success already dem- onstrated "the one feature which has contributed more than any other single factor to the enormous growth of the cigarette industry-advertising" (Tennant 1971, p. 137). This opinion was upheld by the sales performance of cigarettes during the Great Depression: "The growth of cigarette consumption has, itself, been due largely to heavy advertising expenditure.... It would be hard to find an industry that better illustrates the economic value of advertising in increasing consumption of a commod- ity.... There can be no doubt but that steady advertising pressure has been a dominating force in increasing ciga- rette consumption among both men and women" (Weld 1937, pp. 70-2). John Orr Young's agency, Young & Rubicam, who had previously done work for the tobacco industry, ob- served in 1964 that cigarette makers had continued to use "attractive boys and girls" to serve as "decoys in cigarette advertisements. Advertising agencies are retained by cigarette manufacturers to create demand for cigarettes among both adults and eager youngsters. The earlier the teenage boy or girl gets the habit, the bigger the national sales volume" (AA 1964c, p. 3). Another leading adver- tising executive, the President of McManus, Johns & Adams, stated, "There is no doubt that all forms of advertising playe&a part in popularizing the cigarette" (AA 1964e, p. 107): One of the agency executives who had worked on the Marlboro account with Leo Burnett later wrote: "I don't think cigarettes ought to be advertised....(W]hen all the garbage is stripped away, successful cigarette advertising involves showing the kind of people most people would like to be, doing the things most people would like to do, and smoking up a storm. I don't know any way of doing this that doesn't tempt young people to smoke, and, in view of my present knowledge, this is something I prefer not to do" (Daniels 1974, p. 245). More recently, the late Emerson Foote, a founder of Foote, Cone and Belding and more recently a member of McCann-Erikson, ridiculed the industry claims that its advertising only affects brand switching and has no ef- fect whatsoever on recruitment: "I don't think anyone really believes this.... I suspect that creating a positive climate of social acceptability for smoking, which en- courages new smokers to join the market, is of greater importance to the industry.... In recent years, the ciga- rette industry has been artfully maintaining that ciga- rette advertising has nothing to do with total sales. Take my word for it, this is complete and utter nonsense" (Foote 1981, pp. 1667-8). Because of their conviction that cigarette advertis- ing played-a role in recruiting the young, many advertis- ing professionals refused to work with the cigarette companies. Just before the first Surgeon General's report was published in 1964, Advertising Age (1963i) stated emphatically, "It seems safe enough to say that no adver- tiser, no agency man, and no media man would want to continue advertising cigaret[te]s if it were clear that they pose a serious and positive danger to the health of the ordinary smoker....[L]et's not have any more sidestep- ping" (p. 22). When the Surgeon General's report was issued, several advertising industry leaders publicly avowed that their ad agencies would cease or refuse cigarette advertising accounts on moral grounds-a po- sition that clearly acknowledged advertising's role in building and sustaining demand. Those who refused included several who were highly visible and promi- nent-Bill Bernbach of Doyle, Dane, Bernbach (AA 1964b); David Ogilvy of Ogilvy and Mather (AA 1964d); Nelson Foote of Foote, Cone and Belding (O'Gara 1964); and John Orr Young of Young & Rubicam (AA 1964a). The United States Tobacco Journal The United States Tobacco Journal's frequent and unabashed comments on the power of advertising be- came something of an editorial litany during the 1950s and early 1960s. In 1953 the journal observed that "ad- vertising, in the hands of manufacturers of tobacco prod- ucts, has become a powerful tool for the construction of the massive edifice of this industry" (USTJ 1953, p. 4). After the industry rebounded from the reports during the early 1950s of a tobacco-cancer link, the journal stated, "There is no obstacle to large-scale sales of tobacco prod- ucts that cannot be surmounted by aggressive selling" (USTJ 1955a, p. 4) and elsewhere noted "the pivotal importance of advertising" (USTJ 1955b, p. 4). A year later, the journal could claim that "the effectiveness of current advertising by tobacco products manufacturers has been demonstrated repeatedly by the upward trend in sales volume that results there from" ( USTj 1956, p. 4). Advertising and Promotion 173 TIMN 0139025

Preventing Tobacco Use Among Young People that has been incorporated into many of the prevention programs developed later. The intervention consisted of three sessions delivered on consecutive days, followed by four booster sessions delivered over the remainder of the seventh-grade school year. Nine months after pre- test, 5.6 percent of the treatment group and 9.9 percent of the control group reported smoking during the previous week-a statistically significant 56 percent difference be- tween the groups. These reductions in smoking preva- lence were observed up to the 10th grade. Life Skills Training Botvin (1986) has developed another variation of the social influences approach that includes resistance skills, behavioral rehearsal, role playing, self-control, de- cision making, problem solving, and self-reward, as well as components devoted to increasing self-esteem, self- confidence, autonomy, and assertiveness. The program, called Life Skills Training, includes various aspects of cognitive-behavioral psychological training. The pro- gram consists of 15 to 20 sessions for seventh-grade students; booster sessions are given in the eighth and ninth grades. The specific objectives of the program are to teach skills that help students resist direct pressures to smoke; to enhance students' self-esteem, self-mastery, Table 5. and self-confidence in order to decrease their susceptibil- ity to indirect social pressures to smoke; to prepare stu- dents to cope with anxiety induced by social situations; to enhance students' knowledge of the actual prevalence of smoking among adolescents and adults; and to pro- mote attitudes and beliefs consistent with nonsmoking. This pxogram has been evaluated extensively in progressively larger studies over the past decade; the encouraging results have ranged from 40 to 80 percent reductions in smoking prevalence, and long-term effects have lasted up to fouryears (Botvinand Dusenbury 1989). In the most comprehensive evaluation of the Life Skills Training program to date, 56 schools in three different geographic regions were randomly assigned to three study conditions: Life Skills plus one-day teacher train- ing, Life Skills plus video training for teachers, and a control condition. Significant positive effects were re- ported for cigarette use (see Table 5) and for smoking- related knowledge, attitudes, and normative expectations. In most cases, the two treatment conditions had similar results; students in both groups demonstrated more posi- tive effects than students in the control group (Botvin et al. 1990). The effects of the Life Skills Training program have been demonstrated when the program has been delivered by project staff, older peers, or regular classroom teachers. These effects have also been demonstrated on inner-city Outcomes of the Life Skills Training (LST) program: adjusted third-year follow-up mean for smoking-related knowledge, expectations, personality measures, and behavior Adjusted mean scores* Smoking variable LST (with teacher training) LST (with video training) Control Knowledge Smoking prevalence 1.10° 1.16' .93. Smoking coniequences 4.80° 4.60° 4.13 Smoking acceptability 1.495 1.52° 1.37 Normative expectations Adult smoking 3.92' 3.95'' 4.22 Peer smoking 3.80t 3.77 3.92 Personality measures Self-esteem 34.25t 34.07 33.65 Self-efficacy 19.27 19.20 19.26 Social anxiety 28.71t 29.36 29.92 Smoking behavior 1.46§ 1.50# 1.63 Source: Botvin et al. (1990). *Means for LST groups differ from control group at *p < .05,=p < .01, ip < .001, and °p < .0001. Prevention 221 T11V.IN 0139071

tiLiY;R'Ufl (_,l'IA'/'dl• Rqvrt In 1959, the journal anticipated the launch of multiple new brands and the associated intense advertising drives to "increase sharply the trend toward greater volume in the ~,'hole tobacco industry" (USTI 1959, p. 3). "The purpose of advertising ... has a simple answer: to sell goods," the journal declared in 1960 (USTI 1960a, p. 4), later pointing out that "steady increases in sales of cigarettes offer the classic example of what advertising can do ... advertising pays off" (USTI 1960b, p. 4). By 1963, the ever-increasing spending on cigarette adver- tising and promotion led the journal to declare: "The money invested by the tobacco industry in various forms of advertising and promotion essentially reflects the industry's faith in the effectiveness of advertising as a vital sales-building tool. This faith appears justified by the continued annual rise in sales of cigarettes in this country" (USTI 1963c, p. 4). These observations from the tobacco industry's chief trade journal testify to the industry's view of advertising as an increasingly neces- sary and proven means of selling cigarettes. From a perspective two decades after the 1964 Surgeon General's report, the official history of the R.J. Reynolds Com- pany comments that "the company's advertising ex- penditures and those of its major rivals were extraordinary, reflecting the apparent agreement on the necessity of large-scale advertising to fuel expansion" (Tilley 1985, p. 330). The view was shared throughout the industry, which embraced increasingly sophisti- cated advertising strategies in an almost concerted ef- fort. George Washington Hill, proud of his role in building the modern tobacco industry, said, "The impe- tus of those great advertising campaigns not only built this for ourselves, but built the cigarette business as well, because ... you help the whole industry if you do a good job" (Tennant 1971, p. 137). ' The "Maturity" of the Cigarette Market As a spokesperson for the cigarette industry has argued in a congressional hearing (Ward 1989), the in- dustrv considers itself>to_ be operating in a "mature" market-mature because the growth in this market has slowed over the pastttwadecades and because the prod- uct being marketed is well known to consumers. This theoretical concept of a mature market is drawn from the "product life cycle," an analogy to the stages of biological development from birth to death. The application of this theory to the cigarette industry hinges on the belief that markets develop in predictable stages and that these stages govern the intent of corporate behaviors, such as advertising and promotion. It has been asserted before congressional hearings, for example, that "in 'mature' markets such as the one for tobacco products, awareness of the product is universal. The function of advertising in a 'mature' market is to promote brand loyalty or brand switching" (Ward 1989, p. 304). The argument contin- ues that the tobacco industry has no strategic interest in youthful nonsmokers because "advertising cannot in- fluence a nonuser to begin using the product category" (Ward 1989, p. 306). Few studies have specifically examined how the product life cycle applies to the cigarette industry. One early study written in support of the concept defined three substages of market maturity. Of 33 cigarette brands examined, only 36 percent of them were classified into any of the three mature stages, in contrast with 56 per- cent of health care and personal care products and 60 percent of food products (Polli and Cook 1969). A few years later, two research directors from the J. Walter Thompson advertising agency reviewed this study and others and counseled readers of the Harvard Business Review: "Most writers present the [product life cycle] concept in qualitative terms, in the form of idealization without empirical backing. Also, they fail to draw a clear distinction between product class (e.g., cigarettes), prod- uct form (e.g., filter cigarettes), and brand (e.g., Winston). But, for our purposes, this does not matter. We shallsee that it is not possible to validate the model at any of these levels of aggregation" (Dhalla and Yuspeh 1976, p. 103), Advertising textbooks counsel that even when faced with so-called mature markets, advertising firms can and often should attempt both to increase usage among exist- ing customers and to address potential new users. For example, one leading textbook makes it clear that prod- uct maturity by no means rules out the capacity--or the need-to attract new users: Product class maturity is typified by a slowdown of growth and a fairly constant level of sales. This means that competition may become very intense because any brand can only increase its sales by taking them from a competitor or by developing new uses, users, or changing the product.... The brand's objectives during maturity are to defend its position, take share from the competition, promote new uses and users, and support the retailer.... In addition, the advertising should stress new uses, new users, and new usage occasions in an attempt to increase overall sales of the product class (Rothschild 1987, p. 105). It appears that no matter what the appropriate classification of the product, different classes of potential , consumers will still exist as market segments with differ- ent and particular ci "rcumstances. Marketing will thus have to address these individual segments-including ` that of young people for whom the product and brands are less well known, and for whom appeal must be created, since cigarettes are not a necessity of life. 174 Advertising and Promotion TIMN 0139026

P1't':'t'llflllg 70hItto U,t'A'NNII,~ }t11(/!y' Pt'Ofllt' For example, the most frequently cited categories ur ads that reached ,vounger women were individualism (29 percent), recreation (26 percent), and sociability (20 percent). The most frequently pictured activities in ads that reached younger men were individualism (21 per- cent), work (21 percent), recreation (20 percent), and adventure (1-1 percent). The authors noted that "portray- als of individualism were more likely to appear in ciga- rette ads placed in younger men's and younger women's magazines." Despite this and other noted differences between ads in various types of media, "this study found a striking universality of theme, regardless of audience orientation. Individualistic/solitary and recreational themes were most frequently portrayed in virtually all magazine types" (King et al. 1991, p. 77). Schooler and Basil ( 1990) studied all types of bill- board ads in San Francisco neighborhoods. Billboard advertising is held to be important because it allows neighborhood-level targeting and ethnic segmentation. Like point-of-sale store signage, billboard advertising has more permanence than magazine ads, allowing mul- tiple incidental exposures for all ages of persons who are on the neighborhood street regularly, going to work, stores, or schools. Of the 901 billboards photographed between May 1985 and September 1987 in 210 commer- cial districts, tobacco ads were the most frequent (19 percent), closely followed by alcohol (17 percent). Black and Hispanic neighborhoods had significantly more to- bacco and alcohol ads than white or Asian neighbor- hoods. Billboards of any type were 1.7 times more common in black neighborhoods (2.2 per 1,000 people) than in a citvw•ide sampling (1.3 per 1,000). Tobacco billboard ads were even more common in black neigh- borhoods, appearing at 2.4 times the citywide rate. The content of these ads was coded for several social cues: sex, ethnicity, apparent social "class" of the models, reward cues (e.g., romance, sociability, recre- ation, sportiness and active lifestyle, and adventure/ risk), and attractiveness cues (e.g., rugged individualism, machismo, fashionableness, sex appeal, fame/expertise, and friendliness)-. The most prevalent reward cue im- ages associated wft smoking were sportiness and active lifestyle, recreatiozr,and adventure/risk. The most preva- lent attractiveness cue on tobacco billboards was rugged individualism or machismo. The statistically significant results indicated how important social cues are to these tobacco products. The study suggests that people are more likely to be portrayed in cigarette and alcohol ads (59 percent) than in advertising generally (16 percent), and cigarette and alcohol ads were more likely than others to use models that matched the ethnicity of the neighborhoods. When advertising for smoking and for alcohol were compared, the study concluded that alcohol ads use modeling cues that suggest that prociut:t t:un5umption will enhance one's social life, whereas tobacco billboards emphasize rewards that are more individualistically ori- ented. "Rugged individualism," the study obsen•ed, "was the most prevalent attractiveness cue on tobacco billboards. The epitome of these ads is the Marlboro man" (Schooler and Basil 1990, p. 15). These research results are reported in brief elsewhere (Altman, Schooler, Basil 1991), and additional statistical analyses of the same database reach the same conclusions (Schooler, Basil, Altman 1991). Altman and colleagues' (1987) analvsis of 778 magazine ads (from the 1960s through 1985) also found that images of adventure and risk had become more prevalent across all magazine types. Youth magazines were even more likely than other types to depict images of adventure/risk and recreation. Other Related Research Perceptions of Models' Ages Mazis et al. (1992) studied the perceived age of the models used in cigarette ads appearing in 97 magazines in October 1987. In the 101 issues (some magazines were published more often than once a month) that contained cigarette ads, 393 cigarette ads for 22 brands were found, of which 119 were unique (i.e., did not appear in another of the 97 magazines that month). Narrowing the sample to ads with models whose faces were "clearly visible" (i.e., their faces were at least two-thirds exposed and were depicted close enough to discern approximate age) yielded 50 unique ads with 65 models. Two samples of 280 and 281 judges were recruited from a racially and economically diverse shopping mall, with quotas that guaranteed a cross-section of gender and age (13 years old and older). Each participant was asked tb estimate the age and assess the attractiveness of the models in a random sample of 25 ads. These data were compared to data on the median age of the audiences of the magazines used as sources. A positive and statistically significant correla- tion was found between perceived model age and median audience age. For example, young-looking mod- els tended to appear in media read by young audi- ences-a correlation advantageous to the advertisers, since young viewers proved more likely than older view- ers to perceive that attractiveness declined with advanc- ing perceived age. Fourteen (22 percent) of the 65 models were judged, on average, to be less than 25 years old, and eleven (17 percent) were attributed a mean per: eived age far enough below 25 years old to be statistically significant. Nine of these young-looking models were women, four of them in various Virginia Slims ads. "Some cigarette Advertising and Promotion 183 TIMN 0139035

PPi:'t'lltiil` Tt'hltLt' Ll>i .'j/NWIt ) t'itltN PCt'F'lc' pressure of being accepted by their peers" ( I'ollay 1989b, p. 24). R.J. Reynolds' Export A brand had a special appeal fot young Canadian teens and preteens, as the company recognized in its Export Family Strategy Docu- ment of 1982 (AG222): "Very young starter smokers choose Export A because it provides them with an in- stant badge of masculinity, appeals to their rebellious nature and establishes their position amongst their peers" (AG-222, p. 7299). Imperial Tobacco Limited's Project Stereo (1985) provided creative guidelines for the effective display of freedom and independence in advertising imagery de- signed to appeal to a young market. Its Final Report (AG-27) made recommendations for designing adver- tisements for the Player's brand that showed someone "free to choose friends, music, clothes, own activities, to be alone if he wishes"; who "can manage alone" and be "close to nature" with "nobody to interfere, no boss/parents"; someone self-reliant enough to experi- ence solitude without loneliness (AG-27, p. 60). Project Stereo also described how Player's and its closest rival for young males, Export A, both used im- ages, not words, to convey the critical concepts of inde- pendence, self-reliance, autonomy, and freedom from authority. Both brands used advertisements that fea- tured strong, masculine, hardy men who were typically alone in the fresh air of the outdoors. But as is shown in the chart below, the two competitors conveyed their respective images with relatively small yet important differences. Player's Smoker's Image Export A Smoker's Image Chooses to be alone. Is a loner. Conveys masculinity Conveys machismo but also gentleness. ruggedness. Can show feelings. Does not show feelings. Can include women. Excludes women. Has a good job, is a Is working-class. good worker. Is adventurous.. Is a daredevil. Is independent and Isn't concerned about strong willed. _ society. (AG-27, p. 18). The more subtle, less excluding Player's image proved far more successful than the uncompromising Export A image. Images of the American Ideal United States advertisers, too, have long thought that individualism and the stimulating notions of indepen- dence, self-reliance, and autonomy are important strategic concepts in ad development. The Marlboro con.'boy (alsu known as the Marlboro man) epitomizes this stereotype of American independence. Usually depicted alone, he interacts with no one; he is strikingly free of interference from authority figures such as parents, older brothers, bosses, and bullies. Indeed, the Marlboro man is bur- dened by no one whose authority he must respect or even consider (see Figure 1). One account (Meyers 1984) describes the success of Philip Morris's George Weissman and Jack Landry, who were instrumental in making Marlboro the best-selling cigarette brand in the United States. Marlboro had long been sold as a woman's cigarette, with lipstick-colored filters and a"Mild as May" slogan (see Figure 1). The first attempt to reposition the brand as "male" featured the breathy, sensual singing of Julie London and male models with tattooed hands. But when Weissman, then head of marketing for Philip Morris, assumed responsi- bility for the campaign in the late 1950s, his research informed him that postadolescents in search of an iden- tity were beginning to smoke as a way of declaring independence from their parents. Jack Landry, the ad- vertising executive for Philip Morris, coordinated with the Leo Burnett agency and came up with "commercials that would turn rookie smokers on to Marlboro. ...[that would convey] the right image to capture the youth market's fancy ...[and project] a perfect symbol of inde- pendence and individualistic rebellion"-in other words, the Marlboro cowboy (Meyers 1984, p. 70). The power of the associative psychological style of advertising was demonstrated by the Marlboro brand's capture of a sig- nificant market share of starters every year, until it soon became the best-selling brand. This success has proved long-lived. In 1993, Marlboro commanded 21 percent of the domestic market share-by far the largest share (Maxwell 1993). As Philip Morris's president and CEO, R. W. Murray observed, the Marlboro man still has a powerful attraction: "The cow- boy has appeal to people as a personality. There are elements of adventure, freedom, being in charge of your destiny" (Trachtenberg 1987, p. 109). Marlboro's success led to much imitation and com- petition in the industry. The FTC reported that one of the popular advertising strategies of the late 1960s was the use of associative themes, where an image portrayed "one or more personality characteristics which the ad- vertiser hopes will appeal to the audience of existing and potential cigarette smokers.... The classic example of this approach is the Marlboro cowboy-ruggedly mas- culine, self-sufficient. ... The theme of masculine inde- pendence has been used by several other advertisers" (FTC 1970, p. 8). Advertisements for Camel, Newport, and Old Gold were named as examples. Advertising and Promotion 177 TIMN 0139029

Preventing Tobacco Use Among Young People ADVERTISING AGE. Interpretation of cigaret[tel code gives 'Hillbillies' a pass. Advertising Age 1967b;38(8):1A. i, ADVERTISING AGE. RJ. Reynolds to drop'Hillbillies' under cigaret[tel code. Advertising Age 1967c;38(20):2. ADVERTISING AGE. Tobacco marketers disclaim intent to lure kids with candy cigaret[te]s. Advertising Age 1967d;38(11):3,97. AITKEN PP, EADIE DR. Reinforcing effects of cigarette ad- vertising on under-age smoking. British Journal of Addiction 1990;85(3):399-412. AITKEN PP, LEATHAR DS, O'HAGAN FJ. Childrein's per- ceptions of advertisements for cigarettes. Social Science and Medicine 1985;21(7):785-97. AITKEN PP, LEATHAR DS, O'HAGAN FJ, SQUAIR SI. Children's awareness of cigarette advertisements and brand imagery. British Journal of Addiction 1987;82(6):15-22. AITKEN PP, LEATHAR DS, SQUAIR SI. Children's aware- ness of cigarette brand sponsorship of sports and games in the UK. Health Education Research 1986;1(3):203-11. ALBRIGHT CL, ALTMAN DG, SLATER MD, MACCOBY N. Cigarette advertisements in magazines: evidence for a differ- ential focus on women's and youth magazines. Health Educa- tion Quarterly 1988;15(2):225-33. ALEXANDER HM, CALLCOTT R, DOBSON AJ, HARDES GR, LLOYD DM, O'CONNELL DL, ET AL. Cigarette smok- ing and drug use in schoolchildren: IV-Factors associated with changes in smoking behavior. International Journal of Epidemiology 1983;12(1):59-65. ALTMAN DG, SCHOOLER C, BASIL MD. Alcohol and ciga- rette advertising on billboards. Health Education Research 1991;6(4):487-90. ALTMAN DG, SLATER MD, ALBRIGHT CL, MACCOBY N. How an unhealthy product is sold: cigarette advertising in magazines, 1960-1985. Journal of Communication 1987;37(4): 95-106. . ANDERSON WK_ Will they force us to it? Christian Century 1929 December;46:1576-7. ARMSTRONG BK, DE KLERK NH, SHEAN RE, DUNN DA, DOLIN PJ. Influence of education and advertising on the uptake of smoking by children. The Medical Journal of Australia 1990;152(3):117-24. ' BAKER SS. The permissible lie: the inside truth about advertising. Cleveland: World Publishing, 1968. BAKER W, HOMEL P, FLAHERTY B, TREBILCO P. The 1986 survey of drug use by secondary school students in New South Wales. Sydney (Australia): New South Wales Drug and Alco- hol Authority, 1987. BARTON J, CHASSIN L, PRESSON CC, SHERMAN SJ. Social image factors as motivators of smoking initiation in early and middle adolescence. Child Development 1982; 53(6):1449-511. BASIL MD, SCHOOLER C, ALTMAN DG, SLATER M, ALBRIGHT CL, MACCOBY N. How cigarettes are advertised in magazines: special messages for special markets. Health Communication 1991;3(2):75-91. BAUER RA, GREYSER SA. Advertising in America: the con- sumer view. Boston: Harvard University Press, 1968. BERNAYS EL. Biography of an idea: memoirs of public relations counsel Edward L. Bernays. New York: Simon & Schuster, 1965. BLAKE GH. Smoking and the military. New York State Journal of Medicine 1985;85(7):354-6. BLUM A. Candy cigarettes. New England Journal of Medicine 1980;302(17):972. BLUM A. The Marlboro Grand Prix. Circumvention of the television ban on tobacco advertising. New England Journal of Medicine 1991;324(13):913-7. BORDEN N. The economic effects of advertising. Homewood (IL): Irwin, 1942. BOTVIN GJ, GOLDBERG CJ, BOTVIN EM, DUSENBURY L. Smoking behavior of adolescents exposed to cigarette adver- tising. Public Health Reports 1993;108(2):217-23. BOWEN DJ, DAHL K, MANN SL, PETERSON AV. Descrip- tions of early triers. Addictive Behaviors 1991;16(3-4):95-101. BRECHER R, BRECHER E, HERZOG A, GOODMAN W, WALKER G, EDITORS OF CONSUMER REPORTS. The con- sumers union report on smoking and the public interest. Mount Vernon (NY): Consumers Union, 1963. BUCHANAN DR, LEV J. Beer and fast cars: how brewers target blue-collar youth through motor sport sponsorships. Washington (DC): AAA Foundation for Traffic Safety, 1990. BURNETT L. The Marlboro story: how one of America's most popular filter cigarettes got that way. The New Yorker 1958;XXXIV(39):41 3. BURNETT L. Communications of an advertising man. Chicago: Burnett, 1961. Advertising and Promotion 197 TIMN 0139049

Surgeon General's Report Table 9. Published studies examining vending machine sales to minors, United States, 1989-1992 Relative Study and location Number of machines or attempts Baseline sales rate (%) Follow-up sales rate (%) reduction in purchases by minors (%) Time period Altman et al. 30 100 100 NS* 6 months (1989) California Jason et al. 3-6 100 50 -50 1 month (1991) Illinois 0 -100 12 months Feighery, 25 84 93 NS 6 months Altman, Shaffer (1991) California 83 NS 11 months Forster, Hourigan, McGovern 79 82 80 NS 3 months (1992) Minnesota Forster, 77 86 30 -65 3 months Hourigan, Kelder (1992) Minnesota 48 -44 12 months DiFranza et al. 6 86 NAt NA NA (1987) Massachusetts Thomson and Toffler (1990) Oregon 10 100 NA NA NA Hoppock and Houston (1990) Kansas 10 100 NA NA NA Centers for Disease Control (1990) Colorado 24 100 NA NA NA *NS = Not significant. tNA = Not available. 252 Prevention TIMN 0139102

Preventing Tobacco Use Among Young People POLLAY RW, LAVACK AM. The targeting of youths by cigarette marketers: archival evidence on trial. In: McAllister L, Rothschild M, editors. Advances in consumer research. Provo (UT): Association for Consumer Research, 1992. POLLAY RW, LEE JS, CARTER-WHITNEY D. Separate, but not equal: racial segmentation in cigarette advertising. Journal of Advertising 1992;XXI(i):45-57. POLLI R, COOK V. Validity of the product life cycle. The Journal of Business 1969;42(4):385-400. POPPER ET. Sampling and couponing promotional activity in the domestic cigarette market: a report to the Office on Smoking and Health. US Department of Health and Human Services, Office on Smoking and Health, Interagency Task Force on Smoking and Health, Washington, DC, June 4,1986. PRINTERS' INK. Cigarette ads back on old path. Printers' Ink 1960;273(12):37-8. PUTO CP, WELLS WD. Informational and transformational advertising: the differential effects of time. In: Kinnear TC, editor. Advances in consumer research. Vol. XI. 1983. RAY ML. Advertising and communication management. Englewood Cliffs (NJ): Prentice Hall, 1982. READER'S DIGEST.... And slow death. Reader's Digest 1963;82(490):49-53. RINGOLD DJ. A preliminary investigation of the information content of cigarette advertising: a longitudinal analysis. In: Wallendorf M, Anderson P, editors. Advances in consumer research. Vol. XIV. Provo (UT): Association for Consumer Research, 1987. RINGOLD DJ, CALFEE JE. The informational content of cigarette advertising: 1926-1986. Journal of Public Policy & Marketing 1989;8:1-23. RINGOLD DJ, CALFEE JE. What can we learn from the infor- mational content of cigarette advertising? A reply and further analysis. Journal of Public Policy & Marketing 19909:30-41. RJ REYNOLDS TOBACCO COMPANY. The Camel cash catalog. Volume three. Winston-Salem (NC): R.J. Reynolds Tobacco Company,199Z ROAD & TRACK. [Marlboro advertisement]. Road & Track 1990;43(3): back cover. ROAD & TRACK [Marlboro advertisement]. Road & Track 1992;43(8): back cover. ROBINSON RG, BARRY M, BLOCH M, GLANTZ S, JORDAN J, MURRAY KB, ET AL. Report on the tobacco policy research group on marketing and promotions targeted at African Americans, Latinos, and women. Tobacco Control 1992 September;(1 Suppl.):S24-S30. ROGERS M, GOPAL A. Up in smoke: fifty years of cigarette advertising in. America. In: Nevett T, Hollander S, editors. Marketing in three eras. Proceedings of the Third Conference on Historical Research in Marketing; 1987 Apri123-26; East Lansing. East Lansing (MI): Michigan State University, 1987. ROSSITER JR, PERCY L. Advertising and promotion manage- ment. New York: McGraw-Hil1,1987. ROTHSCHILD ML. Advertising: from fundamentals to strate- gies. Lexington (MA): Heath, 1987. SCHOOLER C, BASIL MD. Alcohol and cigarette advertising on billboards: targeting the social cues. Paper presented at the International Communication Association Conference, Dublin, Ireland, June 1990. SCHOOLER C, BASIL MD, ALTMAN DG. Billboard advertis- ing for alcohol and cigarettes: targeting with social cues. Stanford (CA): Communication Department, Stanford University, Work- ing Paper, June 1991. SCHUDSON M. Advertising, the uneasy persuasion. Its dubious impact on American society. New York: Basic Books, 1984. SCHWARTZ DA. What do ads connote for the average smoker? Advertising Age 1976;47(44):75. SHERMAN SJ, PRESSON CC, CHASSIN L, CORTY E, OLSHAVSKY R. The false consensus effect in estimates of smoking prevalence. Underlying mechanisms. Personality and Social Psychology Bulletin 1983;9(2):197-207. SLADE J. Camel flip flops. Tobacco Control 1992;1(3):207. SMITH GH. Motivation research in advertising and marketing. New York: McGraw-Hill, 1954. SUSSMAN S, DENT CW, MESTEL-RAUCH'J, JOHNSON CA, HANSEN WB, FLAY BR. Adolescent nonsmokers, triers and regular smokers' estimates of cigarette smoking preva- lence: when do overestimations occur and by whom? Journal of Applied Social Psychology 1988;18(7):537-51. TENNANT RB. The American cigarette industry. A study in economic analysis and public policy. Hamden (CT): Archon Books, 1971. Advertising and Promotion 201 TIMN 0139053

....'~':.~ :am"diFA 7 ~h titu'.tcont C;ote•ntl', /ic:'iw: the different media has its effects on young people" (Gilbert 1957, p. 183). Promotional efforts targeting college students were estimated by the President of the Student Marketing Institute to have doubled in the five years leading up to 1962. During those years, promotional tactics for the 20 brands active on college campuses included free samples distributed by student "representatives" paid by specific tobacco companies. Brown & Williamson, for example, employed 17 salesmen on college campuses (Neuberger 1964). Philip Morris paid 166 campus representatives $50 a month to distribute free cigarettes. Philip Morris also ran a college contest offering record players in ex- change for collected empty packages. In New York's Cortland State College, Alpha Delta Delta (a sorority for physical education teachers in training) won several prizes by collecting packages accounting for 1,520,000 ciga- rettes (Neuberger 1964). College students were awarded cars as prizes in contests run by the Liggett & Myers Tobacco Company (LISTJ 1963a). Cigarettes ads ac- counted for an estimated 40 percent of the national ad- vertising incomes of the 850 college newspapers in the National Advertising Service (Brecher et al. 1963). Sponsorship of Sports Sports sponsorships were another common means to promote specific brands. Professional sports teams were given financial support by tobacco companies. Liggett & Myers had long been associated with baseball, regularly sponsoring games and using athletes' testimo- nials (AA 1963s). In 1963, R.J. Reynolds sponsored eight different baseball teams, and the American Tobacco Com- pany sponsored six more. Football was also used to reach large audiences and to associate cigarettes with athleticism. Phillip Morris, which used athletes' en- dorsements of its Marlboro brand primarily to appeal to blacks (Pollay, Lee, Carter-Whitney 1992), sponsored National Football League games on CBS (AA 19631) and the league championship games on NBC (AA 1963s). Also in 1963, the American Tobacco Company used New York Giants star Frank Gifford in advertisements for Lucky Strikes (AA 1963g), Brown & Williamson spon- sored football bowl gantes (AA 1963d), and Lorillard had signed to sponsor the Olympic Games of 1964 and was already broadcasting previews (AA 1963u). Criticism of Advertising and Promotional Activities During these early years of the 1960s, there were criticisms of these successful selling efforts of the " cigarette advertisers, just as there are currently. The criticisms were a reaction to the continued increase in cigarette sales among teens despite the growing and still new sworthy concern among scientists that smoking caused cancer. Much of this criticism and concern, how- ever, was muted in the public forum by the reluctance of the media to jeopardize its lucrative cigarette sponsor- ships (AA 1963a). On the other hand, some noncommer- cial media, like Reader's Digest, which does not accept income for advertising, questioned the propriety of me- dia industry behavior. Such questions were also raised in the publication, The Consumers Union Report on Smok- ing and the Public Interest (AA 1963r; Brecher et al. 1963). The Surgeon General's first report on smoking and health was imminent at this time and was anticipated with widespread discussion of the legislative responses it might precipitate (AA 1963i; Cohen 1963). Much of this talk focused on the industry's sponsorship of sports, on its use of athletes' endorsements, and on advertising copy appealing to the young. Tobacco companies' targeting of youth was de- bated both inside and outside the advertising commu- nity. From within, a leading trade magazine for the advertising industry, Advertising Age (AA 1963b), and a leading advertising industry executive, John Orr Young of Young & Rubicam (AA 1964a), saw effective market- ing to the young as strategically important to maintain- ing the industry's size and fostering further growth. Other industry spokespersons judged that the use of athletes was problematiC, not only because it implied a healthfulness that was unwarranted, but also because it was a means of focusing on the teenage market. One critic asserted that television commercials focused on teens "by means of allusions to athletic prowess, popu- larity, datability and sexual allure.... It is basically a narcotic dream with an inexcusable dosage of dishon- esty" (AA 1963e, p. 12). An editorial in Advertising Age counseled the in- dustry to put less emphasis on youth and athletes in their ads (AA 1963h). The National Association of Broadcast- ers, working on the development of a self-regulatory process, declared that "tobacco advertising having an especial appeal to minors, expressed or implied, should be avoided" (AA 1963o, p. 85). At the same time, Reader's Digest (1963) condensed an article from Changing Times magazine that cited the American Tobacco Company, R.J. Reynolds, and Lorillard as companies whose adver- tising and promotional activities were aimed explicitly at young people. The artide, noted the on-campus efforts targeted at college students, the hiring of students to distribute cigarette samples, and the dominant presence of cigarette advertising in campus publications. "No- where in that bright wonderful world depicted in the ads," the artide observed, "is there any hint to young- sters that cigaret[te]s might be harmful" (Changing Times 1962, p. 35). The National Congress of Parents and Teachers (also known as the National Parent Teacher 168 Advertising and Promotion TIMN 0139020

Preventing Tobacco Use Among Young People examining actual data and discussing young people's tendency to overestimate smoking prevalence, students learn that smoking is not a normative behavior in our society. After exploring why adolescents smoke, students discuss positive alternatives to smoking. Students then learn how these misperceptions about smoking are estab- lished in our culture through advertising and role model- ing by peers and adults. Students practice the skills to resist the social influences that promote smoking, in- cluding peer influences and advertising techniques. Near the end of the program, students state a goal to remain nonsmokers. In evaluating the effects of the MSPP in eight junior high schools, Murray et al. (1988) reported that after four years, the peer-led social influences intervention reduced the incidence of daily and weekly smoking by 35 to 50 percent. In contrast, no reduction was observed in an adult-led group that was taught the health consequences of smoking or in a comparison group enrolled in an existing curriculum covering general health topics. These differences, however, were no longer statistically sig- nificant at the five- and six-year follow-ups (Murray et a1.1988). As part of this overall research program, the Class of 1989 Study was established to test the efficacy of the MSPP approach when introduced as part of a broader, community-based health promotion effort (Perry et al. 1992). Researchers hypothesized that the school-based intervention program would have longer-lasting effects if it was introduced in cdmmunities where adults were involved in communitywide smoking-cessation pro- grams, where antismoking ordinances in the schools and public community spaces were being considered, and where integrated school and community intervention Figure 2. Six-year follow-up of the first Waterloo School Smoking Prevention Trial: proportion of subjects smoking regularly and experimentally at each wave of the study 45 40 35 15 10 5 0 Q Experimental ~ Regular ~au ~ Control Program Control Program Control Program Control Program Control Program Control Program Control Program (End of Trial) (Year 1 (Year 2 (Year 3 (Year 4 (Year 5 (Year 6 follow-up) follow-up) follow-up) follow-up) follow-up) follow-up) Study condition Source: Flay et al. (1989). Prevention 223. TIMN 0139073

Preventing Tobacco Use Among Young People Enforcement method Community education, direct education of . merchants, contact with management of chains/franchises Intervention stores were mailed an informational packet and a supply of warning signs containing that state's required wording prohibiting tobacco sales to persons under 18 Educational program (6 months); "sting" operations, citations, media publicity (after 5 more months) Quarterly "stings," license suspension, fines of up to $500 None after initial educational campaign reported above (Altman et al. 1989) None, other than publicity surrounding new state law that increased penalties for sales to minors None, baseline study only None, baseline study only None, baseline study only None, baseline study only None, baseline study only None, baseline study only None, baseline study only Comments Minors' ages: 14-16; minimum legal age was 18 Minors' ages: 14-16; 40% of intervention stores and none of control stores posted warning signs, but no effect on sales rate was observed Minors' ages: 14-16; minimum legal age was 18; stores visited varied between preintervention and post- intervention samples Minors' ages: 12 and 13; all stores in local area visited before and after passage of local ordinance; proportion of local junior high school students reporting they were "regular smokers" decreased from 16% to 5% Minors' ages: 14-16; minimum legal age was 18; study illustrates recidivism without continued enforcement Minors' ages: 12-15; minimum legal age was 18; all outlets visited multiple times by different minors; rates averaged Minors' age: 11; minimum legal age was 18 Minors' ages: 10-13; no minimum legal age in effect Minors' ages: 11-17; minimum legal age was 18 Minors' ages: 9-17; minimum legal age was 18 Minors' ages: 12 and 15 Minors' ages: 13-14; no law in effect, but new law making 18 the minimum age recently passed Minors' ages 14-17; minimum legal age was 18 TIMN 0139101 Prevention 251

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Lin- coln (NE): University of Nebraska Press, 1980. FLAY BR. Youth tobacco use: risks, patterns, and control. In: Slade J, Orleans CT, editors. Nicotine addiction: principles and nranurgement. New York: Oxford University Press, 1993. FLAY BR, D'AVERNAS JR, BEST JA, KERSELL MW, RYAN KB. Cigarette smoking: why young people do it and ways of preventing it. In: McGrath P, Firestone P, editors. Pediatric and Adolescent Behavioral Medicine. New York: Springer-Verlag, 1983. FLEMING R, LEVENTHAL H, GLYNN K, ERSHLER J. The role of cigarettes in the initiation and progression of early substance use. Addictive Behaviors 1989;14(3):261-72. FRANZKOWIAK P. Risk-taking and adolescent develop- ment: the functions of smoking and alcohol consumption in adolescence and its consequences for prevention. Health Pro- nwtion 1987;2(1):51-61. GERBER RW, NEWMAN IM. Predicting future smoking of adolescent experimental smokers.. Journal of Yonuttr and Adole.- cence 1989;18(2):191-20T. GERBER RW, NEWMAN IM, MARTIN GL. Applying the theory of reasoned action to early adolescent tobacco chewing. Journal of School Health 1988;38(10):410-3. Psyclwsocictl Risk Factors 151 TIMN 0139003

Surgeon General's Report BURTON D, JOHNSON CA, GRAHAM J, UUTELA A, VARTIAINEN E. Perceptions of smoking prevalence by youth in countries with and without a tobacco advertising ban. Un- published data. BURTON D, MOINUDDIN M, GRENIER B. Advertising images and product symbolism as contributors to product desirability among blackand white adolescents. Unpublished data. BURTON D, SUSSMAN S, HANSEN WB, JOHNSON CA, FLAY BR. Image attributions and smoking intentions among seventh grade students. Journal of Applied Social Psychology 1989;19(8):656-64. CHASSIN L, PRESSON CC, SHERMAN SJ, CORTY E, OLSHAVSKY RW. Predicting the onset of cigarette smoking in adolescents: a longitudinal study. Journal of Applied Social Psychology 1984;14(3):224-43. CHESKIN L. Secrets of marketing success. New York: Trident Press, 1967. CHRISTEN AG. The case against smokeless tobacco: five facts for the health professional to consider. Journal of the American Dental Association 1980;101(3):464-9. COHEN JB. Counting advertising assertions to assess regula- tory policy: when it doesn't add up. Journal of Public Policy & Marketing 1989;8:24-9. BUSINESS OF RACING. [Marlboro advertisement]. New York Times Magazine 1989 July 9; 5A. BUSINESS WEEK. Cigarette scare: what'll the trade do? Business Week 1953a;No.1266:58-68. BUSINESS WEEK. Fear and jitters. Business Week 1953b;No.1263:54. CALFEE JE. Cigarette advertising, health information and regula- tion before 1970. Bureau of Economics, Working Paper No.134. Washington (DC): Federal Trade Commission, December 1985. CENTERS FOR DISEASE CONTROL. Cigarette advertis- ing-United States, 1988. Morbidity and Mortality Weekly Re- port 1990;39(16):261-5. CENTERS FOR DISEASE CONTROL. Comparison of ciga- rette brand preferences of adultand teenaged smokers-United States, 1989, and 10 U.S. Communities, 1988-1990. Morbidity and Mortality Weekly Report 1992;41(10):169-73,179-81. CENTERS FOR DISEASE CONTROL AND PREVENTION. Cigarette smoking among adults-United States, 1991. Mor- bidity and Mortality Weekly Report 1993;42(2):230-3. CENTERS FOR DISEASE CONTROL AND PREVENTION, OFFICE ON SMOKING AND HEALTH. Unpublished data. CHANGING TIMFS. Cigaret[te] ads: a study in irresponsibil- ity. Changing Times. `The Kiplinger Magazine 1%2;16(12):33-6. CHAPMAN S, FITZGERALD B. Brand preference and adver- tising recall in adolescent smokers: some implications for health promotion. American Journal of Public Health 1982;72(5):491-4. CHASSIN L, PRESSON CC, SHERMAN SJ, CORTY E, OLSHAVSKY RW. Self-images and cigarette smoking in adoles- cence. Personality and Social Psychology Bulletin 1981;7(4):670-6. 198 Advertising and Promotion COHEN JB. Research and policy issues in Ringold and Calfee's treatment of cigarette health claims. Journal of Public Policy & Marketing 1992;11(1):82-6. COHEN SE. Surgeon General's smoking report to kindle fires of 'what next?' hassle. Advertising Age 1963;34(46):44. COLLINS LM, SUSSMAN S, MESTEL-RAUCH J, DENT CW, JOHNSON CA, HANSEN WB, ET AL. Psychosocial,pnedic- tors of young adolescent cigarette smoking: a sixteen-month, three-wave longitudinal study. Journal of Applied Social Psy- chology 1987;17(6):554-73. CONE FM. With all its faults: a candid account of forty years in advertising. Boston: Little, Brown, 1969. CONNOLLY GN, ORLEANS T, BLUM A. Snuffing tobacco out of sport [commentaryl. American Journal of Public Health 1992;82(3):351-3. CONRAD K, FLAY BR, HILL D. Why children start smoking cigarettes: predictors of onset. British Journal of Addiction 1992;87(2):1711-24: CUMMINGS KM, GIOVINO G, MENDICINO AJ. Cigarette advertising and black-white differences in brand preference. Public Health Reports 1987;102(6):689-701. DANIELS D. Giants, pigmies and other advertising people. Chi- cago: Crain Communications, 1974. DAVIS RM, JASON LA. The distribution of free cigarette samples to minors. American Journal of PreUentive Medicine 1988;4(1):21-6. DAY C. Ad trends in cigarettes. Printers' Ink 1955;253(13):15-7. DHALLA NK, YUSPEH S. Forget the product life cycle con- cept! Harvard Business Review 1976;54(1):102-112. TIMN 0139050

Surgeon Genernl's Report Public Opinion About Preventing Tobacco Use Among Young People Introduction The information in this section is derived from several different sources, including national surveys con- ducted by the federal government and by private organi- zations (e.g., the Gallup Organization, Louis Harris and Associates), statewide surveys conducted by government agencies or private organizations (e.g., the American Cancer Society [ACSD, and community-based surveys. A remarkably consistent pattern emerges regarding public opinion of tobacco-control policies. First, both smokers and nonsmokers express much greater support for poli- cies to prevent youth from smoking than for policies to discourage adult smoking. A second finding is that nonsmokers are consistently more supportive of govern- ment efforts to regulate tobacco than are smokers. Public Opinion About Tobacco Education Historically, public support for efforts to keep chil- dren from smoking has been stronger than support for efforts to reduce smoking among adults. During the first half of this century, most states instituted laws thatprohib- ited the sale or gift of cigarettes to minors (Hawkins 1964), since tobacco use was viewed as an adult behavior and children were seen as a group to be protected from poten- tially harmful substances. However, as the health dangers of smoking became known, the public looked to schools to do more to educate children about the hazards of tobacco use. For example, a 1957 national survey of adults (N = 1,541) conducted by the Gallup Organization (1957) found that 68 percent of respondents believed that the danger from smoking was great enough to warrant literature being distributed to schoolchildren to warn them of these dangers. Fifty-three percent of the respondents also felt that the danger was sufficient to warrant an announce- ment from the federal government (presumably, to adult smokers) regarding the danger of smoking. Traditionally, gublic and private efforts to reduce the initiation of smoking by children have involved schools (U.S. Department of Health and Human Services [USDHHS] '1989). A number of states have enacted laws that mandate education about smoking and health in schools. In part, the emphasis on school-based education reflects a belief that education is the most effective way to discourage children from smoking. A 1984 national survey of adults sponsored by the American Board of Family Practice (Research and Forecasts, Inc. 1985) asked. respondents to indicate what approaches they believed were effective in discouraging smoking. The highest- rated approach, mentioned by 81 percent of those surveyed (N = 1,007), was providing smoking-related education to children in grade school. The use of public service campaigns, television shows, and other media to motivate teenagers not to smoke was mentioned by 66 percent of respondents. Twenty-one percent felt that legally banning the use of tobacco would be effective. There is strong public support for tobacco educa- tion efforts in the schools. The 1989 Smoking Activity Volunteer-Executed Survey (SAVES), which was admin- istered to adults in four states (Arizona, Michigan, Penn- sylvania, and Texas), collected information on a wide range of issues relevant to policies concerning smoking (Marcus et al., in press). Trained and supervised ACS volunteers used standardized questionnaires to conduct telephone interviews of the sampled adults. Data col- lected in this survey found that a high proportion of the respondents (87 to 91 percent) agreed with the statement, "There should be a strong tobacco education program in the school system" (Marcus et al., in press). Only a minority of these respondents (13 to 33 percent) agreed with the statement, "Currently, schools are doing enough to prevent children from starting to use tobacco." This finding is consistent with the results of'a 1990 telephone survey of Californiz adults, in which 74 percent of re- spondents felt that antitobacco education in schools should be increased (California Department of Health Services 1991). Restrictions on Smoking in Schools Traditionally, even secondary schools that prohibit smoking by students have allowed teachers and staff to smoke in designated areas away from students (USDHHS 1989). This double standard reflects public opinion about restricting smoking in school settings. A 1987 telephone survey of adults in Minnesota (Forster et a1.1991) found strong support (93 percent) for a policy prohibiting stu- dents from smoking in school, and a smaller percentage (77 percent) favored a ban on smoking among teachers and staf£ School smoking policies, like those for other workplaces, havebecome more restrictive in recent years. Several states and many communities have enacted laws that completely ban or severely restrict smoking in schools and on school property (Coalition on Smoking OR Health 1992). These laws are discussed later in this chapter. The 1989 Surgeon General's report on smoking and health (USDHHS 1989) dearly documented the trend of Americans to increasingly support restrictions on smok ing in a wide range of public locations, such as restau- rants, worksites, and schools. In general, surveys that 210 Prevention TIMN 0139060

:.y awareness of antismoking campaigns and the relative credibility of various sources of information, such as doctors, teachers, government employees, and manufac- turers. Perhaps the most striking component of this massive research effort, however, was the measurement of personality traits using a clinical psychometric instru- ment, Cattell's 16 Personality Factors. Scales of this instrument measure elements of personality defined as ranging from tough-minded to tender-minded, trusting to suspicious, or shy to adventuresome, among others. Youth Target Study '87 used cluster analysis to divide the youth market into seven psychographic groups: "Big City Independents;" "Tomorrow's Leaders," "Tran- sitional Adults;' "Quiet Conformers," "T.G.I.F.'s," "In- secure Moralists," and "Small Town Traditionalists;' (RJR-M-6, pp. 8-10). The T.G.LF. (Thank God It's Fri- day) segment was the largest, containing about 30 per- cent of this population of 15- through 24-year-olds. Since 62 percent of the T.G.I.F. group were reported to be smokers, they were considered an important segment. The T.G.I.F. group primarily comprised underachievers who were "rooted in the present. They live for the moment and tend to be self-indulgent.... Achievement and leadership is not a goal for this group compared to others. Societal issues are relative nonissues.... They are the most prominent supporters of smoking .... They do read newspapers and some magaziries, including Play- bo>.l and Penthouse. Heavy metal and hard rock are com- mon music choices" (RJR-M-6, pp. 8,21). Portraying Youthful Behavior As a matter of policy, "positive lifestyle images" were used by Imperial Tobacco Limited to suggest the continued social acceptability of smoking. The company chose models and activities to facilitate young people's identification with the company's products. Creative guidelines for the Player's brand, for example, specified that the target market would "emphasize the under-20- year-old group in its imagery reflection of lifestyle (activity) tastes" (AG-35, p. 42). The models used in Player's advertising. Oer@._to be "25 years or older, but should appear to be b~.N.ween 18 and 25 years of age' (AG-35, p. 52). R.J. Reynolds-MacDonald, however, learned that models can be too young appearing for the young consumer's taste. When the Tempo brand cigarette was test-marketed in selected cities, most of its media budget was allotted to out-of-home media, targeting key youth locations and meeting places close to youth-frequented sites, such as theaters, record stores, and video arcades. To target the young, who were perceived to be "extremely influenced by their peer group," the J. Walter Thompson advertising recommendations called for "imagery which 176 Advertising and Promotion portrays the social appeal of peer group acceptance-- where acceptance by the group provides a sense of be- longing and security" (AG-16, p. 4). The media featured young-looking models arm-in-arm, wearing casual clothes perceived as trendy by the young. The brand met with mixed results in the test market, however, in part because it was too explicitly young in character. Few teenagers, it seems, wanted an explicitly teen product, instead prefer- ring to use products associated with adulthood. Conveying Pictures of Health The images used in many of Canada's cigarette ads were carefully crafted to feature attainable activities that appealed to youth but were not so intense as to be unbelievable in the context of smoking. The Player's Filter'81, Creative Guideline (AG-222) required that ads feature activities that "should not require undue physical exertion. They should not be representative of an elitist's sport nor should they be seen as a physical conditioner. The activity shown should be one which is practiced by young people 16 to 20 years old or one that these people can reasonably aspire to in the near future" (AG-222, pp. 1-2). These images were tested to ensure that they elic- ited minimal counterargument from viewers. For ex- ample, in the Project Stereo Advertising Evaluation (AG-220), a windsurfing ad for the Player's brand re- ceived the following evaluation: The reaction to windsurfing as an activity is neutral with regard to whether or not the people who engage in it are likely to be smokers or not. How- ever, the more physically fit and healthy-looking the protagonists, the stronger the no-smoking clas- sification elicited. The same person sitting on the beach-perceived by most as resting after surfing- or shown carrying a surfboard-whether getting out of the water or walking toward the ocean- evokes different reactions regarding smoking. Re- spondents are willing to accept the man smoking while resting but are reluctant to think of him as a smoker while his well-built body is in full view (AG-220, p. 6). Projecting Images of Independence The brands most successful with teenagers seem to be those that offer adult imagery rich with connota- tions of independence, freedom from authority, and/or self-reliance. Imperial Tobacco Limited's Project Sting tested "overtly masculine imagery, targeted at young males" (Pollay 1989b, p. 24). Young males were seen as "going through a stage where they are seeking to express their independence and individuality under constant TIMN 0139028

I'!c': I(i\ F,'I':iltt' L/•t 1mh'!1,,' } RILEY «'T. BARENIE IT. MYERS DR. T% 'puluKv and ccrrre- late!,uf smokeles. tobaCcu use. Juurrrol or A~tt!le,~ t rit Ht'alth Care 1y t9;1()( +):3;'-t,2. RI`GWALT C.•1 •pecial rr%~t7trclt report. Student rrthlett's anut n'!t tthfet~ :.10 their re;e' t!t. •nrd l1elier-5 rhvut alcohol intil otlrer fru~~ lrr~!' Raleigh (NC): North Carolina Department of I'ublic In.tructiun, AIcohOl and Drug Defense Division, 1989. ROUSE BA. Epidemiology of smokeless tobacco use: a na- tional>tudv. In: National Cancer [nstitute. Smokele:s tobacco tt>e in the United States. Monograph No. 8. L;S Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute. Bethesda (MD): NIH Publication No. 89-3055, 1989, 29-33. ROYAL COLLEGE OF PHYSICIANS OF LONDON. Smokirtg artd the your g. London: The Lavenham Press, Ltd., 1992. SALOMON G, STEIN Y, EISENBERG S, KLEIN L. Adoles- cent smokers and non-smokers: profiles and their changing structure. Prez,entit'e Medicine 1984;13(S):-I-I6-61. SANTI S, BEST JA, BROWN KS, CARGO M. Social environ- ment and smoking initiation. btternational /ournal of the Addic- tions 1990-91;25(7A & BA):881-903. SCHAEFER SD, HENDERSON AH, GLOVER ED, CHRIS- TEN AG. Patterns of use and incidence of smokeless tobacco tonsumption in school-age childreh. Archiz'es ol'Otolarurrgolot y 1985;1 l l( 10):639-12. SCHEIER L%1, NEWCOMB %ID. Differentiation of early ado- lescent predictors of drug use versus abuse: a developmental risk-factor model. /otn'nal ot Substarrce Abuse 1991;3(3)2i i-99. SCHI\ KE SP, GILCHRIST LD, SCHILLI:tiG RF [I, SENECHAL VA. Smoking and smokeless tobacco use among adolescents: trends and intervention results. Public Health Reports 1986;10 1(4):373-8. SCHINKE SI', SCHILLING RF II, GILCHRIST LD, ASHBY MR, KITAJIMA E. Pacific North,.cest tiative American youth and smokeless tobacco use. International Journal of the Addic- ttt!rt-~ ~.. . SCHI\KE SP, SCH~LL•ING RF II, GILCHRIST LD, ASHBY ',1R, KITAJIMA E. Native youth and smokeless tobacco: preva- lence rates, gender differences, and descriptive characteristics. In: National Cancer Institute. Smokeless tobacco use in the United States. Monograph No. 8. US Department of Health and Human Sen•ices, Public Health Service, National Institutes of Health, National Cancer Institute. Bethesda (MD): NIH Publi- cation No. 84-3055, 1989, 39-I2. SEVIMER \K, CLEARY PD, DWYER JH, FUCHS R, LIPPERT P. Psychosocial predictors of adolescent smoking in two Ger- man cities: the Berlin-Bremen studv. Morbiditt/ artd Mortality Lb'eeklti Report 1987:36(4 Suppl):3S=11S. SE,'-IMER \K, LII'I'E(tT I', FLCIIS (t. CLI::\I:1 I'O SCHINDLER A. Adole~,cent smoking frcrm a tunctumal per- spective: the Berlin-Bremen study. Furopeitu /rwnrrd ou 1'•u i holi>k u of Education 19ti7;2(4):387 -•1O I. SHEAN RE. Peers, parents and the next,ciKarette: smokir.); acquisition in adolescence Idissertatiuni. Nedlands: I:ntver- sitv of Western Australia, 1991. SKINNER WF, MASSEY JL, KROHN MD, LAC:ER RM. So- cial influences and constraints in the initiation and ce5satiun of adolescent tobacco use. journal of Behavioral Medicine 19)i;; 8(4):353-76. STACY AW, FLAY BR, JOHNSON CA, HANSEN WB. A comparison of informational, normative, and individual dif- ference factors as longitudinal predictors of adolescent smok- ing. Unpublished data. STACY AW, SUSSMAN S, DENT CW, BURTON D, FLAY BR. Moderators of peer social influence in adolescent smoking. Personality and Social Psycholo~gy Bulletin 1992;18(2):163-72. STEIN' JA, NEWCOMB MD, BENTLER PM. Initiation and maintenance of tobacco smoking: changing determinants and correlates across the life-span. Unpublished data. STERN RA, PROCHASKA JO, VELICER WF, ELDER JP. Stages of adolescent cigarette smoking acquisition: measurement and sample profiles. Addictive Behaviors 1987;12(-I):319-29. STEVENS M, YOGELLS F, WHALEY R, LINSEY S. Preva- lence and correlates of alcohol use in a survev of rural elemen- tarv school students: the New Hampshire study. /ournal of Drtig Education 1991;21(4):333-47. SUSSMAN S, DENT CW, FLAY BR, HANSEN WB, JOHNSON CA. Psvchosocial predictors of cigarette smok- ing onset bv white, black, Hispanic, and Asian adolescents in Southern California. Morbidity and Mortality Weekly Report 1987; 36(4 Suppl):11S-17S. SUSSMAN S, DENT CW, SIMON TR, STACY AW, BURTON D, FLAY BR. Identification of which high-risk youth smoke cigarettes regularly. Health Values 1993;17(1):42-53. SUSSMAN S, DENT CW, STACY AW, BURCIAGA C, RAYNOR A, TURNER GE, ET AL. Peer-group association and adolescent tobacco use. /ournal of Abnormal Psyclwlogy 1990;99(4):349-52. SUSSMAN S, HOLT L, DENT CW, FLAY BR, GRAHAM JW, HANSEN WB, ET AL. Activity involvement, risk-taking, de- mographic variables, and other drug use: prediction of try- ing smokeless tobacco. In: National Cancer Institute. Smokeless tobacco use in the United States. Monograph No. 8. US Depart- ment of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute. Bethesda (MD): NIH Publication tio. 89-3055,1989, 57-62. Psyckosocial Risk Factors 155 r rIMN 0139007

Surgeon General's Report campaigns to reduce smoking. A 1987 national survey sponsored by the American Medical Association (Harvey and Shubat 1987) found that 79 percent of adults favored an increase in the tax on tobacco products if the money from the increase went to Medicare. A 1992 survey of Michigan adults (ACS 1992) found that 72 percent would support raising the state's cigarette excise tax if the addi- tional revenue would be targeted for health care and education. Interestingly, 58 percent of respondents to this survey claimed that they would vote for a candidate who supported the tobacco tax increase, whereas 27 percent would vote for a candidate who opposed the tax increase. Some relevant information on public opinion re- garding tobacco taxes comes from a survey conducted in Canada, where tobacco taxes have increased sharply in the past decade. A December 1990 poll conducted for the Council for Tobucco-Free Ontario (Council for a Tobacco- Free Ontario/Non-Smokers' Rights Association 1992) questioned Ontarians about their support for a substan- tial increase in the tobacco tax. Overall, 58 percent of Ontarians supported a 50-cent per pack increase in the cigarette tax; this support did not change when respon- dents were informed that taxes currently accounted for 60 percent of the retail price of cigarettes. However, when respondents were told that higher tobacco prices could prevent children from starting to smoke, support for the tax increase climbed to 67 percent. Support was even higher when respondents were told of different ways to use revenues raised by the new tax, such as reducing the budget deficit (70 percent support), helping people quit smoking (78 percent support), and establish- ing a fund to help prevent smoking among young people (84 percent support; 77 percent among smokers). Educational Efforts to Prevent Tobacco Use Among Young People ..a School Based Smoking Prevention Programs Introduction Since the 1964 publication of the first Surgeon General's report on smoking and health (Public Health Service [PHS] 1964), smoking prevention has been recog- nized as a primary strategy for controlling smoking in the general population. The first report identified the diffi- culty that long-term adult smokers typically experience in their attempts to quit. The report thus advocated programs directed at educating high school and college students about the health hazards of smoking; in theory, school-based programs would interfere with the devel- opment of smoking behavior before smoking became firmly established.., j When the term "pxevention" was applied to health- related issues in the 1960s, however, the concept referred not exclusively to school curricula but also to efforts to disseminate warnings about products and practices that public health professionals considered potential health hazards (Schwartz 1969). The approach to prevention research at that time consisted of biomedical research to establish physiological mechanisms of smoking-related diseases, coupled with epidemiologic research to iden ti[y etiologic characteristics of smokers. This research led, when appropriate, to the dissemination of findings and recommendations to the public. A proclamation and direct warning from the U.S. Surgeon General about the life-threatening characteristics of cigarette smoking was expected to convince smokers to quit and nonsmokers to avoid taking up the piactice. Had this effect been the case, the concept of smoking prevention might never have amounted to more than "spreading the word" to those segments of the population who had not yet re- ceived it. Unfortunately, nearly three decades later and despite monumental efforts to disseminate warnings, cigarette smoking remains the single most preventable cause of death and disease in our society (USDHHS 1989). This section reviews the evolution of the concept of smoking prevention since the 1960s and identifies av- enues for future progress in this area. Early Approaches to Smoking Education and Prevention In the 1960s and early 1970s, strategies to prevent the onset of cigarette smoking were often based on the premise that adolescents who engaged in smoking be- havior had failed to comprehend the Surgeon General's warnings on the health hazards of smoking (Thompson 1978). The assumption was that these young people had a deficit of information that could be addressed by pre- senting them with health messages in a manner that caught their attention and provided them with sufficient justification not to smoke. Improvements in knowledge levels, or cognitive factors, would thus lead directly to changes in behavior. 216 Prevention TIMN 0139066

Preventing Tobacco Use Among Yoiing People ask about limiting smoking in various settings have found that support for such restrictions in schools is usually stronger than for other locations. For example, findings from a telephone survey for the 1989 National Cancer Institute (NCI) Community Intervention Trial for Smok- ing Cessation (COMMIT) (Centers for Disease Control [CDC] 1991a) revealed that fewer than.one-quarter of adult respondents in 10 U.S. intervention communities supported a complete ban on smoking in private worksites and restaurants, whereas over half endorsed a ban on smoking on school grounds. Support for banning smok ing in secondary schools possibly reflects the broad soci- etal belief that schools have an important role to play in discouraging tobacco use by children. Restrictions on Tobacco Advertising and Promotion Numerous national, state, and local surveys have tried to assess public opinion about restrictions on to- bacco product advertising. In a series of national Gallup surveys (Gallup Organization 1978, 1987, 1988, 1991, 1993) conducted between 1977 and 1993, support for a complete ban on cigarette advertising increased from 36 to 53 percent. The 1989 COMMIT survey (CDC 1991a) of a representative sample of 300 to 400 adults.25 to 64 years old in each of 10 intervention communities in 9 states found that between one-half and three-quarters agreed with the statement, "All tobacco advertising should be eliminated." Some surveys have asked about limiting specific types of tobacco advertising (e.g., billboards, newspa- pers, magazines) and promotional practices (e.g., distri- bution of free tobacco samples, tobacco company sponsorship of sporting and cultural events) (Table 1). A 1987 telephone survey (Forster et a1.1991) of 821 adults from seven Minnesota communities asked respondents to indicate their support for restrictions on various forms of advertising. Seventy-three percent of respondents favored a ban on tobacco signs and billboards; 70 percent supported a ban on tobacco advertising in newspapers and magazines:F The ACS-sponsored 1989 SAVES survey of four stabes found that support for a ban on cigarette advertising in newspapers, in magazines, and on billboards ranged from 61 to 69 percent (Marcus et al., in press). Over three-quarters of respondents in this survey agreed with the statement, "Tobacco companies should be prohibited from distributing free tobacco samples on public property or through the mail." Com parable results were obtained in a 1990 telephone survey of adults in California (California Department of Health Services 1991). Fifty-four percent of respondents in this survey supported a ban on tobacco ads on outdoor bill boards; 49 percent supported a ban on tobacco ads in newspapers and magazines; 67 percent supported a ban on the distribution of free tobacco samples or coupons to obtain free samples by mail; and 75 percent supported a ban on the distribution of free tobacco samples on public property. Three surveys (California Department of Health Services 1991;.CDC 1991a; Marcus et al., in press) have measured public opinion about tobacco company spon- sorship of sporting and cultural events (Table 1). In the 1989 COMMIT survey (CDC 1991a) of 10 communities, from one-third to more than one-half of respondents supported a ban on such sponsorship. The 1989 SAVES survey (Marcus et al., in press) found that about one-half of respondents agreed with the statement, "Tobacco com- panies should be prohibited from sponsoring sports events or advertising their products at these events:' Fifty-two percent of respondents in the aforementioned 1990 California survey (California Department of Health Services 1991) believed that sponsorship of sporting or cultural events by tobacco companies should be banned. In all three surveys, support for a ban on tobacco com- pany sponsorship of sporting and cultural events was about twice as strong among nonsmokers as - it was among smokers. The function and effect of tobacco advertising have been the subject of much controversy and debate among scientists and within the tobacco industry. The tobacco industry has argued that advertising targets adults only and encourages regular smokers to switch brands or to maintain brand loyalty (Tobacco Institute 1964; see "The 'Maturity' of the Cigarette Market" in Chapter 5). Many health experts assert that tobacco advertising targets chil- dren to encourage them to start using tobacco (Tye 1987; DiFranza et a1.1991; Fischer et a1.1991; Pierce et a1.1991; CDC 1992a). In fact, a major newspaper, the Seattle Times, voluntarily discontinued tobacco advertising in June 1993, citing "growing medical evidence on the dangers of smok- ing, as well as tobacco advertisers' recent targeting of youth and racial minorities" (Nogaki and Gupta 1993, p. El). Legislative proposals to restrict or prohibit to- bacco advertising are often 'presented as. a means of protecting children (Myers and Hollar 1989). In 1986, about half of the respondents to the Adult Use of Tobacco Survey (AUTS) (USDHHS 1990c) agreed with the state- ment, "If cigarettes were not advertised anywhere, fewer young people would start smoking." In July 1990, a national Gallup survey (Gallup Organization 1990c) of adults found that more respondents (49 percent) thought that advertising and promotion paid for by the tobacco companies represented an active attempt to get teenag- ers and young people to start smoking than believed that such efforts were to encourage brand switching among people who already smoke (38 percent). Prevention 211 TIMN 0139061

hrc-z'c'HNNti litl'dci0 U•c'.Atntt/iti }t'l/ift Pt'oplc' JOHNSTON LD, BACH.',,IANJG. Monitoring the future: ques- tionnaire responses from the nation's high school seniors 1973. Ann Arbor (MI): Institute for Social Research, Universitv of MichiKan, 1980. JJOHNSTON LD, BACHMAN JG, O'MALLEY PM. Monitor- ing the future: questionnaire responses from the nation's high school seniors 1477. Ann Arbor (Ml): Institute for Social Research, C:niversih.' of Michigan, 1980a. JOHNSTON LD, BACHMAN JG, O'MALLEY PM. Monitor- ing the future: questionnaire responses from the nation's high school seniors 1979. Ann Arbor (MI): Institute for Social Research, University of Michigan, 1980b. JOHNSTON LD, BACHMAN JG, O'MALLEY PM. Monitor- ing the future: questionnaire responses from the nation's high school seniors 1981. Ann Arbor (MI): Institute for Social Research, University of Michigan, 1982. JOHNSTON LD, BACHMAN JG, O'MALLEY PM. Monitor- ing the future: questionnaire responses from the nation's high school seniors 1983. Ann Arbor (MI): Institute for Social Research, University of Michigan, 1984. JOHNSTON LD, BACHMAN JG, O'MALLEY PM. Monitor- ing the future: questionnaire responses from the nation's high school seniors 1985. Ann Arbor (MI): Institute for Social , Research, University of Michigan, 1986. JOHNSTON LD, BACHMAN JG, O'MALLEY PM. Monitor- ing the future: questionnaire responses from the nation's high school seniors 1987. Ann Arbor (MI): Institute for Social Research, University of Michigan, 1991. JOHNSTON LD, BACHMAN JG, O'MALLEY PM. Monitor- ing the future: questionnaire responses from the nation's high school seniors 1989. Ann Arbor (MI): Institute for Social Research, University of Michigan, 1992. JOHNSTON LD, O'MALLEY PM, BACHMAN JG. Drttg use antong ,3nterictnt high .cltool seniors, college students and yotutg adults,l9: 5-1990: c'olume 1, high school seniors. US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse. Bethesda (MD): DHHS Publication No.(ADM) y1-1813;1991a. JOHNSTON LD, O'MALLEY PM, BACHMAN JG. Drug ttse antattg Atnt'rican high school seniors, college students and yototg adults,1975-1990: z'ohtme[I,collegestudentsand youngadults. US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administra- tion, National Institute on Drug Abuse. Bethesda (MD): DHHS Publication No.(ADM) 91-1835,1991b. JOHNSTON LD, O'MALLEY I'M, BACWv1A\ IG. tintt hl/t~ ttriltkilig, attd illicit drug nse utnunt> Ame'rtcan •ritttulart/ ~LAu0l studettts, colh se ~tl(deltts, altd ttotu~s ndults, [975-1991: c'ttltune' I secottdm•tlsdtoot :tuclent:. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Drug Abuse. Bethesda (MD): NIH Pub- lication No. 93-3480, 1992a. JOHNSTON LD, O'MALLEY PM, BACHMAN JG. Sntukttt,~, drinking, and illicit drug use among Anterictut secondartt schuul >tudents, college studettts, and iloung atlult<,1975-1992: :'ohtme 11. college studettts and youttg adults. US Department of Health and Human Service, Public Health Service, National Institutes of Health, National Institute on Drug Abuse. Bethesda (4D): NIH Publication No. 93-3481, 1992b. JOHNSTON LD, O'MALLEY PM, BACHMAN JG. National surreyresultsondrugusefromMonitoringtheFutureStttdtt, 1975- 1992: aolume 1, secondary school students. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Drug Abuse, in press. JONES EE, SIGALL H. The bogus pipeline: a new paradigm for measuring affect and attitude. Psttchological Bulletin 1971;76(5):349-64. JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. Consensus Conference. Health applications of smokeless to- bacco use. fournal of tlte American Medical Association 1986;255(8):1045-8. KOLBE LJ. An epidemiological surveillance system to moni- tor the prevalence of youth behaviors that most affect health. Health Edttcation 1990;21(6):44-8. KOLBE LJ, KANN L, COLLINS JL. Overview of the Youth Risk Behavior Surveillance System. Public Heal tJt Reports. 1993; 108(1Suppi):2-10. KOPSTEIN AN, ROTH PT. Drug abuse among racial/etlutic grou ps. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Drug Abuse. Bethesda (MD): Special Report, 1993. LUEPKER RV, PALLONEN UE, MURRAY DM, PIRIE PL. Validity of telephone survey in assessing cigarette smoking in young adults. American Journal of Pttblie Health 1989;79(2):202-1. MARCUS AC, CRANE LA, SHOPLAND DR, LYNN W R. Use of smokeless tobacco in the United States: recentestimates from the Current Population Survey. In: National Cancer Institute. Smokeless tobacco use in the United States. Monograph No. 8. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Insti- tute. Bethesda (MD): NIH Publication No. 89-3055,1989,17-23. TIMN 0138969 Epidetniulogil 117

Preventing Tobacco Use Among Young People Figure 2. Pages from The Camel Cash Catalog, Volume Three Source: R.J. Reynolds Tobacco Co. (1992).. competition. Although this is undoubtedly the case for some price offers, value-added promotion has two other effects. The first is to reduce the cost of entering the market-a notable effect, since some research studies indicate that the cigarette market is price sensitive (see "Effects of Excise Taxes on Tobacco Use" in Chapter 6). Any money-saving action that facilitates market trial and adoption may disproportionately affect youth, who usu- ally have slim ~l reserves and low earning power. Recently, Philip Morris began aggressive price-cutting fM` laYs On iM Snch tM fi~/ t YL IM MNL q COCI lft si Inm C7.Mtlir.MYiiYr/wMw urirMlnU7. / T rnn tqiu .~m<Nt v:maNt m:u ~..+nu ~ wue Ip e+m w tnw~n rm, N 10 G.N OM~nN NO Cu. Vn lvOt .lnm;Ca11Cf T MCS~ htl IwM • S ln' . t;• . 7r 11.~4rr.nl.lr~s;a•.nw,.NYRe I.ICn 1aNS Ne rywi~ s/ eM[. b N. Ne . <ewr s v.ews xvw.allrrrM •i!lGOI6 ® tx.n.ama C.x. :... . rm r un OYot Yd ANOMLtY tMl IN tn I wll I~ny Mw ~.. Cu.N 1d..ryM u.w a+«M ewaN MM u.Y SIM hW .M Ns 4n ~.~1~. Onu .NOU a.0 .vww 7MCal0 Etw.n.w~r..,arro.<w+~ Tn ery./ tN+=w>x.M uwf .M 13 ~st~lY I~u+M 51.~.( ww % IN'tr0 lMMUwMS IlLiRf Ir IIN/W inNU11Y~- Z Y/.R~ I~R-iMM1.I. tlrr0 IIYIYN'.tu /LIa/uh.~11111ON Ni.1 YI.~aM'RyM w1 ~NI'.M{N fOS-N:2et NIM1. 159400 Z Ud" rt\f. -f.'s.allrtbE.[! AIINiwi dlcw IN f e.IM Mtl ql~ CY. !.I /AY Yw.rM.~ ~IMY fLl VM W Wlwwealtl 11CaRJ Ir 'LrM' M~ CIC -GO tlnp sn u Niws yy tnn W.n 0 pee u pil mw IWI [wY1.Ml N. ada~ Yt. W Sh can a. wr w.n Nnr/ w.o+r• rwa.+.a.tt' Iruwt 4~eqelJ/.M111~1If/MIM.MYf ,.NIN y 4M~1~ lM IIY Wlf{ a0 <11vN MrSL/YiYS 1aHaa0n\• .anllfiM IiN11Q ~IN1HiNhx0lMiN-IIUN't0 Ns.'N1tlYYf6Y.N// MP.dI S.MG.MUpmlpl. XC# promotions using coupons for Marlboro (Levin 1993), the predominant brand used by teenagers (CDC 1992). The second effect of coupons and other retail value- added devices is to encourage repeat purchases. Often coupons are enclosed with sample or trial packs and are included with other brand-trial devices. In using these coupons, the smoker moves toward habitually purchas- ing and using a particular brand and identifying with that brand's image. Moreover, coupons can encourage new users to progress from a trial stage of smoking to regular, addicted use of cigarettes. Advertising and Promotion 187 TIMN 0139039

Preventing Tobacco Use Among Young People Format and duration (in seconds) Content TV (60) Dancing girls stomp on cigarettes to model quitting; viewers invited to write in for poster TV (60) Cartoon of a "butthead" getting shunned by peers Radio (60) Smoking portrayed as "out" ~ TV (30) A boy in a run-down neighborhood appears to be buying drugs, but it's a pack of cigarettes TV (15) Quick and humorous messages: smoking stinks! TV (15) TV (60) Fast-paced music video: smoking's not cool TV (30) Cartoon: young kids are smart and don't smoke TV (30) Tobacco executives joke about "getting" smokers TV (15) Disgusting look of a cigarette butt in the mouth TV (15,30) Smoking makes your clothes smell TV (30) Smoking for animals and people is unnatural TV (30) It may look like kids are smoking, but not many do Radio (60) A rap song says smoking makes breath smell Radio (60) Smokeless: disgusting goo on teeth Radio (60) Smokeless: heavy metal tune, chewing isn't cool TV (30) Three boys show disgust for a girl's smoking TV (60) Situation comedy: it's okay to refuse a cigarette TV (60) Rock video: benefits of quitting TV (30) Cartoon: drawbacks of smoking TV (30) Situation comedy: girl pummels talking cigarette pack TV (30) Dramatic - and disgusting: smoking gives you wrinkles Prevention 241 TIMN 0139091

Surgeon General's Report TIDE. Tobacco for teens. Tide 1948;22(39):20-1. TIDE. Diess rehearsal for a press conference. Tide 1955; 28(20):31. TILLEY NM. The R. J. Reynolds Tobacco Company. Chapel Hill (NC): University of North Carolina Press, 1985. TOBACCO INSTITUTE. Cigarette advertising code. Washing- ton (DC): The Tobacco Institute, 1986. TRACHTENBERG JA. Here's one tough cowboy. Forbes 1987;139(3):108-10. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. Reducing the health consequences of smoking: 25 years of progress. A report of the Surgeon General. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS Publication No. (CDC) 89-8411,1989. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. Smoking and tobacco control. Smokeless tobacco or health. An international perspective. Monograph 2. US Department of Health and Human Services, Public Health Service, National Insti- tutes of Health NIH Publication No. 92-3461, 1992a. TYE JB. Buying silence: self-censorship of smoking and health in national newsweeklies. World Smoking and Health 1990;15(1):9-11. TYE JB, WARNER KE, GLANTZ SA. Tobacco advertising and consumption: evidence of a causal relationship. Journal of Public Health Policy 1987;8(4):492-508. UK DEPARTMENT OF HEALTH. Effect of tobacco advertising on tobacco consumption: a discussion document reviewing the evidence. London: UK Department of Health, Economics and Operational Research Division, 1992. US CONGRESS. Hearings on HR 2248 before the Committee on Interstate and Foreign Commerce, House of Representa- tives, 89th Congress, 1st Sess. Serial No. 89-11. Washington (DC): US Government Printing Office, 1965. US CONGRESS. Hearings before the House Subcommittee on Health and the Environment of the Committee on Energy and Commerce. July 18 and August 1, 1986. 99th Congress. Advertising of tobacco products. Serial No. 99-167. Washing- ton (DC): US Government Printing Office, 1986. US DEPARTMENT OF COMMERCE, BUREAU OF ECO- NOMIC ANALYSIS. Survey o f Current Business 1992a;72(7):59. US DEPARTMENT OF COMMERCE, BUREAU OF ECO- NOMIC ANALYSIS. Natiorurl income and product account of the United States 1959-88. SPO No. 003-010-00231-0. Washington (DC): US Department of_Costmaterce,1992b. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. The health consequences of smoking jbr women. A report of the Surgeon General. US Department of Health and Human Ser- vices, Public Health Service, Office of the Assistant Secretary for Health, Office on Smoking and Health, 1980. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. The health consequences o f using smokeless tobacco. A report of the advisory committee to the Surgeon General. US Department of Health and Human Services, Public Health Service, National Institutes of Health, NIH Publication No. 86-2874,1986. 202 Advertising and Promotion US DEPARTMENT OF HEALTH AND HUMAN SERVICES. Spit tobacco and youth. US Department of Health and Human Services, Office of Inspector General. Publication No. OEI 06-92-00500,1992b. ' UNITED STATES TOBACCO JOURNAL. By example [edito- rial]. United States Tobacco Journal 1950a;153(6):4. UNITED STATES TOBACCO JOURNAL. Cigarette execu- tives expect added volume. United States Tobacco Journal 1950b;154(26):3. UNITED STATES TOBACCO JOURNAL. The industry's ads [editorial]. United States Tobacco Journal 1953;159(14):4. UNITED STATES TOBACCO JOURNAL. The industry re- covers [editoriall. United States Tobacco Journal 1955a;163(24):4. UNITED STATES TOBACCO JOURNAL. No need for epi- grams [editorial]. United States Tobacco Journal 1955b;164(9):4. UNITED STATES TOBACCO JOURNAL. More advertising [editorial]. United States Tobacco Journal 1956;166(10):4. UNITEDSTATESTOBACCO JOURNAL Philip Morris sched- ules comic strip campaign. United States Tobacco Journal 1958a;169(12):3,7. UNITED STATES TOBACCO JOURNAL Sell pleasure [edi- torial]. United States Tobacco Journal 1958b;170(4):4. UNITED STATES TOBACCO JOURNAL. New brands, ads aid entire industry. United States Tobacco Journal 1959;172(18):3. UNITED STATES TOBACCO JOURNAL. Principle or prac- tice? [editorial]. United States Tobacco Journal 1960a;173(15):4. UNITED STATES TOBACCO JOURNAL Advertising pays [editorial]. United States Tobacco Journal 1960b;173(19):4. UNTTED STATES TOBACCO JOURNAL 2 University of Kentucky students win Tempest in L&M Grand Prix 50 con- test. United States Tobacco Journal 1963a;179(24):5. TIMN 0139054

tiIIYvo It IJe IICItII" I~C'tIo Yf were more likely to display recreation, and were some- what less likelv to depict erotic imagery. Tombstone ads were less likely to appear in youth magazines, or con- versely, vouth magazines were more likely to feature image-based ads.' Like Warner (1985a), Altman et al. found a decline in the evidence of visible smoke and the act of smoking. The database of Altman et al. (1987) was extended by Basil et al. (1991), who examined differential target- ing, or how cigarette advertising strategies varied de- pending on the characteristics of the primary readership. These researchers added two magazines with a prima- rily black readership (Jet and Essence) and updated the sample to include magazines from the 1960s through July 1989 for an enlarged sample of 1,171 ads. These investigators also delineated three subcategories of ro- mantic/erotic themes: (1) horseplay-males and females cavorting; (2) erotic content-romantic or sexy situa- tions, innuendo; and (3) seductive poses-wanton looks or suggestive glances or poses. From 1984 through July 1989, the number of ads per magazine issue declined in general in men's and women's magazines but was relatively stable in those magazines reaching black and youth audiences. The most common type of ads in men's and youth maga- zines showed models engaged in lower-intensity sports, such as water skiing or volleyball. Analysis of variance between magazine types found that ads depicting inci- dents of horseplay and romantic contact were most preva- lent in black- and youth-oriented publications. A separate analysis found that incidents of horseplay had grown significantly more frequent over time and were signifi- cantly related to the average age of a magazine s readers; magazines with a younger readership were more likely to run ads featuring horseplay. Comparing results for all consumer segments, the researchers concluded that these ad strategies appear to depend on the segment's current rate of smok- ing.... Readers with high smoking rates are often pitched to choosecertain brands with appeals based on some aspect af the brand rather than on the models depicted': iitsthe ad. However, readers with low smoking rates appear to be given appeals that focus on models, suggesting that smoking is fun, helps you make friends, and will make you desir- able. Groups with lower smoking rates are more frequently given appeals that appear to be attempt- ing to recruit new smokers (Basil et al. '1991, p. 88). =Research (such as Fischer et a1.1989) that has examined the effect that health warning labels in cigarette advertising have on young people is discussed in Chapter 6. The work of King et al. (1991) partially contradicts and partially replicates findings from the previously de- scribed studies. King et al. followed a similar sampling strategy, drawing ads from one issue for each available year, between 1954 and 1986, for each of eight magazines representing five distinct audience orientations: general interest (Time), older women (Ladies Home Journal and Redbook), younger women (Vogue), older men (Popular Mechanics and Esquire) and younger men (Sports fllustrated and Playboy). This sampling yielded 1,100 cigarette ads for an analysis that focused on visually oriented content. Like other studies, King et al. noted a large increase in magazine advertising: the number of ads per issue was more than ten times greater for the period 1971-1983 than for the period 1954-1970. Playboy had both the largest number of cigarette ads per average issue and the lowest median audience age. Unlike earlier studies, however, King et al. found no systematic relationship between the median age of a magazine's audience and the average number of ads published. As was found in previous multiyear studies, ciga- rette ads in general relied more and more on visual imagery and became increasingly larger (e.g., more ads were multipaged), more photographic, more colorful, and more visual than verbal. The volume of cigarette ads varied significantly over time; the greatest changes were a decline in the proportional importance of general-inter- est magazines, a relative stability for both older and younger men's magazines, and a growth in both older and younger women's magazines. The ads in the younger men's and women's magazines together constituted 39 percent of the total cigarette ad volume in this sample of magazines during 1954 through 1970,33 percent during 1971 through 1983, and 45 percent during 1984 through 1986. Similarly, Warner and Goldenhar's (1992) analysis of the use of 92 magazines as cigarette advertising ve- hicles from 1959 through 1986 found the largest increase in women's magazines and in magazines reaching pre- dominately blue-collar readers. Imaging Individualism, Independence, and. Self-Reliance In King and colleagues' (1991) analysis, the activi- ties of the models fall into six categories: adventure (op- erating a speedboat), recreation (playing ball), erotic (being romantic with another), sociability (tallcing with peers), working (ranching), and individualistic/solitary (read- ing a book, watching a sunset). The study defined indi- vidualism solely in terms of restful behaviors; this decision and the resulting classification of the Marlboro cowboy as "working" rather than "individualistic solitary" are debatable elements of this study, but the results nonethe- less indicate the importance of the independence theme. 182 Advertising and Promotion TIMN 0139034

SurQeon Gerieral'ti ReF)ort activities were offered. Throughout junior and senior high school, smoking prevalence was significantly lower among students in the intervention community than among students in the control community. The results of this study are discussed later in this chapter, along with other communitywide programs. International Research on Smoking- Prevention Programs Intervention studies reported in the English- language literature outside the United States concentrate primarily on school-based interventions directed at sec- ondary school students (persons aged 11 years or older). In many cases, these intervention programs have adopted some elements of U.S. school programs in order to reflect different local conditions. This section reviews several of the more rigorously evaluated programs and pays par- ticular attention to programs that have been followed up for two or more years after intervention. Health educators from the project team delivered a direct, intensive intervention (intervention A) in two schools (one urban and one rural). A less intensive, countywide intervention (intervention B) provided ma- terials and training to local youth and temperance work- ers. The evaluation involved the two intervention A schools, two matched intervention B schools selected from the county, and two matched reference schools selected from another county that did not receive an organized intervention. Puska et al. (1982) found that among boys, the prevalence of occasional smoking (one or two times per month) had increased by 30 percent in the reference group, by 8 percent in the A group, and by 13 percent in the B group. Among girls, the prevalence of occasional smoking had increased by 20 percent in the reference group, by 18 percent in the A group, and by 9 percent in the B group. Vartiainen et al. (1990) reported the results of an eight-year follow-up and found that the prevalence of "any smoking" in the reference group was 10 percent higher than in the A group and 16 percent higher than in the B group. Western Australia Armstrong et al. (1990) conducted a large random- ized trial evaluating peer- and teacher-led social influ- ence programs among 12- and 13-year-old students in Western Australia. The authors used the MSPP program (Arkin et a1.1981) and resurveyed the students one year and two years after the intervention. Although the ef- fects of the program were not strong, at the two-year follow-up, the smoking prevalence in the control group was 6.6 percent higher than in the teacher-led interven- tion group and 8.1 percent higher than in the peer-led intervention group. North Karelia Youth Project The North Karelia Youth Project in Finland (part of the International Know Your Body study) was a two- year controlled trial that targeted schoolchildren in grade seven (12 and 13 years old) and included components on smoking prevention, physical activity, and reduction of dietary fat and alcohol consumption (Puska et al. 1981, 1982). The smoking intervention program was peer-led and involved three 45-minute sessions for grade seven; these students received seven shorter sessions the fol- lowing year (a schedule similar to that of Project CLASP). The program included sessions on social pressures to smoke, ways to resist such pressures, ways to cope with social anxiety, the short- and long-term health effects of both active and passive smoking, and the impact tobacco growing has on the environment. United Kingdom In the United Kingdom, Nutbeam et al. (1993) con- ducted a controlled trial of two school-based interven- tions. The Family Smokirig Education Project was derived from a program first developed in Norway (Aaro et al. 1983). Directed toward 10- through 12-year-olds, the project consisted of five lessons on the immediate health effects of smoking and on the wider environmental im- pact of tobacco growing and use. A notable feature was a leaflet sent to parents to encourage their support for school-based smoking education. The Smoking and Me project was the United Kingdom adaptation of the MSPP. Directed toward 10- through 12-year-olds, the program consisted of six sessions highlighting a range of social influences and equipping students with skills to manage these social pressures. At the first-year and second-year follow ups, no differences were observed between the intervention population and the control population for either smoking uptake or personal skills. Overall, school-based smoking education programs that have been evaluated internationally have met with limited success in the past decade. In general, these programs were brief and were not continued through the high school years. Many countries are taking more com- prehensive approaches to smoking control among young people; such approaches include community action, fur- ther restrictions on tobacco advertising and promotion, and substantially higher tobacco tax rates than are found in the United States. 224 Prevention TIMN 0139074

Preventing Tobacco Use Among Young People DICHTER E. Handbook of consumer motivations: the psychology of the world of objects. New York: McGraw-Hill, 1964. DIFRANZA JR, RICHARDS JW, PAULMAN PM, WOLF- GILLESPIE N, FLETCI TER C, JAFFE RD, ET AL. RJR Nabisco's cartoon camel promotes Camel cigarettes to children. Journal of the American Medical Association 1991;266(22):3149-53. DUNLAP OE JR. Radio in advertising. New York: Harper & Brothers, 1931. ERNSTER VL. Mixed messages for women: a social history of cigarette smoking and advertising. Nem York State Journal of Medicine 1985;85(7):335-40. FEDERAL TRADE COMMISSION. Trade regulation rule for the prevention of unfair or deceptive advertising and labeling of ciga- rettes in relation to the health hazards of smoking and accompanying statement of basis and purpose of rule. Washington (DC): Federal Trade Commission, June 22,1964. FEDERAL TRADE COMMISSION. Report to Congress: pursu- ant to the Federal Cigarette Labeling and Advertising Act. Wash- ington (DC): Federal Trade Commission, 1968. FEDERAL TRADE COMMISSION. Report to Congress: pursu- ant to the Public Health Cigarette Smoking Act. Washington (DC): Federal Trade Commission,1970. FEDERAL TRADE COMMISSION. Staff f report on the cigarette advertising investigation. Washington (DC): FederalTrade Com- mission, May 1981. FEDERAL TRADE COMMISSION. Report to Congress for 1990: pursuant to the Federal Cigarette Labeling and Advertising Act. Washington (DC): Federal Trade Commission, 1992. FEDERAL TRADE COMMISSION. Report to Congress: pursu- ant to the Comprehensive Smokeless Tobacco Health Education Act of 1986. Washington (DC): Federal Trade Commission, 1993. FISCHER PM, RICHARDS JW JR, BERMAN EJ, KRUGMAN DM. Recall and eye tracking study of adolescents viewing tobacco advertisemertts: Journal of the American Medical Asso- ciation 1989;261(1):S!l~=9. FISCHER PM, SCHWARTZ MP, RICHARDS JW JR, GOLDSTEIN AO, ROJAS TH.. Brand logo recognition by children aged 3 to 6 years. Mickey Mouse and OId Joe the camel. Journal of the American Medical Association 1991;266(22):3145-8. FOOTE E. Advertising and tobacco. Journal of the American Medical Association 1981;245(16):1667-8. , FORTUNE. The uproar in cigarettes. Fortune 1953; XLVIII(6):130-3,161-2,164. FORTUNE. Embattled tobacco's new strategy. Fortune 1963;LXVII(1):100-2,120,125-6,131. FOX S. The mirror makers: a history of American advertising and its creators. New York: William Morrow, 1984. GELB BD, PICKETT CM. Attitude-toward-the-ad: links to humor and to advertising effectiveness. Journal of Advertising 1983;12(2):34-42. GEORGE H. GALLUP INTERNATIONAL INSTITUTE. Teen- age attitudes and behavior concerning tobacco: report of the findings. Princeton (NJ): George H. Gallup International Insti- tute, 1992. GILBERT E. Advertising and marketing to young people. Pleasantville (NY): Printers' Ink Books, 1957. GLOVER ED, CHRISTEN AG, HENDERSON AH. Just a pinch between the cheek & gum. Journal of School Health 198151(6):415-8. GRUBE JW, WEIR IL, GETZLAF S, ROKEACH M. Own value system, value images, and cigarette smoking. -Personal- ity and Social Psychology Bulletin 1984;10(2):306-13. .; : GUNTHER J. Taken at the flood: the story of Albert D. Lasker. New York: Harper & Brothers, 1960. HETTINGER HS, NEFF WJ. Practical radio advertising. Englewood Cliffs (NJ): Prentice Hall,1938. HOWE H. An historical review of women, smoking and advertising. Health Education 1984;15(3):3-9. HUANG PP, BURTON D, HOWE HL, SOSIN DM. Black- white differences in appeal of cigarette advertisement among adolescents. Tobacco Control 1992;1(4):249-55. JOHNSON CA. Untested and erroneous assumption under- lying antismoking programs. In: Coates TJ, Petersen AC, Perry C, editors. Promoting adolescent health: a dialogue on research and practice. New York: Academic Press,1982: KESSLER L. Women's magazines' coverage of smoking re- lated health hazards. Journalism Quarterly 1989;66(2):316-23. KING KW, REID LN, MOON YS, RINGOLD DJ. Changes in the visual imagery of cigarette ads, 1954-1986. Journal o f Public Policy & Marketing 1991;10(1):63-80. KLEIN JD, FOREHAND B, OLIVERI J, PATTERSON CJ, KUPERSMIDT JB, STRECHER V. Candy cigarettes: do they encourage children's smoking? Pediatrics 1992;89(1):27-31. KOTLER F. Marketing management: analysis, planrling,: imple- mentation, and control. 7th ed. Englewood Cliffs (NJ): Prentice Hall, 1991. Advertising and Promotion 199 TIMN 0139051

F.+hatvo ~, I,t'.}011111 Pt't'Pit' what action, if any, would be taken. Candy cigarettes imitating Camel, Luckv Strike, L&M, Marlboro, Pall Mall, Salem, Winston, and Vicerov were still available in the United States into the late 1970s (Blum 1980). Such candv has since become less widely available, but it has not been banned by law. A recent study of the role candy cigarettes play in the development of smoking behaviors used focus groups, student survevs, and a distributional analysis to find that most children knew where to obtain candy cigarettes, even though they were available at only some conve- nience stores. The study also observed that repeated candy cigarette purchases were significantly correlated with experimental tobacco use, even when the analysis controlled for parents' smoking status (Klein et a1.1992). Changes in the Style of Cigarette Advertising Before reports in the early 1950s began linking cancer and smoking, cigarette advertising characteristi- cally had used explicit health claims, assertions, and reassurances, such as "Not a Cough in a Carload;' "No Throat Irritation," "More Doctors Smoke Camels Than Any Other Cigarette;' "Smoking's More Fun When You're Not Worried by Throat Irritation or 'Smoker's Cough"' (Calfee 1985). With greater public concern about cancer, however, these continuing health claims, although intended to reassure consumers, were likely increasing consumer awareness of the suspected health risks of smoking. Ad slogans like Philip Morris's "The cigarette that takes the fear out of smoking" were thus judged by a Business Week article (1953b) to be "strange somer- saults.... The company comes as close as is possible to the word 'cancer' without actually using it" (p. 54). Similarly, an artide in Fortune called industry atten- tion to the fact that many campaigns were so "riddled with warnings and appeals to fear" that "the present cigarette turmoil could be considered an inside job....[The] indus- try may be promoting itself toward a dead end" (Fortune 1953, p. 164). A Business Week article pointed out that the manufacturers' explicit health claims were exacerbating consumer concern. Although the industry could attribute its impressivegtbwth to advertising, "the cigarette compa- nies achieved rriuclt of this remarkable result by screaming at the top of their lungs about nicotine, cigarette hangovers, smoker's cough, mildness and kindred subjects.... From the early 1930s on, this meant almost solely one thing-sell health" (Business Week 1953a, pp. 66,68). The leading trade journal for the tobacco industry, the United States Tobacco Journal, pointed out that the industry had been "warned editorially on many occasions that the'health' theme was a risky one" and counseled selling "pleasure" instead of health (USTJ 1958b, p. 4). Motivation Research and the Image Era Market motivation researchers were likewise ad- vising the industry to create positive images of cigarette5. The researchers pointed out that "the differences be- tween the taste of different cigarette brands are much more imagined than real" (Dichter 1964, p. 345) and that "logic does not play a major role in marketing cigarettes" (Cheskin 1967, p. 135). Leo Burnett, the advertising expert who led the agency that repositioned the Marlboro campaign from a distinctly feminine to a distinctly masculine image, noted that "those who do smoke do so for various conscious or unconscious reasons" (Burnett 1958, p. 43). Social Research Inc. did motivation research on the psychology of smokers (Day 1955) and concluded that "advertising makes cigarettes respectable, and is thus reassuring" (Neuberger 1964, p. 38). Young & Rubicam also did a series of deep motivational interviews of smok- ers to extract social meanings, conflicted feelings, atti- tudes, perceptions, and beliefs about health aspects (Smith 1954). The results showed the importance of the themes of freedom and escape to smokers. Motivation research- ers concluded that people were "really interested in the properties from a psychological point of view :... Is it an exotic cigarette? . . . [Is it] masculine? . . . [Does it] allevi- ate my health worries?" (Martineau 1957, p. 61). They pointed out that health appeals may capture momentary competitive advantages, and they may offer some reas- surance to the inveterate smoker. But they do nothing to widen the market, to tap the driving force of'the real psychological satisfactions of smoking. According to these researchers, "the psychological satisfactionsare. . . the best material for advertising themes and appeals, because they carry their own reassurance. They are emotional supports which have developed in American society to make smoking seem reasonable, justifiable, and highly desirable. They obviously cannot be thrown in people's faces in their bare essence; but when they are implied, when they are communicated, they are understandable and satisfying" (Martineau 1957, p. 65). Put simply, the recommendations were to use reas- suring pictures, not words; images, not information. This tactic of employing. visual imagery, lifestyle portrayals, and drama to create mood and attitude, rather than words, facts, and data to create knowledge and compre- hension, is now known as "transformational" or "im- age" advertising, which stands in contrast with "informational" advertising (Puto and Wells 1983). • A leading text on advertising (Wells, Burnett, Moriarty 1989) uses the Marlboro repositioning cam- paign (discussed in detail later in this chapter) as the prototype example of this strategy. Marhneau (1957) Advertising and Promotion 171 TIMN 0139023

Preventing Tobacco Use Among Young People Enforcement methods Community education, direct education of mer- chants, contact with management of chains/fran- chises Letters to merchants, quarterly "stings," license suspension, fines up to $500 Educational program (6 months); "sting" opera- tions, citations, media publicity (7-11 months) None, other than publicity surrounding new state law that increased penalties for sales to minors None, other than new local ordinance requiring installation of locking devices on vending machines None, baseline study only None, baseline study only None, baseline study only None, baseline study only Comments Minors' ages: 14-16; minimum legal age was 18 Minors' ages: 12 and 13; all machines in local area visited before and after passage of local ordinance Minors' ages: 14-16; minimum legal age was 18 Minors' ages: 12-15; minimum legal age was 18; all outlets visited multiple times by different minors; rates averaged _ Minors' age: 15; at 1 year, 30% of machines were still out of compliance with the locking device law; 91% of machines without and 39% of machines with locking devices sold to a minor at 1-year follow-up Minors' age: 11; minimum legal age was 18 Minors' ages: 11-17; minimum legal age was 18 Minors' ages: 12 and 15 Minors' ages: 9-17; minimum legal age was 18 TIMN 0139103 Preverrtiorr 253

Preventing Tobacco Use Among YoLsng People Meta-Analyses of School-Based Smoking Prevention Extensive discussions of the methodological issues inherent in research on smoking prevention have been thoroughly discussed elsewhere (Cook and Campbell 1979; Flay 1985; Biglan, Severson, et a1.1987; Murray and Hannan 1990). The primary issues have included ques- tions of mixed units of analysis, attrition of the subject (student) population, integrity of implementation, and homogeneity of the subject population. These issues have been partly accounted for in four important meta- analytic studies published since 1980. Tobler (1986) examined 143 studies of drug-use prevention programs for 6th- through 12th-grade stu- dents and found that these programs had an overall significant impact on behavior, skills, and knowledge. The study also found that peer-led programs and pro- grams dealing with social influences were more effective than other modalities. Tobler (1992) later confirmed these findings with more rigorous analytic methods. The Rundall and Bruvold (1988) meta-analysis of 40 studies of school-based programs to prevent smoking examined knowledge, attitude, and behavioral outcomes of social influence programs versus traditional programs; the so- cial influence programs were more likely to affect ,attitudes and behavior. Rooney (1992) examined 90 school-based tobacco-use prevention programs con- ducted from 1974 through 1989 that sought to develop skills to resist social influences.. The meta-analysis took into account the clustering of students in schools and used the school as the unit of analysis. Results indicated that smoking prevalence was 4.5 percent lower among students in the social influence programs than among students in control conditions. The social influence pro- grams that were most effective at one-year follow-up were those that were delivered to sixth-grade students, that used booster sessions, that concentrated the pro- gram in a short time period, and that used an untrained peer to present the program. Under these more optimal conditions, long-term smoking prevalence was reduced by about 25 percent Bruvold's meta-analysis (1993) included 94 sepa- rate interventions from the 1970s and 1980s. The inter- vention programs were categorized as rational (providing factual information), developmental (increasing self- esteem and decision-making skills), social-norms- oriented (providing alternatives and reducing alienation), and social-reinforcement-oriented (developing skills to deal with social pressures to smoke). The meta-analysis showed that the rational approach had very little impact on smoking behavior, that the developmental and social norms approaches had equivalent and intermediate impact on smoking behavior, and that the social rein- forcement approach had the greatest impact on smoking behavior (Bruvold 1993). Discussion In retrospect, research on smoking prevention has by its very nature had to contend with various threats to validity posed by factors such as mixed units of analysis, differential attrition, and inconsistent implementation. To a large extent, the most recent research studies have been designed to deal with these methodological ob- stacles and have still found moderately strong preven- tion effects (Rooney 1992; Bruvold 1993). Therefore, most reviews of the smoking-prevention research literature consis- tently have come to the same conclusions, which can be sum- marized under three general findings. First, a variety of individual research reports (Botvin and Dusenbury 1989; Flay et a1.1989), seve}al comprehen- sive literature reviews (Flay 1985; Best et a1.1988), and four meta-analyses (Tobler 1986; Rundall and Bruvold 1988; Rooney 1992; Bruvold 1993) have all reported lower prevalences of smoking among students in social influence programs than among students in equivalent comparison groups or randomly assigned control groups. The differ- ence between treatment and nontreatment groups ranges from 25 to 60 percent and persists from one to four yearrs. Second, as Best et al. (1988) have underscored, given the number of research studies, the variability in program for- mat and scope•, the various communities and cultures in which these studies were undertaken, and the potential threats to internal and external validity in school-based research, the consistency of overall findings and reductions in smoking prevalence across all these studies is rather remarkable. Third, it has been observed repeatedly that the positive shorter-term intervention effects reported in adolescent smoking-prevention studies tend to dissi- pate over time (Murray et al. 1989; Pentz, MacKinnon, Dwyer, et al. 1989; Flay et al. 1989; Ellickson, Bell, McGuigan 1993). This general trend has been particu- larly evident among school-based intervention studies that included little or no emphasis on booster sessions, few (if any) communitywide activities, or few (if any) mass-media-based components (Botvin, Renick, Baker 1983; Perry, Klepp, Shultz 1988; Botvin and Botvin 1992). These interventions may be enhanced if they are em- bedded in a more comprehensive school health educa- tion program (Allensworth and Kolbe 1987; Walter, Vaughan, Wynder 1989). The comprehensive school health approach needs further evaluation but is promis- ing as an effective prevention tool. Only the social influence approaches have been scientifically demonstrated (through replicated research Prevention 225 TIMN 0139075

Preventing Tobacco Use Among Young People even trying) tobacco to stop. Advise smokers of the short-term adverse consequences of tobacco use, such 3s bad breath, other odors, and the cost of cigarettes. Advise smokeless tobacco users of the potential con- sequences of use, such as discoloration of teeth, de- struction of soft tissue in the mouth, and potential early development of oral lesions and cancers. • Assist tobacco users in stopping. Encourage parents who are trying to quit smoking and help them choose effective strategies to help them quit (Richards 1991, 1992). Assistance for parents or adolescents can in- clude selecting a quit date, providing self-help materi- als, and in some cases counseling on the use of nicotine replacement (transdermal nicotine patch or nicotine gum) (Glynn and Manley 1989). Help children and adolescents take additional responsibility for their health behaviors. Encourage participation in pro- grams that develop skills for solving problems, setting goals, making decisions, and countering peer pres- sure (Bingham, Edmondson, Stryker 1984a, b). • Arrange follow-up visits as appropriate. Arrange more frequent follow-up visits for an adolescent who is experimenting with tobacco products. At the first follow-up visit, one to two weeks after a scheduled quit date, discuss progress and problems. Arrange a second visit in one to two months. The five steps described above should be common- place in the medical setting. Richards (1992) notes.that "the words that a physician chooses to discuss smoking with a patient should be considered no less a therapeutic agent than the pharmacologic agent that the physician prescribes" (p. 687). Yet Frank et al. (1991) found that only 14 percent of smokers aged 12 through 17 years who had seen a physician in the previous year had been advised to quit smoking. In contrast, over 50 percent of smokers aged 25 years and older were advised to quit. Clearly, more consistent advice, concern, and counsel from the medical profession is warranted. Role of Health Professionals in the School, in the Community, and in Policy Formation Physicians and other health professionals are often considered leaders in their communities and have the opportunity to mobilize schools and communities to, develop tobacco-use prevention, cessation, and policy change strategies. Health professionals who have exam- ined their roles in this larger context should encourage their colleagues to act as advocates for such programs and, if possible, participate in their development or imple- mentation (Shank 1985; AAP 1987; Blum 1992). Health professionals play a powerful role as sources for nonsmoking advice and assistance, as role models of nonsmoking adults, as providers and sup- porters of a nonsmoking health care environment, and as agents who deliver nonsmoking programs in schools and communities (USDHHS 1991). Several medical organizations have adopted policies and developed programs to encourage member concern and involve- ment in preventing adolescent tobacco use. The AMA House of Delegates has adopted numerous policy reso- lutions that support local tobacco-control activities on behalf of children and others (AMA 1992b). The AAFP (1987) has also published policies and a manual on how to encourage patients of all ages to stop smoking. The AMA Guidelines for Adolescent Preventive Ser- vices recently recommended that physicians actively screen and counsel adolescent patients about tobacco use (AMA 1992a). The AAP, with the NCI, has drafted a set of age-specific recommendations for pediatric practice as part of their Tobacco Free Generation pro- gram to prevent adolescent tobacco use (Epps and Manley 1991a). The AAP also distributes Healthy Beginning kits developed by the American Lung As- sociation for counseling parents on the harmful effects of smoking around children and distributes pamphlets for parents and adolescents regarding tobacco use (AAP 1988, 1990a, b). The American Academy of Oto- laryngology-Head and Neck Surgery, Inc., launched a major public service campaign titled Through with Chew in response to the problem of smokeless tobacco use by youth. The campaign includes a video, a physi- cian volunteer kit to encourage and assist members in community outreach, and a variety of educational aids designed'to persuade young men, especially athletes, not to use smokeless tobacco (American Academy of Otolaryngology-Head and Neck Surgery 1992). Community Programs to Discourage Tobacco Use Introduction Community-based strategies to prevent smoking are important adjuncts to school-based programs. Some studies have shown that classroom-based smoking- prevention programs, by themselves, have produced only short-term effects (Lichtenstein et al. 1990; Pentz, MacKinnon, Flay, et al. 1989; Best et al. 1988). These limited outcomes suggest the need to mobilize parents and elements of the community outside the schools to produce lasting behavior change. Young people who have the highest rates of to- bacco use are those least likely to be reached through school programs (Glynn, Anderson, Schwarz 1991). Messages concerning tobacco use will be more accept able to high-risk adolescents if they are embedded in groups or programs to which these youth already Prevention 233 TIMN 0139083

S«rgeon General's Report This research showed that prevention strategies in the 1960s and 1970s had greatly underestimated the ex- tent to which adolescent smoking was determined by social environmental variables. An exception was the early work of the proactive physicians group Doctors Ought to Care (DOC), which argued that tobacco adver- tising and promotional activities strongly influence the social environment of adolescents (Blum 1980). A de- tailed overview of the relationships of social environ- mental variables to the acquisition of smoking behavior is found in Chapter 4 of this report (see "Environmental Factors in the Initiation of Smoking"). As the major risk factors associated with smoking onset were identified, they were translated into new intervention methods, and the programs that resulted were substantially different from the approaches that had preceded them. Instilling Skills for Resisting Social Influences to Smoke Prevention research grants from the National Insti- tute on Drug Abuse (NIDA) and the National Institutes of Health (Bell and Levy 1984; USDHHS 1984; Stone 1985; Glynn 1989) were largely responsible for creating a wave of prevention program development from the late 1970s throughout the 1980s. These efforts fundamen- tally redefined the concept of primary prevention in several ways. First, programs began to make better use of social, psychological, and behavioral theories as a basis for un- derstanding what approaches might work to modify patterns of smoking onset among adolescents. Program design became far more data driven, as researchers be- gan to design intervention components based directly on findings from theory-based etiologic research on adoles- cent smoking. This orientation led to an improved un- derstanding and targeting of the determinants and correlates of smoking behavior among adolescents. Much information was published about the characteristics and components of successfulsmoking-prevention programs. Much of what has.beiqlearned focuses particularly on social influences, n-oraw and skills training and has the objective of attaining behavioral abilities, methods, skills, and techniques (rather than knowledge, beliefs, or moti- vation) that make it easier to adopt and maintain health- enhancing behavior patterns, such as notsmoking. Lastly, the research methodology used to evaluate the efficacy of preventive interventions became far more sophisti cated and considerably more rigorous. Intervention Objectives This prevention intervention approach recog- nizes the social environment as the most important determinant of smoking onset and focuses on the devel- opment of norms and skills to identify and resist social influences to smoke. Underlying this approach is the assumption that adolescents who smoke may lack spe- cific skills to deal successfully with various social influ- ences that support smoking. Such influences include the misperception that most people smoke, the perceived desirable social image of smoking, the appeal of cigarette advertising and promotional activities, and the persua- sive effects of sibling and peer smoking. Although con- siderable variation can be found across curricula, programs that instill the skills needed to resist such social influences have included a fairly consistent group of components that include training in resisting social pres- sures (e.g., marketing) and peer pressures to smoke and training that fosters general assertiveness, decision mak- ing, and communication skills (Botvin and Wills 1985). These programs also promote healthful normative ex- pectations and particularly correct the misperception that most adolescents smoke. Earlier programs for adolescents designed their messages to generate fear and anxiety about long-term disease risk. Approaches that teach skills to guard ag~inst social influences have assumed that scare tactics based on long-term health risk are not pertinent to the short- term perspective of many adolescents. The principal messages of skills-based intervention have thus focused on the negative, short-term social consequences of smok- ing, on the techniques of tobacco advertising that may be falsely appealing to adolescents, and on the socially sa- lient advantages of being a nonsmoker. Overall Program Structure In 1987, the NCI convened a panel of experts to establish consensus regarding the essential structural elements of effective smoking-prevention programs (USDHHS 1991). The panel agreed that eight features could be considered both necessary and sufficient for effective school-based smoking-prevention programs (Glynn 1989) (Table 4). In a recent meta-analysis (Rooney 1992) of outcomes of research studies conducted from 1974 through 1989 on school-based smoking prevention, the essential elements of the NCI expert panel were examined and mostly supported. This meta-analysis will be discussed later in this chapter. Most of the successful programs that provide skills for resisting social influences share several major cur- riculum components. One of these is to convey the short- term negative consequences of cigarette smoking, including social undesirability and physiological impair- ment. Another component is to have students explore inaccurate normative expectations; students thus learn that cigarette smoking is not a normative behavior for 218 Prevention . T.IMN 0139068

5urgeon General's Report Table 8. Published studies examining over-the-counter cigarette sales to minors, United States, 1989-1993 Relative Study and location Number of stores or attempts Baseline sales rate (%) Follow-up sales rate (%) reduction in successful tries by minors (%) Time period Altman et al. (1989) California 412 74 39 -47 6 months Skretny et al. (1990) 62 intervention, NA 77 -10 * 2 weeks New York 58 control NA 86 Feighery, Altman, approx. 169 72 62 -14 6 months Shaffer (1991) California (see comment) 21 -71 11 months Jason et al. (1991) 20-30 60-70 36 -40 3 months Illinois 3 -93 18 months Altman et al. (1991) California 97 76- 59 -22 12 months Forster, Hourigan, McGovern (1992) Minnesota 301 53 38 -28 3 months DiFranza et aL (1987) Massachusetts 93 63 NAt NA NA Nelson, Marso, Roby (1989) South Dakota 30 87 NA NA NA Thomson and Toffler (1990) Oregon 66 87 NA NA NA Centers for Disease - Control [CDC], (1990) Colorado 97 55 NA NA NA • Hoppock and Houston (1990) Kansas 67 32 NA NA NA CDC (1993) Missouri 89 46 NA NA . NA CDC (1993) Texas • 94 63 NA NA NA *Not statistically significant. tNA = Not available. 250 Prevention TIMN 01391•00

Surgeort General's Report Table 12. Health warnings required on tobacco packages and advertisements in the United States, 1966-1993 Health warnings Effective dates Packages Advertisements Cigarettes CAUTION: January 1, 1966- X Cigarette Smoking May Be Hazardous October 31, 1970 to Your Health. WARNING: November 1, 1970- X The Surgeon General Has Determined October 11, 1985 That Cigarette Smoking Is Dangerous to Your Health. March 30,1972- X* October 11,1985 SURGEON GENERAL'S WARNING: October 12, 1985-present X Xt Smoking Causes Lung Cancer, Heart Disease, Emphysema, and May Complicate Pregnancy. SURGEON GENERAL'S WARNING: October 12, 1985-present X X' Quitting Smoking Now Greatly Re- duces Serious Risks to Your Health. SURGEON GENERAL'S WARNING: October 12, 1985-present X Xt .Smoking by Pregnant Women May Result in Fetal Injury, Premature Birth and Low Birth Weight. SURGEON GENERAL'S WARNING: October 12, 1985-present X Xt Cigarette Smoke Contains Carbon Monoxide. Smokeless tobacco WARNING: February 27, 1987-present X X$ This product may cause mouth cancer. WARNING: February 27, 1987-present X V This product may cause gum disease and tooth loss. WARNING: February 27,1987-present X Xx This product is not a safe alternative to cigarettes. Source: Federal Trade Commission (1981). *Required by Federal Trade Commission consent order. All other warnings required by federal legislation. 'The four warnings mandated for cigarette advertisements on outdoor billboards are slightly shorter versions of the same messages. =The warnings on advertisements must appear in a circle-and-arrow format (see Figure 5). No warnings are requiredron outdoor billboards. 264 Prevention TIMN 0139114

SUrgeon Genernl'> Report Table 13. State* cigarette taxes, July 1, 1993 Excise tax rate Sales tax+ Total state tax State (cents per 20-cigarette pack) (cents per pack) (cents per pack) Alabama 16.5 7 23.5 Alaska 29.0 0 29.0 Arizona 18.0 9 • 27.0 Arkansas 31.5 9 40.5 California 35.0 15 50.0 Colorado 20.0 0 20.0 Connecticut 47.0 12 59.0 Delaware 24.0 0 24.0 District of Columbia 65.0 13 78.0 Florida 33.9 12 45.9 Georgia 12.0 6 18.0 Hawaii 60.0 9 69.0 Idaho 18.0 9 • 27.0 Illinois 30.0 13 43.0 Indiana 15.5 9 24.5 Iowa 36.0 11 47.0 Kansas 24.0 9 33.0 Kentucky 3.0 9 12.0 Louisiana 20.0 8 28.0 Maine 37.0 11 48.0 Maryland 36.0 10 46.0 Massachusetts 51.0 9 60.0 Michigan 25.0 7 32.0 Minnesota 48.0 14 62.0 Mississippi 18.0 11 29.0 Missouri 13.0 7 20.0 Montana 19.3 • 0 19.3 Nebraska 34.0 • 9 43.0 Nevada 35.0 • 13 48.0 New Hampshire 25.0 0 25.0 New Jersey 40.0 12 52.0 New Mexico 21.0 9 30.0 New York 56.0 8 64.0 North Carolina 5.0 6 11.0 North Dakota 44.0 11 55.0 Ohio 24.0 8 32.0 Oklahoma 23.0 8 31.0 Oregon 28.0 0 28.0 Pennsylvania 31.0 11 42.0 Rhode Island 37.0 14 51.0 South Carolina 7.0 8 15.0 South Dakota 23.0 7 30.0 Tennessee 13.0 14 27.0 Texas 41.0 13 54.0 Utah 26.5 9 35.5 Vermont 20.0 9 29.0 Virginia 2.5 7 9.5 Washington 54.0 13 67.0 West Virginia 17.0 10 27.0 Wisconsin 38.0 10 48.0 Wyoming 12.0 0 12.0 Sources: Tobacco Institute (1992); Action on Smoking and Health (1993). *Includes the District of Columbia. rSales tax information is for November 1, 1992. 266 Prevention TIMN 0139116

Surgeon General's Report Table 11. Major legislation related to information and education about tobacco and health in the United States, 1965-1986 Law Date Federal Cigarette Labeling and Advertising Act (Public Law 89-92) 1965 Public Health Cigarette Smoking Act (Public Law 91-222) 1969 Little Cigar Act (Public Law 93-109) 1973 Comprehensive Smoking Education Act (Public Law 98-474) 1984 Labeling requirements Required a health warning on cigarette packages Preempted other warnings on packages Temporarily preempted Federal Trade Commission (FTC) requirements of any health warning on cigarette advertisements Strengthened the health warning on cigarette packages Preempted other warnings on packages Temporarily preempted FTC require- ment of any health warning on cigarette advertisements* None Replaced the previous health warning on cigarette packages and advertise- ments* with a system requiring rotation of four specific health warnings Preempted other warnings on packages Comprehensive Smokeless 1986 Required the rotation of three health Tobacco Health Education Act warnings on smokeless tobacco packages (Public Law 99-252) and advertisements (in circle-and-arrow format on advertisements) Preempted any other health warning on smokeless tobacco packages or adver- tisements (except billboards) Source: U.S. Department of Health and Human Services (1989). *In 1972, an FTC consent order extended the requirement for a health warning on cigarette packages to include cigarette advertisements. 258 Prevention TIMN 01391og

Surgeort General's Report Table 7. Major mass-tnedia campaigns to prevent tobacco use among young people, United States, 1983-1992 Source and dates Year of survey Campaign description Representative spots Office on Smoking and Health (1983-1990) National Cancer Institute (1987) American Lung Association (1988) Michigan Department of Public Health (1988-1992) California Department of Health Services (1989-1992) Minnesota Department of Health (1989-1992) American Cancer Society (1990) Vermont Department of Health (1992) 240 Prevention . A series of TV spots with attractive images of young people dancing or playing sports; the general theme is that living is positive and smoking is out of fashion Radio campaign featuring national radio personality Casey Kasem TV spot with awareness message TV spots, billboards, and bus cards showing negative social aspects of smoking ,Culturally diverse multimedia campaign to deglamorize tobacco use, reposition tobacco marketers as part of the problem, and inform about the dangers of smoking TV, radio, and billboard campaign showing immediate negative conse- quences of smoking and emphasizing that most young people don't smoke; negative aspects of chewing tobacco shown TV spot showing peer disapproval of smoking TV spots showing positive aspects of not smoking and negative aspects of smoking, showing how to refuse a cigarette, and emphasizing that most young people don't smoke Cigarette Mash Nic (A Teen) • Smoking's Out Cigarettes Are Drugs Boy Mouth Girl Mouth Rappers / Pick It' Smart Kids Industry Smokesman In Your Mouth Clothes Animals Smoking Crate Death Breath Charming Intro Billy Smoking Is Real Gross Mindy at the Party Breakaway Nicoflame Shy Girl Beautiful Lady TIMN 0139090

Preventing Tobacco Use Among Young People extent) ninth grades. Parallel analysis failed to show that the intervention had any positive effect on cigarette smoking. The results for smokeless tofiacco use, how- ever, were particularly encouraging, since only two of the seven class periods of the intervention were devoted to smokeless tobacco. The intervention used in the Severson et al. (1991) study sought to make students sensitive to overt and covert pressures to use tobacco and taught effective ways to respond to these pressures. The studLInts practiced how to refuse offers of tobacco. Besides using a struc- tured curriculum with role-play activities, the teacher used videotapes to standardize instruction and maintain student interest. The program was taught by regular classroom teachers; same-age peer leaders assisted in role-playing activities for the seventh-grade students. A videotape titled Big Dipper (Oregon Research Institute 1986) was developed to highlight the physical and social consequences of smokeless tobacco. To involve parents,, brief brochures were mailed to students' homes. Toward No Tobacco Use A study by Sussman et al. (1993) reports positive results in their Toward No Tobacco Use (TNT) project for reducing smokeless tobacco use. The study compared four different prevention curricula developed to coun- teract three types of factors related to the onset of tobacco use that are typically addressed within a comprehensive social-skills program. These include peer approval for using tobacco, incorrect social information provided about tobacco use, and lack of knowledge about physical con- sequences of tobacco use. The development of these curricula is detailed in previous reports (Sussman 1991). Smokeless tobacco use was significantly less preva- lent among students who had received the TNT inter- vention than among those who had not (Sussman et al. 1993). The results of the evaluation of this 10-lesson curriculum intervention suggest that learning about the physical consequences of smokeless tobacco use can be as successful as a social influences program and that a combination of both is probably best for deterring use of smokeless tobacco. The Sussman et al. (1993) study in southern California and the Severson et al. (1991) study in Oregon suggest that smokeless tobacco use can be reduced through school-based programs that try to pre- vent all types of tobacco use among seventh- and ninth- grade students. Project SHOUT Elder et al. (1993) developed Project SHOUT, a social influences program that has been evaluated in 22 junior high schools in San Diego County, Califor- nia. Based on an operant conditioning model of tobacco use (Elder and Stern 1986), the intervention was delivered in randomly assigned schools to seventh-grade students. Intervention and assessment continued for three years (through seventh, eighth, and ninth grades). Because of multiple school changes at the end of the eighth grade, Project SHOUT used telephone calls and program newsletters for the ninth- grade intervention. At the three-year follow-up, the intervention had a significant effect on cigarette use, smokeless tobacco use, and combined cigarette and smokeless tobacco use. The intervention effect was particularl,v strong during the ninth grade (Elder et al. 1993). The three-year intervention and follow-up is a strength of this study; previous studies have been limited to a single intervention year and one-year follow-up. Programs for Native American Populations Smokeless tobacco use by Native American youth on reservations is higher than that of other groups (Schinke et a1.1989). There is evidence of early, frequent, and heavy use of snuff and chewing tobacco by Native American children and Alaskan Natives (Schinke et a1.1987). Young people in these populations begin using smokeless to- bacco at an early age, and girls use it at levels almost equal to boys (Schinke et al. 1987). Current reservation based interventions aimed at reducing this pattern of smokeless tobacco use have not yet been evaluated. These ongoing programs are sensitive to the unique aspects of tobacco use by Native Americans, since tobacco has traditionally played a role in sacred rites. The programs make extant materials appropriate for Native American children by creating a specific curriculum for the tribal group and having Native Americans provide the intervention in schools or other settings on their reservation. Smoking Cessation Introduction Few studies have examined adolescent smoking cessation. The four primary sources of information on adolescent cessation are national probability surveys on patterns of adolescent attempts to quit (see "Attempts to Quit Smoking" and "Self-Reported Indicators of Nicotine Addiction Among Smokers" in Chapter 3), con- venience sample surveys of adolescents who have tried to quit on their own, reports from prevention projects on effects of treatment on youth who were smokers at baseline, and programs that explicitly try to recruit adolescent smokers into cessation programs. The rela- tively few intervention studies vary considerably in sci- entific quality; many are anecdotal or desQiptive accounts of programs. Prevention 227 TIMN 0139077

Preventing Tobacco Use Among Young Pe'ople subjects had quit at the three-month follow-up. The study suggests that a school-based multisession clinic can achieve small cessation rates for adolescent subjects who volunteer, although the volunteer rates for the study were notably low. Persons going through treatment for smokeless tobacco addiction often request an oral substitute to help them through withdrawal. Smokeless tobacco users re- port using cinnamon sticks, gum, sunflower seeds, finely ground mint leaves, or other chewed foodstuffs to lessen the effects of withdrawal (Severson 1992). To evaluate the use of nonnicotine substitutes as aids for smokeless tobacco cessation, a recent study compared the use of a ground-up mint product, chewing gum, and no substi- tute (Chakravorty 1992). Subjects were recruited from six high schools in rural Illinois. Two schools each were randomly assigned to either the treatment group (mint snuff substitute), gum group, or lecture-only control group. Within schools, smokeless tobacco users were invited to volunteer for a two-session school-based ces- sation program. Eighty-three males were recruited to participate. Of the 70 students who completed the treat- ment, 30 were in the mint group, 15 in the gum group, and 25 in the lecture-only group. At the end of the treatment period, all three groups had about the same quit rates. Eleven students reported quitting smokeless tobacco, but nine of these quitters also smoked cigarettes. The author reports that students using the mint snuff substitute significantly reduced their frequency and in tensity of smokeless tobacco use, but the study had no biochemical verification of use. The results suggest that adolescent males who use smokeless tobacco can be recruited to attend sessions at school and that nontobacco oral substitutes may be a helpful adjunct to quitting. Research with adults suggests that health care pro- viders can motivate some adult users of smokeless to- bacco to quit (Stevens et al., in press). The clinical opportunity to provide advice on quitting in the context of health care delivery has been referred to as a "teach- able moment" (Vogt et al. 1989; Morosco 1986). The results are modest in terms of overall quit rates, but having dentists, hygienists, nurses, and physicians coun- sel their patients to quit using smokeless tobacco could have a significant effect on prevalence. The Stevens et al. (in press) study provided the first examination of a large- scale, low-cost intervention to encourage smokeless to- bacco users to quit. This program, which was conducted in the context of regular hygiene visits, provided strong evidence of the effect of smokeless tobacco use on oral health: 73 percent of the adult users in this study had identifiable oral lesions (Little, Stevens, La Chance, et al. 1992). Parallel studies with youth or studies of programs using physicians or other health care providers have not been conducted. Smokeless Tobacco and Cigarettes Young people who use smokeless tobacco may also smoke cigarettes. Studies have reported that from 12 to 30 percent of all regular users of smokeless tobacco also use cigarettes (Eakin, Severson, Glasgow 1989; Wil- liams 1992; Stevens et al., in press; see "Use of Smokeless Tobacco and Cigarettes" in Chapter 3). This relationship is critical, since cessation programs may motivate smoke- less tobacco users to quit using snuff or chewing tobacco, yet not affect their use of cigarettes-and thus not a ffect their addiction to nicotine. Moreover, deprivation of one substance may lead to a direct increase in the use of the other (Biglan, La Chance, Benowitz, unpublished data). Cessation rates among men who use both tobacco prod- ucts are significantly lower than those among men who use smokeless tobacco exclusively (Stevens et al., in press). Research and Programmatic Challenges Certain peculiar aspects of smokeless tobacco use may present problems to those who plan or study cessa- tion programs. The lack of public data on the nicotine content of smokeless tobacco products is not only a research problem but a challenge to cessation efforts that might reduce the severity of nicotine withdrawal by gradually cutting back on nicotine ingestion. Such ef- forts are further hampered, as are studies or programs depending on self-monitoring of product consumption, by the nonuniform (bulk) packaging of most smokeless prpducts and by the variation in the amount of product that constitutes a "pinch" (of chewing tobacco) or a "dip" (of moist snuff) (Severson et al. 1990.) External monitoring of use also has inherent limitations, since snuff (and to a lesser extent, chewing tobacco) can be used surreptitiously. On the other hand, the oral lesions frequently experienced by smokeless tobacco users readily indicate smokeless use-and provide direct physi- cal evidence to the user that this behavior has detrimen- tal health effects (Little, Stevens, Severson, et a1.1992). The relationship between smokeless tobacco use and cigarette smoking also presents problems for re- search and intervention. Because many adolescents per- ceive smokeless tobacco use to be a safe alternative to smoking, motivation to quit using smokeless tobacco products may be low. On the other hand, because as many as one-third of all smokeless tobacco users also smoke cigarettes, the possibility exists (as was discussed previously) that persons trying to quit using smokeless tobacco may continue to smoke-or even increase their smoking-to minimize nicotine cravings. Although the preliminary evidence is that cessa- tion rates for smokeless tobacco are similar to those for smoking, the difficulty in recruitment, the small sample Prevention 231 TIMN 0139081

Surgeon General's Report Table 14. Cigarette taxes and cigarette prices per pack, 1955-1991 Taxes as Realt Average percent- Realt Real' average Average Average cigarette age of average average cigarette state tax federal price average state taxt federal price Year (cents) tax (cents) (cents) price' (cents) tax (cents) (cents) 1955 3.5 8.0 22.7 48.7 13.1 29.9 84.7 1956 3.8 8.0 23.2 47.4 14.0 29.9 85.3 1957 3.9 8.0 23.8 48.8 13.9 28.5 84.7 1958 4.0 8.0 25.0 48.0 13.8 27.7 86.5 1959 4.2 8.0 25.6 46.6 14.4 27.5 88.0 1960 4.7 8.0 26.1 48.9 15.9 27.0 88.2 1961 4.7 8.0 26.1 48.6 15.7 26.8 87.3 1962 5.1 8.0 26.9 48.3 16.9 26.5 89.1 1963 5.2 8.0 26.8 49.4 17.0 26.1 87.6 1964 5.6 8.0 27.9 49.3 18.1 25.8 90.0 1965 5.9 8.0 28.2 49.8 18.7 25.4 89.5 1966 6.9 8.0 30.0 51.4 21.3 24.7 92.6 1967 7.1 8.0 30.5 50.8 21.3 24.0 91.3 1968 8.4 8.0 32.3 49.2 24.1 23.0 92.8 1969 9.1 8.0 32.8 48.9 24.8 21.8 89.4 1970 10.2 8.0 37.1 ' 47.7 26.3 20.6 95.6 1971 10.7 8.0 38.9 46.8 26.4 19.8 96.0 1972 11.6 8.0 40.0 47.7 27.8 19.1 95.7 1973 12.1 8.0 40.3 48.4 27.3 18.0 90.8 1974 12.1 8.0 41.8 47.6 24.5 . 16.2 84.8 1975 12.2 8.0 44.5 44.5 22.7 14.9 82.7 1976 12.4 8.0 47.9 41.4 21.8 14.1 84.2 1977 12.5 8.0 49.2 40.5 .20.6 -13.2 81.2 1978 12.9 8.0 54.3 37.1 19.8 12.3 83.3 1979 12.9 8.0 5f- 5 35.5 17.8 11.0 78.2 1980 13.1 8.0 6i2-.+:; 34.5 15.9 9.7 72.8 1981 13.2 8.0 63.0 33.1 14.5 8.8 69.3 1982 13.5 8.0 69.7 29.9 14.0 8.3 72.2 1983 14.7 12.0 81.9 26.8 14.8 12.0 82.2 1984 15.3 16.0 94.7 33.2 14.7 15.4 91.1 1985 15.9 16.0 97.8 32.3 14.8 14.9 90.9 1986 16.2 16.0 104.5 30.8 14.8 14.6 95.3 1987 16.9 16.0 110.0 29.9 14.9 14.1 96.8 1988 18.2 16.0 122.2 28.1 15.4 13.5 103.3 1989 21.8 16.0 127.5 26.5 17.6 12.9 102.8 1990 24.7 16.0 144.1 26.4 18.9 12.2 110.3 1991 25.9 20.0 153.3 25.6 19.0 11.7 112.6 Source: Tobacco Institute (1992). 'Percentages cannot be calculated directly from the tax and price information, since taxes are weighted average taxes for the entire fiscal year, whereas prices and percentages are generally as of November 1. ''Real taxes and prices are obtained by dividing the actual taxes and prices by the National Consumer Price Index, with the average of 1982-1984 being the benchmark. All data are for the fiscal year ending June 20. xState taxes are a weighted average of the tax in taxing states, including Washington, D.C. (42 in 1955, 51 in 1970 and after). Price refers to the median retail price in all taxing states. 268 Prevention TIMN 0139118

Surgeon General's Report studies) to reduce or delay adolescent smoking. Still, the effects of these programs have not been sustained without additional educational interventions or commu- nity components. This experience suggests that pro- grams grounded in school based skills training are indeed important for preventing smoking, although more sus- tained and comprehensive efforts may be needed for long-term success. The concept of reciprocal determinism (Bandura 1986) would argue that these complementary compo- nents should target the elements of the dynamic person- environment interaction that school-based interventions may not be capable of reaching, much less influencing. These components would include the types of commu- nity, environmental, legislative, policy-based, and soci- etal interventions described later in this chapter. Preventing Smokeless Tobacco Use Introduction The 1986 publication of the Advisory Committee's Report to the Surgeon General (USDHHS 1986b) on the health consequences of using smokeless tobacco (chew- ing tobacco and snuff) and subsequent reports of wide- spread use of smokeless tobacco among children and adolescents (Boyd et al. 1987; USDHHS 1992b) have called forth a wide range of written and media materials (including films, pamphlets, and video programs) on the risks of using smokeless tobacco (Wilson and Wilson 1987; Laflin, Glover, McKenzie 1987). These materials, made available to school personnel and parents, have aimed at countering the perception that smokeless to- bacco is a safe alternative to cigarettes. Materials have been produced by federal agencies (such as the 1VCI and the National Institute of Dental Research), voluntary nonprofit groups (such as the ACS), and professional organizations (such as the American Dental Association and the American Academy of Otolaryngology). These materials have been distributed widely, but the degree of their diffusion has not been evaluated, nor has their effect on young people's use of smokeless tobacco. Evaluation of School-Based Efforts Because the increased use of smokeless tobacco among youth is a relatively recent phenomenon, few pro- grams for preventing adolescent use of these products have been evaluated for either short- or long-term efficacy. Those that have been evaluated have been but one compo- nent of a broad tobacco-prevention program. In response to the emerging concern about the health risks of regular smokeless tobacco use, the Na- tional Institutes of Health has funded numerous research grants to develop interventions to prevent initiation or regular use and to promote or assist cessation for adolescent and young adult users. Nine research grants on smokeless tobacco use have been funded by the NCI since 1987; most are focused on adolescent populations (USDHHS 1990b), and results are pending. Although most of these projects have been school-based preven- tion activities, some programs have targeted youth in non-school settings (e.g., 4-H clubs, Little League base- ball clubs, and Native American community centers). The prevention programs that have been evaluated have targeted both smoking and smokeless tobacco use among middle and high school students. The primary focus has been on middle school (grades 6-8, ages 12-14). Smokeless tobacco prevention has also been included as part of more comprehensive curricula to prevent drug use, such as Here's Looking at You, 2000 (Roberts, Fitzmahan & Associates, Inc., and Comprehensive Health Educa- tion Foundation 1986), or as part of community-based interventions to reduce drug use. Seldom have pro- grams to prevent smokeless tobacco use been instituted independent of other substance-use prevention or of a more general tobacco-use prevention effort. Since smoke- less tobacco products are used primarily by males, the overall prevalence of use is lower than that of smoking. There is also less concern about the health effects of smokeless tobacco than about those of illegal drugs and cigarettes. This logical inclusion, however, of smokeless tobacco prevention in the context of other prevention efforts makes the evaluation of the smokeless tobacco component problematic. A factor that more directly obscures the impor- tance of smokeless tobacco prevention is the widespread acceptance of use by both young people and parents. Youth generally perceive that smokeless tobacco use is a safe alternative to cigarette smoking. For example, in one study, 77 percent of school aged children believed that cigarette smoking was very harmful to one's health, yet only 40 percent believed the same of smokeless tobacco use (Schaefer et a1.1985). Parents are also more likely to accept smokeless tobacco use than smoking among teens (Chassin, Presson, Sherman 1985; see "Parental Reaction to Smokeless Tobacco Use" in Chapter 4). The Oregon Research Institute Program In several studies, young adolescents have received a preventive curriculum that targeted both smoking and smokeless tobacco use. In one such study (Severson et al. 1991), a social influences program conducted by the Or- egon Research Institute was delivered by regular class- room teachers and by same-age peer leaders to entire classrooms in randomly assigned schools. The brief seven-session program significantly reduced sntiokeless tobacco use among males in both seventh and (to a lesser 226 Prevention TIMN 0139076

References ADVERTISING AGE. Luckies runs college drive. Advertising Age 1953a;24(46):99. ADVERTISING AGE. New medium gets to school students on their textbooks. Advertising Age 1953b;24(21):14. ADVERTISING AGE. ACS anti-smoking push'succeeds; but resistance looms. Advertising Age 1963a;34(45):1. ADVERTISING AGE. Advertising Age presents marketing profiles of the 100 largest national advertisers. Advertising Age 1963b;34(35):43. ADVERTISING AGE. American tobacco sets 'adult' theme for Lucky Strikes. Advertising Age 1963c;34(32):102. ADVERTISING AGE. B&W sponsors 2 bowl games. Advertis- ing Age 1963d;34(43):72. ADVERTISING AGE. Beer, cigaret[tel TV ads lure teens via sexual, athletic themes, 'America' writer charges. Advertising Age 1963e;34(1):12. ADVERTISING AGE. Cigaret[tel promotions on college cam- puses end. Advertising Age 1%3f;34(26):1,108. ADVERTISING AGE. Collins 'resents' Luckies ad; it's brazen and cynical.' Advertising Age 1963g;34(49):1. ADVERTISING AGE. Curbs on cigaret[tel advertising. Ad- vertising Age 1963h;34(1):16. ADVERTISING AGE. Decency, honesty will help. Advertising Age 1963i;34(47):22. ADVERTISING AGE. Don't restrict hours; avoid shows with kid appeal, tobacco menurged. AdvertisingAge 1963j;34(29):1,8. ADVERTISING AGE. L'Filters, menthols pace cigaret[te1 sales increase, says 'BusiitM Week' report. Advertising Age 1963k;34(51):68. ADVERTISING AGE. Ford, Marlboro back NFL tilts on CBS- TV; other radio-TV buys. Advertising Age 19631;34(16):%. ADVERTISING AGE. Lorillard cites role of ads in making it no. 3 cigaret[tel maker. Advertising Age 1963m;34(9):10. ADVERTISING AGE. Lorillard puts some $35,000,000 into ads: Cramer. Advertising Age 1963n;34(15):2. 196 Advertising and Promotion Surgeon General's Report ADVERTISING AGE. NAB supports Collins; stiffens medical ad code. Advertising Age 1%3o34(4):1,77,85. ADVERTISING AGE. Philip Morris Inc. sales, profits rise. Advertising Age 1963p;34(7):8. ADVERTISING AGE. PTA pushes effort against cigaret[tel ad appeals to teens. Advertising Age 1963q;34(23):78. ADVERTISING AGE. Regulate cigaret[tel ads CU suggests in smoking-health book. Advertising Age 1963r;34(30):40. ADVERTISING AGE. R.J. Reynolds is lead-off sponsor as'63 baseball emerges from dugout. Advertising Age 1963s;34(11):10. ADVERTISING AGE. This campaign should be dropped. Advertising Age 1963t;34(50):20. ADVERTISING AGE. Three to co-sponsor NBC Olympic games; other radio-TV buys. Advertising Age 1963u;34(3~1):55. ADVERTISING AGE. Tobacco industry to weigh ad code on youth appeals at July 9 meeting. Advertising Age 1963v;34(27):3. ADVERTISING AGE. Agency would refuse cigaret[tel client: Ogilvy. Advertising Age 1964a;35(6):91. ADVERTISING AGE. Bar cigaret[tel appeals to youth, code unit urges. Advertising Age 1964b;35(4):1. ADVERTISING AGE. Brickbats deserved, Young says. Ad- vertising Age 1964c;35(5):3. ADVERTISING AGE. Kids see many cigaret[tel ads on TV, FI'C finds. Advertising Age 1964d;35(16):1. ADVERTISING AGE. Make cigaret[tels unfashionable via ads, Jones urges. Advertising Age 1964e;35(19):1,107. ADVERTISING AGE. Where tobacco companies' ad dollars go. Advertising Age 1964f;35(4):32. ADVERTISING AGE. Cigaret[te1 ads still run on kids' TV, Magnuson warns. Advertising Age 1965;36(39):1. ADVERTISING AGE. Code bars ads for cigaret[tels on youth- appeal TV. Advertising Age 1966;37(19):1. ADVERTISING AGE. Ban candy 'cigaret[tels; FTC asks to- bacco code. Advertising Age 1%7a;38(8):191. TIMN 0139048

Preventing Tobacco Use Among Young People did not report cessation rates, this study cannot be con- sidered conclusive. Perry et al. (1980, 1983) conducted two school- based cessation interventions in California schools. In the first, 10th-grade classes in three high schools (N = 477) received a special program that focused on im- mediate physiological effects of smoking and on social cues that influence the adoption of smoking. Classes in two control schools (N = 394) received standard infor- mation on long-term health effects. The program con- sisted of four consecutive 45-minute sessions in regular health classes conducted in the fall. Posttest outcome data were obtained approximately five months later and included carbon monoxide measures of smoking. At the posttest, the experimental group, compared with the control group, had a significantly greater percentage of subjects who reported abstinence in the previous week (22 vs. 16 percent) and month (30 vs. 24 percent). Parallel significant differences were also found for carbon mon- oxide measures. In their second study, the Perry group (1983) tried to sort out the specific efficacious components within the intervention program by analyzing three kinds of pro- grams-those that discussed long-term health effects (the control group), those that discussed immediate and long- term physiological effects, and those that discussed so- cial consequences-and comparing programs taught by either teachers or college students. Twenty health classes and four high schools were randomizedby using a facto- rial design. The study obtained three-month follow-up data that included self-reports and carbon monoxide breath tests. Using entire 10th-grade health classes solved the recruitment problem but yielded a limited number of current smokers; the relatively small number of pretest smokers in this study (N = 82) precluded finding any significant difference between the groups. Overall, 23 percent of the pretest smokers reported not smoking at the three-month follow-up. Teachers tended to be more effective with the traditional curriculum covering long- term health effects, and college students seemed more effective with the social influences curriculum. The largest and most systematic school-based ado- lescent cessation study has not yet been published. Bur- ton et al. (unpublished data) worked with rural and suburban high schools in two states. Within each of the 16 treatment schools, students volunteering to partici- pate in a cessation clinic were randomly assigned to a clinic or to a control group of students told they were on a waiting list. Clinic students were further randomly assigned either to a clinic designed to address addiction or to one designed around psychosocial dependency. Clinics consisted of five sessions spaced over one month. A follow-up session was held three months after the fifth session. The control participants were also invited to the follow-up session, where smoking status was assessed both by self-report and measurement of saliva cotinine. At the three-month follow-up, 8.4 percent of clinic participants and 10.5 percent of controls were abstinent. When corrected for biochemical verification, these figures become 6.8 and.7.9 percent, respectively. There was con- siderable attrition; students lost to follow-up were as- sumed to be smokers. The negative results in the study are especially sobering because the investigators had previ- ously conducted 31 focus groups with adolescents to help inform the intervention's recruitment strategies and con- tent (Sussman et a1.1991). Difficulty in recruiting adolescent smokers in school programs has been a pervasive problem for investigators. Adolescents may be concerned about parents or teachers learning that they smoke (since parental consent could be required for participation). Adolescents may also be less motivated than adults to quit, since long-term health con- sequences carry less weight with the young. A simpler explanation of low recruitment is that prevalence rates are low; schools do not provide large populations of smokers from which to recruit. Multisite trials that pool subjects may be needed before rigorous and meaningful evalua- tions can take place. Cessation Interventions Based Outside the School Hollis et al. (in press) tried an unusual approach to recruit young smokers. Adolescents, between 14 and 17 years of age who were members of a large health mainte- nance organization (HMO) were mailed a screening ques- tionnaire' that asked about "health habits." Those who reported that they had smoked in the past week were asked if they would participate in a two-year study of adolescent health and were randomly assigned to either an intervention group that received help to quit smoking or a control group that received no such help. The focus of the intervention was an office visit with a nurse practitioner at a conveniently located HMO clinic. Incentives were offered for attending these ses- sions, each of which lasted about 60 minutes. The partici- pants reviewed their health history, watched and discussed a video on adolescent smoking cessation, were encouraged to set a quit date, and were given tips and strategies for successful quitting. Those who wanted to quit smoking received a follow-up call one week later; additional calls were also made, depending on the adolescent's continued interest in quitting. Participants who had quit smoking were eligible to participate in a lottery with chances to win $100. All participants were followed up at one year, at which time both self-report and biochemical (saliva cotinine, carbon monoxide) data were obtained. The ~ Prevention 229 TIMN 0139079

Preventing Tobacco Use Among Young People tobacco industry messages to call attention to the mar- keting of tobacco to children. DOC chapters sponsor youth sports teams and leagues with an antitobacco message, support local minority organizations and events such as the Cincinnati Smoke-Free Jazz Festival, and make "housecalls" (protests) at youth-appealing events sponsored by tobacco companies. DOC has also estab- lished a program whereby medical students can teach in school-based smoking prevention efforts and become specialists in school and community health promotion (Shank 1985). DOC's leadership in innovative activities has been noted nationally and internationally, and these activities have been replicated or have been the basis for many communitywide programs. Other tobacco-control advocacy organizations, such as Stop Teenage Addiction to Tobacco (STAT), SmokeFree Educational Services, Inc., and Americans for Nonsmokers' Rights, sponsor many other creative and effective community-based events, chapters, and conferences. Although the results of these organiza- tional efforts are not usually published in scientific jour- nals, their contributions to smoking-prevention programs and policies in the United States are widely recognized. STAT, for example, is the only organization in the United States dedicated solely to issues of teenage access to tobacco. Public education and information form a major part of STAT's activities. Central to this are the STAT newsletter, the Tobacco 'Free Youth Re- porter, which appears quarterly and is sent to over 100,000 persons worldwide. This newsletter, along with STAT-authored journal articles and press adviso- ries and a STAT-sponsored annual conference, has been used to present and analyze the practices of the tobacco industry. Statewide and community projects to reduce sales of tobacco products to youth have also been central to STAT's activities since its inception. Currently, STAT has a major grant from the Robert Wood Johnson Foundation to expand activities re- lated to teenage access to tobacco in communities in four states and to demonstrate how other communi- ties can take similar actions. The Teens as Teachers program has been created and disseminated by the American Nonsmokers' Rights Foundation. Teens as Teachers reaches young people most vulnerable to tobacco addiction. Although many current smoking-prevention programs do a good job of teaching adolescents how to resist peer influence, Teens as Teachers also teaches them to think critically while examining both the nature of the tobacco industry's strat egies and their right to be protected from primary and secondhand smoke. Teens as Teachers has reached over 1,000 high school students, who in turn have reached over 6,000 elementary and middle school students. Role of the Mass Media in Reducing Tobacco Use Introduction Mass media are particularly appropriate prohealth channels for tobacco education among young people, who are heavily exposed to-and often greatly inter- ested in-the media (Minnesota Department of Health 1989). However, although the general public has re- ceived many antismoking messages in one form or an- other since the 1964 Surgeon General's report on smoking and health (Warner 1989), few messages have been de- signed specifically to prevent young people from trying tobacco. Programmatic Use of Mass Media to Reduce Adolescent Tobacco Use By the early 1980s, the Office on Smoking and Health had responded to the lack of media messages discouraging tobacco use among youth by developing a series of national public service announcements (see Table 7). The major voluntary health agencies have also produced a national broadcast message for youth. DOC began creating counteradvertising in 1977, often involving young people in designing parodies of tobacco advertisements. DOC purchased advertising space, used counterpromotions (e.g., the Emphysema Slims Tennis Tournament) (Solberg 1992), and encoun- tered occasional censorship (Fitzgerald 1990): DOC has maintained visibility by enlisting medical profes- sionals, youth, and parents for innovative media- and community-based 'antismoking campaigns. The pro- gram has not been formally evaluated. Young people have also been a major (but not exclusive) target group of several important statewide tobacco-use prevention and cessation campaigns. At their onset in the late 1980s and early 1990s, campaigns in Minnesota, Michigan, and California used funds from dedicated cigarette taxes to fund multimedia promo- tions. The programs have received funding for several years. These states have employed sophisticated mar- keting techniques (i.e., they have used marketing ex- perts, focus groups, pretesting, pilot campaigns, and ongoing evaluations) to increase their effectiveness and have arranged for extensive paid and donated advertis- ing to ensure adequate reach and frequency of statewide coverage (Minnesota Department of Health 1991; Kizer and Honig 1990). Each of these campaigns also included an outdoor billboard or poster component that mirrored themes in the broadcast media. In 1989, the Michigan Legislature dedicated revenues from a tax on computer software (about $9 million per year) to health promotion, primarily for AIDS and smoking education (Moore & Prevention 239 TIMN 0139089

°S:k.M wr ~~ Sur,yeon Geriernl's Report Convenience Samples of Adolescents Who Try to Quit Smoking Although national surveys ask a great many re- spondents a few questions about quitting smoking, some smaller studies have more deeply probed the experience. The role of nicotine's pharmacologic effects has received increasing attention, culminating in the 1988 Surgeon General's report on nicotine addiction. The report dem- onstrated that cigarette smoking is characterized by the same addictive processes that have been observed with other drugs that are abused (USDHHS 1988). Recent observations of adolescents who have tried to quit smok ing suggest that dependency or addiction has developed in many adolescent smokers and may play an important role in their attempts to quit. Data from both Great Britain (McNeill et a1.1986; McNeill 1991) and the United States (Hansen 1983; Hansen et al. 1985; Ershler et al. 1989) show that many adolescents who try to quit have withdrawal symptoms that parallel those reported by adult smokers (see "Nicotine Addiction in Adolescence" in Chapter 2). In a survey of 116 British schoolgirls (aged 11 through 17) who had tried to quit smoking, 63 percent reported withdrawal effects. The degree of withdrawal effects was related positively to both self-report and biochemical mea- sures of nicotine intake (McNeill et al. 1986). These find- ings were replicated, although without biochemical measures, in a study of American 6th- through 12th= graders of both sexes (Ershler et aL 1989). Over half of the smokers in both of these studies reported attempts to quit, and most were unsuccessful. These observations, along with other data summarized in Chapters 2, 3, and 4, strongly suggest that adolescent smoking is more than socially driven and that addictive processes in adolescents are similar to those that characterize adult smoking. Effect of Smoking-Prevention Programs on Cessation Smoking-prevention programs have typically, and appropriately, targeted younger adolescents. In these populations, prevalence rates tend to be low, and those who smoke are mostly doing so infrequently. These studies, reviewed earlier in this chapter, focus on pre- venting onset or on preventing the progression from experimentation to regular smoking. The impact of smoking-prevention programs on students who are ex- perimental or regular smokers appears to be small and inconsistent (Best et a1.1984; Johnson et al. 1986; Biglan, Severson, et al. 1987). However, the small number of regular smokers (that is, those who smoke every week) tends to preclude meaningful analyses of cessation re- sulting from these programs (Best et a1.1984). Cessation Interventions in the School Young people who smoke have been a persistent concern of both educators and voluntary health agencies. A number of materials and programs for adolescent smoking cessation have been developed and imple- mented, but evaluation typically has been anecdotal or descriptive (Hulbert 1978; Patterson 1984; Brink et al. 1988). Many of the older programs are described by Thompson (1978), USDHEW (1979), and Seffrin and Bailey (1985). Cessation programs are sometimes led by peers, sometimes by teachers or volunteers. Participants are recruited through school channels such as newslet- ters, classes, and public address announcements. Evi- dence from these descriptive reports, as well as from some of the formal research programs described below, indicates that recruitment is difficult; adolescent smokers are hesitant to come forth. In some instances, the par- ticipants in the school cessation programs are referred by school authorities for infractions of school smoking policies and are thus not coming to these programs voluntarily. These issues are illustrated by a program evalua- tion reported by the American Lung Association ~un- published data). The program, developed by a Minnesota affiliate of the American Lung Association, was evalu- ated in 22 schools in four states. A total of 241 students (mean age = 16 years old) participated in eight 50-minute sessions during school hours over a four-week period. Over half the students, however, were required to par- ticipate as a consequence of being caught smoking on school grounds. This inclusion of nonvoluntary partici- pants may partly explain the program's low success rate: at the end of the sessions, only 30 students (14 percent) reported that they were abstinent (program dropouts were counted as smokers). Low cessation rates like these, coupled with recent legislation such as the Oregon law forcing school authorities to take action against stu- dents caught smoking on school grounds, signal the need for more effective cessation approaches for student smokers. Lotecka and MacWhinney (1983) compared an in- tervention group focusing on cognitive behavioral skills (N = 53) with a group only receiving health information (N = 54). Less than 50 percent of the students in each group participated in the three-month follow-up. Of those assessed at that time, 78 percent of the students in the cognitive behaviorgroup reported a decrease in smok ing, and only 4 percent reported an increase; the compa- rable figures for the information-only group were 46 percent and 31 percent. No information was provided on complete abstinence. Given that reported rates of smoking are relatively unreliable and that the program 228 Prevention 013`10~8 ,SI1~i1~

Preventing Tobacco Use Among Young People from other drugs. In most cases, little or no evaluation has been done to measure the effect these programs h;-ve on tobacco use. Project California 4-Health focuses specifically on tobacco and is a joint effort of the University of Califor- nia at Davis and the University of California Coopera- tive Extension 4-H programs. The program, which teaches older teens to present a tobacco-use prevention program to youth aged 9 through 12 in settings outside of school, is currently being evaluated (Project Califor- nia 4-Health 1992). Two programs are noteworthy because they have been designed to reach high-risk youth. Girls Inc. (for- merly Girls Clubs of America) is a nationwide (120-city) network of over 200 centers serving young girls aged 6 through 18; over half of these girls belong to racial and ethnic minority groups. The organization's Friendly PEERsuasion program focuses on avoiding substance abuse (Girls Inc. 1991). Developed under a grant from the Office for Substance Abuse Prevention, Friendly PEERsuasion uses an older-to-younger peer leadership approach to encourage girls aged 11 through 14 to choose healthy alternatives to using illegal drugs, alco- hol, and tobacco. The Boys and Girls Clubs of America, a nonprofit organization that provides programs in sev- eral areas, including health and physical education, has recently established clubs (built on the structures and supports of the Boys and Girls Clubs of America) in several housing developments around the country. Dubbed the SMART Moves (Self-Management and Re- sistance Training) program, these clubs aim to prevent substance abuse (including tobacco use) among high- risk youth by also targeting parents and the community (Schinke, Orlandi, Cole 1992). To counter the association between baseball and smokeless tobacco use, Little League Baseball, Inc., with the support of the NCI and NIDA, has developed for young players two pamphlets that emphasize the negative social consequences of smokeless tobacco. A more extensive program for preventing smokeless to- bacco use among youth who are baseball players is currently being evaluated among Little League and Senior League teams in Harris and Galveston counties in Texas (Evans, Raines, Getz 1992). This intervention targets players and their parents and involves profes- sional baseball players. In 1987, a program developed and implemented in 72 of the 4-H clubs in 24 California counties targeted reduction of smoking and smokeless tobacco use (D'Onofrio, Moskowitz, Braverman, unpublished data). Club members aged 10 through 14 years were involved in the study; 68 percent of the sample were retained at the two-year follow-up. The program included five tobacco-related outcome variables-knowledge, attitudes, perceived social influences, intentions, and behaviors- and involved five sessions of tobacco education provided at the monthly club meetings by volunteers (41 adults and 26 teens) trained to deliver the program. At the first follow-up (one year later), the program demonstrated a significant impact on participants' knowledge of the harm- ful effects of'smokeless tobacco use and on participants' intentions to smoke, but the program had no effect on actual use of smokeless tobacco. The two-year follow-up showed no difference between members of clubs receiv- ing treatment and members of control clubs. The authors concluded that providing a tobacco-prevention program through 4-H clubs was difficult to manage because of time constraints on club meetings, but the effort proved to be a useful complement to school-based programs to change social norms. Other youth organizations that incorporate tobacco- use prevention as part of a general emphasis on prevent- ing substance abuse include the YWCA (Condas 1992), Camp Fire Boys and Girls (Emerson 1992), the Boy Scouts of America (Grau 1992), and the Girl Scouts of the U.S.A. (Eubanks 1992). The National Parent Teacher Association (PTA) has adopted a number of resolutions that recognize the haz- ards of tobacco use and support educational programs and community policies to discourage tobacco use (Na- tional PTA 1984). However, the organization's materials for parents about drugs do not discuss tobacco use. "Just Say No" International is an organization founded in the late 1980s to promote local dubs for youth aged 7 through 14 years. These clubs give children infor- mation, skills, and support to help them resist drugs, including tobacco ("Just Say No" Internationa11992). The parent organization and the 11,000 local clubs are largely funded through private sources and are based in schools and community settings, including same public housing sites. Activities include education, recreation, outreach and peer-education, and community service. An evalua- tion of 121ocal dubs that had been active for at least one year revealed that these clubs can offer young people a meaningful role in improving the community, strengthen- ing community ties, helping community members com- mit to drug-use prevention, and coordinating other prevention efforts (Duper 1992). Prevention Programs Initiated by the Tobacco Industry Since 1984, the Tobacco Institute has distributed a series of publications intended to discourage children from smoking (National Association of State Boards of Education [NASBEI 1984,1987;TobaccoObserver1984). Althoughallof thesepublicationsemphasizededsion makingskills,onlythe Prevention 237 TIMN 0139087

Preventing Tobacco Use Among Young People use. The overall design of the MPP included all commu- nities within metropolitan Kansas City (Kansas and Mis- souri) and Indianapolis (Indiana). Within each of these two areas, cohorts of adolescents were assigned by school to intervention or delayed intervention (control) condi- tions. The intervention programs initially targeted sixth- or seventh-grade students and consisted of a 10-session, school-based social skills curriculum; 10 homework as- signments to be completed with parents or guardians; mass media coverage using television, radio, and print; community organization; and policy change. In the first two years of the project, 22,500 adolescents participated in the school and community intervention. Analyses from students in 42 schools (N = 5,008) indicated a lower prevalence of past-month cigarette, alcohol, and mari- juana use at one-year follow-up for those exposed to the school intervention than for the control group (17 per- cent vs. 24 percent for cigarette smoking, 11 percent vs. 16 percent for alcohol use, and 7 percent vs. 10 percent for marijuana use) (Pentz, Dwyer, et al. 1989). Similar results were observed after two years for a longitudinal panel of students from eight schools in Kan- sas City (N = 1,122) (Pentz, MacKinnon, Flay, et a1.1989) (Table 6). Third-year results demonstrated sustained impact only on tobacco and marijuana use, but reduc- tions were equivalent for adolescents at lower or higher risk (Johnson et al. 1990). The MPP is particularly ' important because it demonstrates the feasibility of a large-scale, communitywide effort focused exclusively on youth. The program has also demonstrated impact on those at high risk, and it has considerable method- ological strength. The MPP's long-term impact on tobacco is still to be determined. The New England Research Institute has developed and tested a community program for smoking prevention among Hispanic (Puerto Rican) adolescents. The program includes a music video, buttons and T-shirts, a smoking cessation booklet, information booths and a traveling music show at area festivals, and a basketball tournament that includes a discussion about pressures to smoke (McGraw 1990). The preliminary results of the evaluation, however, indicate no differences between the intervention group (in Bostori) and a comparison group (in Hartford) in reported smoking rates, attitudes toward smoking, or in- tentions to smoke. Currently under way is Project SixTeen, a commu- nity trial being conducted by the Oregon Research Insti- tute from 1990 to 1995. In this project, experimental communities receive a school program combined with community intervention that includes parental involve- ment, media campaigns, efforts by health care providers, and changes in policies and regulations (Ary and Biglan, unpublished data). State and Federal Tobacco-Control Efforts at the Local Level A number of states have adopted tobacco-control programs that include community-based adolescent components. The Association of State and Territorial Health Officials (ASTHO) has recommended the devel- opment of statewide tobacco-control plans that include both school and nonschool activities for youth (ASTHO 1989). . At least 12 states have developed freestanding statewide tobacco-control plans, and another 22 states have incorporated them into plans for controlling chronic disease (CDC 1991b). All but 15 states have a specific budget devoted to .tobacco-related activities. Examples of state-funded nonschool activities to prevent tobacco use indude the K.I.D.S. Coalition, a Utah program that encourages youth to work with community leaders to Table 6. Outcomes of the Midwestern Prevention Project: adjusted net differences in the percentage of smokers in program and control groups, from baseline to 6-month, 1-year, and 2-year follow-up Adjusted net difference* Smoking variable 6 months 1 year 2 years Lifetime use 2.3 1.2 11.7+ Past-month use -7.5$ -10.2§ -16.09 Past-week use -6.4= -7.9t -11.7§ Source: Pentz, MacKinnon, Flay, et al. (1989). *Analyses done with school as a unit of analysis, adjusted for race and grade. tp <.10 (one-tailed test). tp < .05 (one-tailed test). 9p <.01 (one-tailed test). TIMN 0139085 Prevention 235

Preventing Tobacco Use Among Young People adolescents their age and that the majority of persons in any age group are nonsmokers. Students examine the reasons that adolescents say they smoke, including to be accepted by peers, to appear mature, or to help cope with difficult situations. The factors that affect adolescent smoking can also be explored, including the influence of parents, peers, and mass media; for example, students can learn how role modeling and adverti'sing can falsely establish positive cultural meanings for smoking (see "Research on the Effects of Cigarette Advertising and Promotional Activities on Young People" in Chapter 5). A related component is to engage students in training, modeling, rehearsing, and reinforcing methods that counter these influences and to coach students to com- municate these techniques to others. Some approaches also include generic personal and social skills training to promote overall competence and reduce motivations to smoke (Botvin and Wills 1985). Curriculum Format Among the numerous approaches to teaching skills to resist social influences to smoke, the format variations are in most cases minor (Best et a1.1988). For example, a number of these approaches rely on classroom teachers to deliver the smoking-prevention program. The six- session program designed by Colquhoun and Cullen (1981) focused on refusal skills training provided by classroom teachers with the help of local physicians. Biglan, Glasgow, et al. (1987), on the other hand, trained health and science teachers to deliver intervention ses- sions on four consecutive days, followed by a booster session two weeks later. Other intervention variations have used a combina- tion of trained staff or teachers plus student peer leaders. Perry, IQepp, and Sillers (1989), for example, used same-age peers in a smoking-prevention program that promoted cardiovascular health. Ellickson and Bell (1990), on the other hand, employed trained health educators to deliver their intervention to seventh graders and contrasted this approach by delivering the intervention through students' regular teachers assisted by teen leaders. Similarly, Arkin et al. (1981) organized seventh-grade student nominations of classmates who students felt would be effective peer lead- ers. Those selected then served as discussion leaders and helped students rehearse and role-play appropriate re- sponses to situations that simulated social pressure. In Project SHOUT (Students Helping Others Un- derstand Tobacco), college undergraduate students in psychology, health sciences, and other majors worked for college credit toward their degrees by serving as peer leaders to young adolescents. The college students were mature and reliable enough to deliver interventions (both in the classroom and over the telephone, in booster calls) yet sufficiently youthful to be acceptable to an adult- wary audience (Young et al. 1988; ,Young et al. 1990; Elder et a1.1993). Table 4. Essential elements of school-based smoking-prevention programs 1. Classroom sessions should be delivered at least five times per year in each of two years in the sixth through eighth grades. 2. The program should emphasize the social factors that influence smoking onset, short-term consequences, and refusal skills. 3. The program should be incorporated into the existing school curricula. 4. The program should be introduced during the transition from elementary school to junior high or middle school (sixth or seventh grades). 5. Students should be involved in the presentation and delivery of the program. 6. Parental involvement should be encouraged. 7. Teachers should be adequately trained. 8. The program should be socially and culturally acceptable to each community. Source: Glynn (1989). Prevention 219 TIMN 0139069

Surgeon General's Report what?" Intention to smoke was assessed by the question, ,,po you think you will ever smoke cigarettes in the future?" to which there were six possible responses. Subjects who had small differences between their self-image and their image of smokers, and those who had large differences between their self-image and their ideal self-image, were found to have greater intentions to smoke. These findings can bear closer scrutiny. Smok- ers' images received relatively low scores from all stu- dents, but to a lesser extent among students who had greater intentions to smoke. Since these students had also assigned themselves lower self-images than their peers, they were that much closer to the image scores they assigned to smokers. Also worth elaborating is the observed relationship between greater intention to smoke and greater disparity between self-image and ideal self-image: students intending to smoke assigned themselves lower scores for both images than did their peers. The authors conclude that youth with relatively low self-concepts who do not perceive themselves as being particularly healthy, wise, tough, or interested in the opposite sex may be drawn to smoking as a way of enhancing their low self-image, especially since smoking has been consistently associated with these attributes in advertising. In a study conducted in 1991 (Burton, Moinuddin, Grenier, unpublished data), 239 black and white sev- enth- and eighth-grade students in Chicago were asked to rate 'on a five-point scale their self-image and their ideal self-image according to 13 attributes. Some at- tributes (such as "special" and "important") were promi- nent in both scales; other attributes that were highly rated in one image scale were much lower in the other. The attributes that revealed the largest discrepancies between ideal self-image and self-image were "good- looking," "sexy," "tough," and "athletic." The same students were also asked to indicate on a three-point scale how much they would want to buy a given prod- uct. When responses to the two sets of questions were compared, having _"sexyr' as an ideal self-image at- tribute was associateii.with expressing an intention to purchase Camel cigarvttes, and having "tough" as an ideal self-image attAute was associated with express- ing an intention to purchase Marlboro cigarettes. The image attributions of adolescents described in this set of studies suggests a mechanism of smoking initiation (Figure 3). The visual images in advertise- ments may thus serve to shape the ideal self-image of this impressionable audience, since the ads may portray at- tributes that children and adolescents would like to have. The greater the discrepancy between their self-images and their ideal self-images, the more likely these young people are to try to make their self-images more like their ideal self-images (e.g., by "buying into" an improved self-image through responding with the purchase in- vited by the ads). In commercial advertising theory, this notion in- forms imagery-advertising conceptualization, which pre- sumes that the need for consistency or balance will motivate an individual to try to close the gap between self-image and ideal self-image (McGuire 1989). This con-ceptualization entails an active striving to make the self-image more like the ideal self-image, and not the other way around. Imagery-advertising conceptualization is most compatible with identification theories (e.g., role theories, reference-group theories, and self-presentation theories) that stress the need to expand identity by adopt- ing distinctive thoughts, feelings, or actions (McGuire 1989). Thus, the teeiiaged girl who responds to a Virginia Slims advertisement that portrays independence is moti- vated to buy and use the product in order to enhance her sense of independence. Young f'eople's Misperceptions of Smoking Prevalence and Implications for Tobacco Use In~ contrast to the image-advertising modet de- scribed above, the model in Figure 4 is not concerned with the content of cigarette adver tisements, but instead with the pervasiveness of the ads. According to this conceptualization, the pervasiveness of cigarette ads leads youth to overestim?kte the prevalence of smoking and to consider smoking as normative. Studies have consis- tently reported that adolescents overestimate the preva- lence of cigarette smoking (Johnson 1982; Chassin et al. 1984); moreover, those who smoke overestimate smok ing prevalence to a greater extent than do nonsmokers (Sherman et al. 1983; McCarthy and Gritz 1984). Over- estimating smoking prevalence has been found to be among the strongest predictors of smoking initiation and acquisition (Chassinet a1.1984; Collins et al.1987; Sussman et al. 1988; see 'Terceived Environmental Factors" for smoking in Chapter 4). Burton et al. (unpublished data) examined the rela- tionships among cigarette advertising, estimates of smok- ing prevalence, and intentions to smoke. Children in Helsinki, Finland, where there has been a total tobacco advertising ban since 1978, were compared with children in Los Angeles, where tobacco is advertised in various print media and through promotional activities. Because the Finnish children may have been exposed to tobacco advertising through foreign magazines or through trav- eling to other countries, the study is characterized as comparing pervasive vs. occasional exposure to adver- tising. Classroom samples of 477 Helsinki students and 453 Los Angeles students-aged 8 through 14 years in both samples-whose lifetime cigarette use consisted of 192 Advertising and Promotion TIMN 0139044

Surgeon General's Report sizes, the limited number of studies, the lack of control groups, and the lack of long-term follow-up necessitate cautious interpretation. Further research on cessation must consider the effects of usage frequency and intensity and must focus on relapse rates, use of nico- tine replacement in cessation, self-help attempts at quitting, effects of advice by physicians and other health professionals, and effects of taxation and environmen- tal restrictions. Clinical Interventions to Prevent Tobacco Use Introduction Physicians, dentists, and other health care provid- ers who take care of children are in a unique position to help their patients avoid the use of tobacco (Perry and Silvis 1987). Children perceive these professionals as credible health experts and thus may attend more to what they say than to what parents and other adults say. Health care providers can serve as powerful role models who can positively influence the health behavior of their young patients, especially where a long-term relation- ship has been formed with the child and the family. Lastly, health care providers should know when to pro- vide specific health information at critical times iri a child's development. The medical office provides an important opportu- nity for physicians, dentists, and staff to communicate attitudes about smoking and smokeless tobacco use (Kottke et al. 1989; Richards 1992). By not smoking, health professionals can serve as positive role models, as the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) have recommended. Smoking by physicians, other staff, adolescents, or parents should not be allowed in the physician's office or reception area (AAP 1987; AAFP 1992). The AAP recommends that between birth and 21 years of age, a child should make a minimum of 20 visits to the physician (AAP 1988). These visits offer opportu- nities to prevent and deter tobacco use. To be successful at preventing tobacco use, physicians and other health professionals must know what the risk factors are, how to identify children who are most vulnerable, and how to intervene effectively. Recommendations to Clinicians Who Care for Children and Adolescents Education about tobacco should begin in child- hood, when family standards and values are developing (AAP and Center for Advanced Health Studies 1988). The child's visit may also afford the opportunity for a health professional to advise young parents who smoke to stop (Perry, Griffin, Murray 1985). During infancy and early childhood, clinicians should emphasize to parents the relationship between environmental tobacco smoke and the infant's health, particularly the association be- tween environmental tobacco smoke and children's pneu- monia, bronchitis, asthma, middle ear disease, and sudden infant death syndrome (USDHHS 1986a, 1990a; U.S. En- vironmental Protection Agency [USEPAI 1992). Advice from a child's physician can reinforce advice that parents may have received from their own doctors. Clinicians thus need to learn skills to promote antismoking behav- ior and encourage parents to stop smoking. The 1VCI and the AAP have developed recommen- dations for health professionals to prevent their preadult patients from trying smoking (Epps and Manley 1991b). These brief activities can be carried out during the peri- odic visits that the AAP recommends between birth and 21 years of age, as well as at other visits. Five steps that begin with the letter "a"-anticipate, ask, advise, assist, and arrange follow-up-are recommended: • Anticipate the risks for tobacco use associated with the child's development stage. These risks include expo- sure to environmental tobacco smoke, experimenta- tion with tobacco, and nicotine addiction (Kandel.1975; Hawkins, Lishner, Catalano 1985; Dent et al. 1987; AAP 1988). Children and adolescents are more likely to use tobacco if their siblings and friends use it and if tobacco use is perceived as normative or functional (USDHHS 1986a; see "Interpersonal Factors" and "Per- ceived Environmental Factors," both for smoking and for smokeless tobacco use, in Chapter 4). Adolescents are vulnerable to tobacco use-; :pecially those with fewer coping skills (Doueck et a1.1988), those suscep- tible to cigarette advertising (Blum 1980), and adoles- cent females concerned about their body weight. (Gritz 1986). • Ask at each visit, about tobacco exposures and tobacco use (Richards 1992). Ask about tobacco use by the patient and by the patient's friends and family. When seeing infants and young children, ask parents whether the patient has regular contact with anyone who smokes. Ask if tobacco use is being discussed among the child's friends or in school and, if so, in what classes. Ask about the child's school health education program. Ask the child about participation in sports and extracurricular activities that may be incompat- ible with smoking. In dental examinations, inspect the intraoral soft tissue. If changes are noted in the mucosa, ask about smokeless tobacco use. • Advise tobacco users to stop. Advise women of the adverse effects of smoking during pregnancy. Inform smoking parents of the health consequences that envi- ronmental tobacco smoke can have on their children. Advise children and adolescents who are using (or 232 Prevention ~ TIMN 0139082

Preventir<<ti> Tobacco Use AmonY Yowig People contemporary marketing techniques coupled with be- havioral science theory to develop three campaigns that could be practical and inexpensive enough to be dissemi- nated nationally if proven successful. A radio campaign used eight messages about expected consequences of smoking. Another radio campaign invited young people and their friends to enter a sweepstakes by pledging not to smoke. Lastly, a television campaign combined these two approaches. These campaigns were conducted as paid media, not as public service announcements. The intervention, which involved 10 media markets in the southeastern United States, was expected to reach 75 percent of its adolescent target audience during 1985 and 1986. Although none of these campaign approaches resulted in reductions in the onset of smoking, improve- ments were observed in two important psychosocial fac- tors-the expected utility of smoking and friends' approval of smoking (see "Social Support for Smoking" and "Subjective Expected Utility"' in Chapter 4). The authors also found that radio was as effective as televi- sion for reaching the adolescent audience (Bauman, Padgett, Koch 1989; Bauman et al. 1991). The third study, at the University of Vermont (Worden et a1.1988), tested the ability of mass media interventions to increase the efficacy of a school-based smoking-prevention program. In this intervention strategy, media and school programs shared educational objectives but were otherwise independent. A total of 36 television and 17 radio messages were developed by using extensive diagnostic and forma- tive research with students in grades 4 through 10. The messages were broadcast in a four-year paid campaign in cities in Montana and the northeastern United States from 1986 through 1989. Results indicated that the smoking prevalence for students who received both the media cam- paign and the school program was 34 to 41 percent lower than for students who received the school program only (Figure 4). The study observed consistently positive results for intervening measures (Flynn et a1.1992). An alternative approach that used the community as the unit of analysis also showed a significant difference between treatment groups over time (Flynn et a1.1992). This campaign used various message formats and production styles, including nonauthoritarian appeals that avoided direct exhortations not to smoke. The authors suggested that because the media campaign was not explicitly linked to the school program (e.g., the two components did not share materials, designs, or slogans), adolescent viewers may have perceived that young people across the nation were receiving the same nonsmoking messages-and that nonsmoking was indeed the norm. Other than the three studies funded by the NCI, little mass-media research has been directed at adolescent smoking. The recent California mass media campaign included young people as a major target audience; about one-third of the television messages, one-quarter of the radio messages, and over one-half of the outdoor adver- tisements addressed young people as well as other speci- fied groups (e.g., pregnant women, young adults, adults) (Kizer and Honig 1990). Although the goals of the California campaign in- termingle youth and adult priorities, the goals that seem to apply to youth are those that deglamorize the myths about tobacco use, expose problems created by the to- bacco industry, and provide information about the haz- ards of smoking. A few spots touch on these topics (Table 7), but several others, said to be targeted to the youth audiences in the California media plan, seem to be in- tended for adults, such as spots about youth access to cigarette vending machines and about spots that show children worrying about their parents' smoking. Mea- surements before and after campaign waves, however, indicated significant changes in message awareness (Popham et a1.1991), and a report by Glantz (1993) indi- cates an association between the media campaign and a decline in cigarette consumption throughout California. Recently released data suggest, however, that this decline is not being observed among youth (Pierce et a1.1993). Figure 4. Smoking prevalence in University of Vermont program using mass media to prevent adolescent smoking ,0 18 ~ 1 1 6 y u c ?: 14-I > y 12-J . o» eo c 10 3 0 6 8 Ln ~ / / ~ 6 ~ / 3 4 / 2 0 1 2 3 4 5 6 Study year School program only - - School program and media campaign Source: Adapted from Flynn et al. (1992). Prevention 243 TIMN 0139093

Preventing Tobacco Use Among Young People Advertising requirements Prohibited cigarette advertising on television and radio Preempted any state or local requirement or prohibition based on smoking and health with respect to cigarette adver- tising or promotion Extended broadcast ban on cigarette advertising to "little cigars" None Prohibited smokeless tobacco advertising on television and radio Congressional reporting requirements Other stipulations Annual report to Congress on health None consequences of smoking (U.S. Department of Health, Education, and Welfare (USDHEW]) Annual report to Congress on cigarette labeling and advertising (FTC) Annual report to Congress on • None health consequences of smoking (USDHEW) Annual report to Congress on cigarette labeling and advertising (FTC) h Biennial status report to Congress on smoking and health (U.S. De- partment of Health and Human Services [USDHHS]) Biennial status report to Congress on smokeless tobacco use (USDHHS) Biennial report to Congress on smokeless tobacco sales, advertis- ing, and marketing practices (FTC) None Created the Federal Interagency Committee on Smoking and Health (USDHHS) Cigarette industry must provide a confidential list of cigarette additives' (USDHHS) Required public information campaign on health hazards of using smokeless tobaccot (USDHHS) Smokeless tobacco companies must provide a confidential list of additives and a specification of nicotine content in smokeless tobacco productst (USDHHS) +List of additives does not identify company or cigarette brand, no public disclosure of additives on packages or advertisements required, and no other public disclosure allowed. No funds have been appropriated to carry out this campaign. ~ Prevention 259 TIM~I 0139109.

Sureeon General's Report create social change around the tobacco issue (Utah De- partment of Health 1991), and the Body Guards cam- paign, a program sponsored by the Minnesota De- partment of Health that trains minority youth (aged 12 through 14 years) to involve their families and others in the community in tobacco-free pledges and messages (ASTHO 1992). The Federal Comprehensive Smokeless Tobacco Health Education Act of 1986 (Public Law 99-252), which included a mandate for health education programs and materials about risks of smokeless tobacco, coincided with an increase in state-funded community programs addressing smokeless tobacco. In Ohio, for example, the Department of Health has involved American Lung As- sociation affiliates, Boysand GirlsClubs of America, Little League, the Cleveland Indians baseball team, 4-H Clubs, and juvenile detention centers in efforts to reach youth at high risk of using smokeless tobacco (Capwell 1990). The most comprehensive state tobacco-control pro- gram operates in California. Administered by the state's Department of Health Services and Department of Edu- cation, the program has been funded since 1989 by a cigarette excise tax increase of25 cents per pack (asa result of Proposition 99), one-fifth of which is dedicated to antitobacco education (Bal et al. 1990). Community- based prevention services are specifically directed to high-risk youth (i.e., those who have parents who smoke, those who have dropped out of school, or those who are economically disadvantaged) (Tobacco Education Over- sight Committee 1991). During its first two years, this program created local tobacco-use prevention coalitions in all 61 local health jurisdictions, organized a youth summit called Kids Choose a Tobacco Free Future, held training workshops for county staff of the Child Health and Disability Prevention Program t