Why children start smoking cigarettes: predictors of onset

Patterns of health risk behaviors for chronic disease: a comparison between adolescent and adult American Indians living on or near reservations in Montana

PURPOSE

To compare the chronic disease health risk behavior patterns of adolescents and adults among American Indians living on or near reservations in Montana.

METHODS

We analyzed data from the 1993 Youth Risk Behavior Survey of American Indians in Grades 9-12 living on or near Montana reservations. Risk factors included tobacco use, low physical activity, attempted weight loss, and low consumption of fruits, vegetables, and green salad. Similar data were analyzed from a 1994 Behavioral Risk Factor Survey of American Indian adults living on or near reservations in Montana.

RESULTS

The prevalence of most adolescent health risk behaviors was high, especially cigarette smoking (45% for males, 57% for females), smokeless tobacco use (44% for males, 30% for females), and infrequent consumption of salad or vegetables (59-76%). With the exception of daily cigarette smoking and inadequate fruit consumption among adolescents of both genders and physical inactivity among adolescent males, the prevalence of chronic disease health risk behaviors among adolescents was similar to or higher than the prevalence of the same risk behaviors among adults.

CONCLUSIONS

Many health risk behaviors for chronic diseases are common by the time this group of American Indians in Montana has reached adolescence. Possible reasons may include modeling of familial behaviors, peer pressure, advertising, or age cohort effects. If these risk behavior patterns continue into adulthood, morbidity and mortality from chronic diseases are likely to remain high. Substantial efforts are needed to prevent or reduce health risk behaviors among adolescents and adults in this population.

Girls, pecking order and smoking

Against a background of growing concern about the failure to reduce cigarette smoking amongst young people, particularly girls, this paper attempts to unravel the complex interrelationships between smoking, peer group structure and gender. We were particularly intrigued to explore a recent hypothesis in the literature that suggests that girls who smoke, far from lacking self-esteem, are more self-confident and socially skilled than their non-smoking peers. Sociometric and qualitative analyses revealed that smoking behaviour was indeed shaped by gender, and that the psychosocial processes involved in smoking uptake may be different for boys and than for girls. Peer group structure, consistently described by young people as hierarchical, was closely related to smoking behaviour. Girls at the top of the social pecking order who projected an image of high self-esteem were identified as most likely to smoke, while only a small minority of girls fitted the stereotype of the young female smoker who has poor social skills and low self-esteem. Boys of high social status were less vulnerable, since sport and a desire to be fit to some extent protected them. Our findings raise fundamental questions about the meaning of self-esteem in relation to smoking uptake, arguing instead for an exploration of the term "self-worth". They suggest the need for health education programmes which are sensitive both to gender and to peer group structures.

Cigarette smoking in young adults: childhood and adolescent personality, familial, and peer antecedents

Three models (independent, interdependent, and mediational) were hypothesized in this study, to examine the interrelation of personality, family, and peer determinants and their effects on tobacco use by young adults. Mothers were first interviewed about their children when they were between the ages of 1 and 10 years old. Three subsequent interviews were conducted with the children when they reached adolescence and young adulthood. Results show support for the mediational model. In accordance with family interactional framework conceptions, there was a sequence in patterning: from parenting during early adolescence; to personality and peer factors, extending to smoking in late adolescence; and culminating in smoking in adulthood. With a developmental approach, a number of psychosocial measures were related in both younger and older children. Nevertheless, some interesting developmental differences emerged. The findings suggest at least four possible targets for therapeutic or preventive intervention: the parent, the child, the adolescent, and the peer group.

Preteenage drug use in Australia: the key predictors and school-based drug education

PURPOSE

The promise that early intervention school-based drug education is it will have public health benefits. This argument was explored through identifying the key predictors of early adolescent social drug use.

METHODS

A cross-sectional survey involving 3,019 6th year students, aged 11-12 years (participation rate: 99%), enrolled in 86 Melbourne primary schools was carried out to determine students' social drug use. In addition data were collected on known key social, personal, and education predictors. Logistic regression was used to identify significant predictors of drug experimentation and use.

RESULTS

The key predictors of girls' tobacco use were friends' smoking (OR: 6.7), low literacy (OR: 4.4), and alcohol use (OR: 3.9). For boys they were friends' smoking (OR: 8.6), low literacy (OR: 4.2), and alcohol use (OR: 3.1). For alcohol use, the key predictors for girls were smoking (OR: 4.2), parents' drinking (OR: 3.9), and friends' drinking (OR: 3.8). For boys they were friends' drinking (OR: 3.3), smoking (O: 2.8), and poor literacy (OR: 2.6). Regarding analgesic use, for girls the key predictors were alcohol use (OR: 3.3), analgesic self-administration (OR: 2.4), and parents' drinking or working as tradespersons/laborers (OR: 1.7, respectively). For boys they were analgesic self-administration (OR: 2.5), drinking (OR: 1.9), smoking (OR: 1.7).

CONCLUSIONS

The key predictors of social drug use--which suggests multiple recruitment pathways--were all outside the ambit of drug education programs. The impact of education on recruitment to drug use or experimentation among the young is therefore likely to be slight.

Cigarette sales to African-American and white minors in low-income areas of Baltimore

OBJECTIVES

This study documented illegal sales of cigarettes to minors in low-income African-American and White urban areas in East Baltimore.

METHODS

Six youths, aged 14 through 16 years, were sent to a random sample of 83 corner stores to attempt to purchase cigarettes. The youths provided the investigators with data on merchant, store, and purchase characteristics.

RESULTS

The youths successfully purchased cigarettes in 85.5% of the stores; 58% of the stores displayed five or more cigarette advertisements outside their premises.

CONCLUSIONS

Cigarette sales to minors and associated advertising remain prevalent in this urban community.

Sociobehavioral influences on smoking initiation of Hispanic adolescents

PURPOSE

To study the sociobehavioral influences on smoking initiation of Hispanic adolescents over a 3-year period using a national sample.

METHODS

Hispanic adolescents (N = 385), ages 15-22 years, from the 1989 and 1993 Teenage Attitudes and Practices Surveys (TAPS I and II), were selected for analyses. Data collected included measures of smoking initiation and attitudes, beliefs toward smoking of the adolescent, and smoking status of family and peers.

RESULTS

At the 3-year follow up, 43.4% of nonsmokers at TAPS I had initiated smoking. Risk factors associated with initiating smoking were having male and/or female friends who smoked, and positive attitudes and beliefs towards smoking. Parental and sibling smoking status had little effect on adolescent smoking status.

CONCLUSIONS

The peer influence on Hispanic adolescent smoking is consistent with previous research on Caucasian and African-American adolescents. The formation of attitudes and beliefs toward smoking in this population warrants further examination given the influence of attitudes and beliefs on smoking initiation in this study.

Are adolescents receptive to current sales promotion practices of the tobacco industry?

BACKGROUND

The tobacco industry increased the portion of its marketing budget for sales promotion to $2.5 billion in 1993. Although it claims not to target those under age 18 years, it is important to determine the extent to which adolescents are affected as participation may lead to smoking initiation.

METHODS

California population surveys, conducted in 1993 among youth ages 12-17 years (N = 5,531) and in 1994 among both youth (N = 1,735) and adults (N = 4,170), asked questions regarding possession and willingness to use promotional items.

RESULTS

In 1994, young adults (18-24 years) were the most likely to possess a promotional item (27.5 +/- 4.1, +/- 95% confidence limit). However, willingness to use an item was highest among those ages 15-17 years (35.4 +/- 3.4%) and was also high among those ages 12-14 years (24.4 +/- 2.7%). Among youth, ownership or willingness to use promotional items was more likely for boys, whites, those reporting below average school performance, and those smoking or susceptible to smoking. Youth ownership of promotional items increased from 1993 to 1994, as did the frequency of their obtaining items from coupons.

CONCLUSIONS

Promotional marketing undertaken by the tobacco industry was effective in capturing the interest of adolescents, although actual acquisition was highest among young adults. The rapidly increasing interest in tobacco promotional items from 1993 to 1994 may soon translate into increased adolescent smoking rates.

Do as I say: parent smoking, antismoking socialization, and smoking onset among children

This study examined relationships between smoking and antismoking practices of parents and early onset of smoking among elementary-grade children. The parent practices we investigated were direct modeling of cigarette smoking and antismoking socialization variables, such as setting rules to eliminate cigarette smoking in the home, awareness of children's smoking behaviors, and making clear the disciplinary consequences of cigarette smoking. Surveying a sample of 1.213 third- and fifth-grade children, we found (1) children's risk of early onset of smoking increases with level of exposure to parent smoking models; (2) if one or both parents are current smokers, children who have never tried smoking have significantly greater risk of intending to smoke, perceiving easy access to cigarettes, and being ambivalent about smoking; (3) risk rates for children of former smokers indicate that parents' quitting smoking does not eradicate the effects of parent modeling; and (4) children whose parents engage in antismoking socialization have significantly lower rates of smoking onset, even if parents are current smokers. The implications of these results for preventive intervention and future research are discussed.

Identification of adolescents at risk for smoking initiation: validation of a measure of susceptibility

Primary prevention of smoking in adolescents requires effective screening instruments for identifying those adolescents who are most likely to experiment with cigarettes. This study investigated the predictive value of a measure of susceptibility to smoking (the lack of a firm commitment not to smoke) for predicting smoking initiation 1 and 2 years later among 687 seventh-grade nonsmokers. Results showed that susceptible adolescents were approximately two to three times more likely to experiment with cigarettes during the ensuing 2 years than were nonsusceptible adolescents. At the lower levels of smoking, these relationships persisted even after controlling for psychosocial variables. Measures of susceptibility to smoking could be an effective tool for identifying adolescents at increased risk of experimenting with cigarettes or assessing their readiness for smoking-prevention programs.

Trends in cigarette smoking among children in a southern community, 1976-1994: the Bogalusa Heart Study

Cigarette smoking among adolescents continues to be a major public health problem in the United States. Smoking trends from 1976-1977 to 1992-1994 were examined in the Bogalusa Heart Study, an investigation of cardiovascular disease risk factors among black and white, male and female adolescents in a semirural town in the southern United States. Age-race-sex specific chi 2 tests for trends over five survey periods were conducted. In almost every age group, black boys and girls were less likely to be current smokers or to have ever smoked or tried cigarettes, as compared with white boys and girls, respectively (P < 0.01). Within age groups, few significant trends in smoking status from 1976-1977 through 1992-1994 were observed among white boys and girls. Among black males and females, however, sharp decreases were observed among all age groups in the prevalence of having ever smoked or tried cigarettes (P = 0.0001) and among the older age groups in the prevalence of being a current smoker (P = 0.0001). Thus, substantial declines in the prevalence of smoking were observed among black children but not among white children. Further research is required to understand why these ethnic differences in smoking occurred so that public health programs may target further the smoking behaviors in children.

Cigarette smoking habits among schoolchildren

STUDY OBJECTIVE

Cigarette smoking is a major preventable cause of morbidity and mortality worldwide. Most adult smokers start smoking regularly some time before 18 years of age. The aim of this study was to determine the age at which children begin cigarette smoking, to study the environmental factors that influence children to smoke, and to understand the reasons why children smoke. The results of this study may help lead to the development of more effective smoking prevention programs.

METHODS

We carried out a cross-sectional survey of all students in grades 6 to 11 (ages: 11 to 17 years) in two high schools in the Jerusalem area, using an anonymous self-completion questionnaire. The students were asked questions regarding the age at which they began smoking, initiation, their smoking habits, their reasons for smoking, and their views on children who smoke. In addition, they were asked about the smoking status of their parents, siblings, and friends. Finally they were asked about the health hazards of smoking.

RESULTS

Of the 847 students who answered the questionnaire, 35% stated that they had smoked at least once and 14% stated that they were currently smoking. The percentage of students who were currently smoking increased gradually with age to 36%. There was a sharp increase in experimental smoking after seventh grade (ages 12 to 13 years). Having a friend who smoked substantially increased the likelihood of smoking, whereas parental smoking or having a sibling who smoked did not increase the likelihood of smoking. The most common reason for starting to smoke was "to try something new" (55%). There was a significant difference between the views of students with different smoking statuses regarding children who smoke: nonsmoking children associated more negative characteristics to smoking. All of the children studied were well aware of the health hazards of cigarette smoking.

CONCLUSIONS

Smoking is highly prevalent among schoolchildren in Jerusalem. The increase in the rate of smoking at the age of 12 years indicates that smoking prevention programs need to be started at an earlier age. Peer pressure is a very strong stimulus for smoking in children. Since children are aware of the health hazards of smoking, prevention policy should be aimed more at associating smoking with negative images and addressing peer pressure.

Development of a school-based drug abuse prevention curriculum for high-risk youths

This paper presents the rationale for and description of the empirical curriculum development process in Project Towards No Drug Abuse (Project TND), which is a five-year grant funded by the National Institute on Drug Abuse. First, the target population is described, continuation high-school youths who are at high risk for drug abuse. The rationale for developing a classroom-based curriculum tailored for them is also provided. Second, a brief description is provided of state-of-the-art generic social influences drug abuse prevention programming, which has been found to be the most effective among young adolescents. There is a the need to consider other prevention activities, particularly those that include motivational variables, to maximize prevention efforts among higher-risk youths. Third, five types of curriculum development studies are discussed that led to a curriculum that is being implemented with continuation high-school students at schools in five counties in southern California. Finally, the contents of the final curriculum product is provided, which consists of motivation, skills-training, and decision-making components.

The role of adolescent peer affiliations in the continuity between childhood behavioral adjustment and juvenile offending

This research reports on a structural equation model analysis of the relationships between childhood behavioral adjustment, adolescent peer affiliations, and adolescent offending using data gathered during the course of a 16-year longitudinal study of a birth cohort of New Zealand children. The model developed contained parameters that estimated (a) the continuities between early behavior and later offending, (b) the associations between early behavior and adolescent peer affiliations, and (c) the potentially reciprocal relationship between adolescent peer affiliations and adolescent offending behaviors. This analysis suggested that, when due allowance was made for reporting error, there was evidence of relatively strong continuity (r = .50) between early behavior and later offending. The model estimates suggested that these continuities arose from both direct continuities in behavior over time and from the effects of adolescent peer affiliations in reinforcing and sustaining earlier behavioral tendencies. The implications of the analysis for the understanding of the role of adolescent peer affiliations in behavioral continuities and discontinuities are discussed.

Cigarette smoking and its risk factors among elementary school students in Beijing

OBJECTIVES

This study investigated patterns of and risk factors for smoking among elementary school children in Beijing, China.

METHODS

In 1988, anonymous questionnaires were administered to a multistage stratified cluster sample of 16996 students, aged mostly 10 to 12, in 479 fourth- to sixth-grade classes from 122 Beijing elementary schools.

RESULTS

Approximately 28% of boys and 3% of girls had smoked cigarettes. The most frequently cited reasons for smoking initiation were "to imitate others' behavior" and "to see what it was like." Girls were more likely to get cigarettes from home than to purchase their own. Having close friends who smoked and being encouraged by close friends to smoke were strong risk factors for smoking. Smoking was also associated with lower parental socioeconomic status; having parents, siblings, or teachers who smoked; buying cigarettes for parents; performing poorly in school; and not believing that smoking is harmful to health.

CONCLUSIONS

Gender differences in smoking prevalence among adolescents in China are larger than those among US teenagers, whereas the proximal risk factors for smoking are similar. Major efforts are needed to monitor and prevent smoking initiation among Chinese adolescents, particularly girls.

Smoking effects on diurnal variations of cardiovascular parameters

Previous studies have reported that nicotine increases heart rate and blood pressure, showing a peak 10 min after intake. But most of the work has focused on the period of maximum effect on cardiovascular parameters and has been limited to morning measurements. The aim of this study is to evaluate the effects of smoking in diurnal variations of heart rate and blood pressure, when no restrictions are placed on the pattern of consumption and activity is controlled. The sample consisted of healthy subjects, 21 smokers and 21 non-smokers, from 18 to 26 years. The recordings were carried out hourly from 8:00 to 21:00 h in resting conditions. Heart rate was measured beat-to-beat for 2 min, and blood pressure was assessed by conventional electronic monitor. Smokers and non-smokers did not differ in diurnal levels of heart rate nor blood pressure when time of day was not considered. However, when time of day was taken into account, the groups differed significantly for heart rate and systolic blood pressure, while diastolic blood pressure only showed differences for post-lunch period. The influence of nicotine on the cardiovascular system of young and healthy smokers is more apparent in the diurnal variations than in the mean level of heart rate and blood pressure. The results emphasize the importance of a chronobiological approach in the study of the early stages of smoking on cardiovascular parameters.

Transitions to cigarette smoking during adolescence

The process of transition from nonsmoking to regular weekly smoking during a period from 10 to 16 years was examined using data gathered during the course of a longitudinal study of 957 New Zealand adolescents. These data were analyzed using a latent Markov model to estimate both rates of transition between stages of smoking and errors of measurement in report data. The fitted model suggested that the process of transition to smoking was a progressive and one-way process in which once teenagers had graduated to a given smoking status, return to earlier stages was uncommon. This process also showed a clear tendency to accelerate with age, so that rates of transition to smoking behaviors after the age of 14 years were far higher than rates of transition at age 10 years. The model also made it possible to estimate the accuracy of smoking reports. This suggested that individuals who were nonsmokers or regular smokers were classified with better than 95% accuracy on the basis of report data. However, the reporting accuracy of occasional smoking was poor, with 42% of occasional smokers being falsely classified as nonsmokers. The implications of these findings for the understanding of the processes of transition to smoking behaviors and the effects of measurement errors in report data are discussed.

Longitudinally predicting late adolescent and young adult drug use: childhood and adolescent precursors

OBJECTIVE

To examine the childhood and adolescent personality determinants of young adult drug use.

METHOD

Data were obtained on children when they were approximately 5.5 (time 1; T1), 14 (T2), 16 (T3), and 22 (T4) years of age. T2-T4 interviews of subjects and their mothers assessed child personality and behavior. At T1, 976 mothers were interviewed. The analysis was based on 734 subjects.

RESULTS

Specific childhood and adolescent personality traits are related to stage of drug use in young adulthood. Regressions showed that (1) traits at T2 and T3 mediated the effect of traits at earlier ages on T4 drug use and (2) stage of drug use was stable from T3 to T4 despite controlling for personality. Significant interaction revealed two buffers weakening the effect of T3 drug use on T4 drug use. Many more T1-T3 personality traits, particularly low aggression, enhanced the effect of low T3 use on T4 use.

CONCLUSIONS

Earlier findings that childhood personality is related to adolescent personality and then to drug use were extended to young adulthood. This mediational model indicates the stability of personality across development. Despite this stability, other results suggest ways to modify drug use.

The social life of bonding theory

'Bonding' as a crucial factor of the early post-partum entered obstetric and paediatric practice after the publication of Maternal and Infant Bonding in 1976 by Klaus and Kennell. The concept has held its place since, as witnessed by medical textbook accounts of it, and the perception of 'instantaneous bonding' as a vital component of the ideal birth experience has dominated media representations of childbirth and, until very recently, feminist writing. Only during the last few years has this literature taken into account research findings concerning the guilt and anxiety experienced by women whose expectations regarding 'bonding' are not realised. While it is now generally acknowledged that maternal attachment develops over an extended period of time, 'bonding' as used extensively in both popular and scientific literature conflates a wide range of meanings and blurs the boundaries between process and outcome. This facilitates the entry of ideological elements into a field which is, by its very nature, deeply significant for human experience. We therefore argue for a continuing critical appraisal of the role of 'bonding' in both general and scientific research.

Socio-economic differences in smoking: Dutch adolescents' beliefs and behaviour

Smoking behaviour is more frequent among those who have a low than those who have a high socio-economic status. The present study confirms that this is also true for Dutch adolescents. The purpose of this study was to investigate whether adolescents with a low socio-economic status (LSES) have different motives for smoking or non-smoking than those with a high socio-economic status (HSES), the aim being to formulate more specific recommendations for prevention strategies for the various groups. HSES adolescents perceived a stronger association between smoking and a number of health-related, personal and social disadvantages, while linking smoking more clearly with the discovery of the taste and with relief from boredom than LSES adolescents. LSES adolescents viewed smoking as a way of meeting people. HSES adolescents experienced less positive norms and less social pressure towards smoking than did LSES adolescents. Smoking among LSES adolescents seems to be embedded in the social culture, and has a stronger social function. Smoking prevention programmes for this group will have to be integrated into a broader, community-based approach, which should also pay attention to the smoking behaviour of the social environment in general and that of the parents in particular. Finally, improved legislation with regard to smoking prevention will be required, in order to facilitate the adoption and implementation of smoking prevention programmes.

Lifestyle, health and social class in adolescence

The paper considers mechanisms for indirect health selection in adolescence, as part of the explanation for health inequalities between social groups. Aspects of adolescent lifestyles are identified as potentially important factors for the production of class based differences in adult health status. Survey data from a Scottish longitudinal study of adolescent socialization and lifestyles are utilized in order to locate such health lifestyle factors within the wider contexts of the individual's personal and social environment at this stage of the life cycle. Relationships and attitudes to family, school and peers in middle adolescence at 15-16 years of age are first examined, and distinctive patterns of integration within these contexts are identified. The inter-connections between these broader aspects of lifestyle, social class and individual health behaviours are then examined. Mid-adolescent patterns of social integration are found to have a clear structural basis, and most importantly, they anticipate social position in later adolescence at 17-18 years of age. It is also found that such patterns of integration into the family, peer and school contexts are linked to subsequent health related behaviours and to self assessed health in later adolescence, and that these links are independent of the young person's social class background. Thus, we conclude that behavioural--cultural lifestyle factors, when these are located within a broader social context, provide a clear and plausible mechanism for indirect health selection in adolescence.

A profile of tobacco smoking

Cigarette smoking has for years been declining slowly in a number of major Western countries. It nevertheless remains highly prevalent, with one-quarter to one-third of adults being current smokers in the USA and Britain, and only some 40 per cent of those who have ever smoked cigarettes regularly have given up. Smoking is increasingly becoming a marker for deprivation and for a stressful life-style, and is also associated with consumption of other drugs. There is abundant and convincing evidence that, far from being confined to a minority of problem users, high levels of dependence on tobacco are experienced by a majority of smokers in the general population, with an onset early in the smoking career. The rewards which underpin continued smoking are unclear, but it may be that avoidance of the unpleasantness of not smoking is more significant than positively rewarding effects.

Active and passive tobacco exposure: a serious pediatric health problem. A statement from the Committee on Atherosclerosis and Hypertension in Children, Council on Cardiovascular Disease in the Young, American Heart Association

This review defines the substantial pediatric morbidity from tobacco use, including health effects on the cardiovascular system, the respiratory system, the fetus and newborn, and risk-taking behaviors of adolescents. More recent research suggests effects may extend to other areas, including reports that cigarette smoking decreases breast milk production in mothers, byproducts of tobacco use are transmitted in breast milk, exposure to passive smoking may alter children's intelligence and behavior, and passive smoke exposure in childhood may be a risk factor for developing lung cancer as an adult. Primary prevention is the most effective strategy to decrease the prevalence of smoking. Those who never smoke never become addicted to nicotine and never have to quit. Secondary prevention must also be emphasized, because children whose parents smoke are exposed to health risks and are themselves more likely to smoke in the future. Parental health can be improved by smoking cessation. To accomplish the goals of primary and secondary prevention, the aggressive public health strategy directed at both parents and children should be expanded. This strategy requires the strong support of physicians, with emphasis on prevention in practice, support of public health initiatives, medical and public policy, and the conduct of high-quality research.

Social class and adolescent smoking behaviour

The paper examines class based differences in smoking behaviour in middle and later adolescence. The analyses are based on questionnaire survey data drawn from a longitudinal study of adolescent socialisation, leisure and lifestyles in Scotland. Perhaps surprisingly, the social class of the family is found to have little relationship to smoking in middle and later adolescence. By contrast, marked variations in smoking are evident with respect to the current socio-economic position occupied by young people themselves in middle and later adolescence. The connections between smoking, social class background, and current social class position are examined through a consideration of inter-generational occupational mobility, and once more a clear pattern of differences is found. Thus, we conclude that there is an emergent pattern of class based differences in adolescent smoking behaviour, as young people make the transition towards adulthood. We consider the possible role that factors from the family, the peer group, and the school contexts may play in the production of these differences in smoking behaviour. We also highlight the importance that our findings may have for the health inequalities debate, and particularly for explanations which link the production of class based differences in health to processes of inter-generational mobility.

The report of the Surgeon General: preventing tobacco use among young people

This year's surgeon general's report on smoking and health is the first such report to focus on young people. From extensive data that indicate that tobacco use is a pediatric epidemic, the report reached six major conclusions: (1) Nearly all first use of tobacco occurs by age 18. (2) Most adolescent smokers are addicted to nicotine. (3) Tobacco is often the first drug used by young people who subsequently use illegal drugs. (4) There are identified psychosocial risk factors for the onset of tobacco use. (5) Cigarette advertising also appears to increase young people's risk of smoking. (6) Communitywide efforts have successfully reduced adolescent use of tobacco. This commentary restates each of the six conclusions, summarizes the data that support each, and then considers the implications of the conclusions for public health action.