Why children start smoking cigarettes: predictors of onset

Smoking in Scottish youths: personal income, parental social class and the cost of smoking

OBJECTIVE

To examine the relation of young people's personal income and parental social class with smoking from early to mid adolescence.

DESIGN

Longitudinal, school based, study of a cohort of 2586 eleven year-olds followed up at ages 13 and 15.

SETTING

West of Scotland.

PARTICIPANTS

93% baseline participation, reducing to 79% at age 15.

MAIN OUTCOME MEASURES

Ever smoked (age 11), current and daily smoking (ages 13 and 15) and the proportion of income spent on tobacco (13 and 15) based on recommended retail prices of usual brands.

RESULTS

Strong independent effects of parental social class and personal income were found at 11 years, both reducing with age. The higher incomes of lower class participants attenuated the social class effect on smoking at ages 11 and 13, but not at 15. Analysis within class groups showed variation in the effect of income on smoking, being strongest among higher class youths and weak or non-existent among lower class youths. This was despite the fact that the proportion of weekly income apparently spent on tobacco was greater among lower class youths.

CONCLUSIONS

The results confirm the importance of personal income and parental social class for youth smoking, but they also show that personal income matters more for those from higher class backgrounds. This suggests both that lower class youths have greater access to tobacco from family and friends and to cheaper sources of cigarettes from illegal sources. This complicates the relation between fiscal policies and smoking and might have the unintended consequence of increasing class differentials in youth smoking rather than the reverse.

Identifying health disparities across the tobacco continuum

AIMS

Few frameworks have addressed work-force diversity, inequities and inequalities as part of a comprehensive approach to eliminating tobacco-related health disparities. This paper summarizes the literature and describes the known disparities that exist along the tobacco disease continuum for minority racial and ethnic groups, those living in poverty, those with low education and blue-collar and service workers. The paper also discusses how work-force diversity, inequities in research practice and knowledge allocation and inequalities in access to and quality of health care are fundamental to addressing disparities in health.

METHODS

We examined the available scientific literature and existing public health reports to identify disparities across the tobacco disease continuum by minority racial/ethnic group, poverty status, education level and occupation.

FINDINGS

Results indicate that differences in risk indicators along the tobacco disease continuum do not explain fully tobacco-related cancer consequences among some minority racial/ethnic groups, particularly among the aggregate groups, blacks/African Americans and American Indians/Alaska Natives. The lack of within-race/ethnic group data and its interactions with socio-economic factors across the life-span contribute to the inconsistency we observe in the disease causal paradigm.

CONCLUSIONS

More comprehensive models are needed to understand the relationships among disparities, social context, diversity, inequalities and inequities. A systematic approach will also help researchers, practitioners, advocates and policy makers determine critical points for interventions, the types of studies and programs needed and integrative approaches needed to eliminate tobacco-related disparities.

Influence of smoking by family and best friend on adolescent tobacco smoking: results from the 2002 New Zealand national survey of year 10 students

OBJECTIVE

To compare the relative importance on adolescent smoking of the influence from parental smoking and peer smoking.

METHOD

National New Zealand crosssectional survey of 14,936 female and 14,349 male Year 10 students (aged 14 and 15 years) who answered an anonymous self-administered questionnaire in November 2002.

RESULTS

Adolescents with both parents smoking had the highest smoking risk compared with those with one or neither parent smoking. The relative risk of adolescent daily smoking associated with both parents smoking, compared with neither, varied with ethnicity, being 2.34 (95% Cl 2.05-2.67) in Maori, 2.87 (2.21-3.73) in Pacific Islanders, 11.37 (7.87-16.42) in Asian, and 4.92 (4.35-5.55) in European/Other students, adjusting for age and sex. These values were lower than the adjusted relative risks of daily adolescent smoking associated with having a best friend who smoked: 4.18 (3.59-4.88) in Maori, 5.19 (3.98-6.76) in Pacific Island, 14.35 (9.48-21.71) in Asian and 10.18 (9.07-11.43) in European/Other students. Adolescent smoking was also positively associated with pocket money amount and living in a home where smoking was allowed, both parental-related factors. Combined exposure to one or more of the following factors - parental smoking, pocket money >$5 per week and smoking in the house - explained 64% of daily adolescent smoking, very similar to the 67% attributable to best friend smoking.

CONCLUSION

Parental behaviour is a key determinant of smoking by New Zealand adolescents and explains a similar proportion of daily adolescent smoking to that by peer smoking.

Disentangling social selection and social influence effects on adolescent smoking: the importance of reciprocity in friendships

AIMS

The goal of this study was to examine social selection and social influence within reciprocal and non-reciprocal friendships, and the role of parents and siblings, as factors explaining similarity of smoking behaviour among adolescent friends. A new social selection-social influence model is proposed.

DESIGN

Longitudinal design with two measurements.

SETTING

Data were gathered among Dutch high school students in the control group of the European Smoking prevention Framework Approach (ESFA) study.

PARTICIPANTS

The sample consisted of 1886 adolescents with a mean age of 12.7 years.

MEASUREMENTS

The main outcome measures were the smoking behaviours of the respondents, best friends, parents and siblings. We tested the social selection-social influence model with structural equation modelling techniques.

FINDINGS

Social selection and social influence both played an important role in explaining similarity of smoking behaviour among friends. Within non-reciprocal friendships, only social selection explained similarity of smoking behaviour, whereas within reciprocal friendships, social influence and possibly also social selection explained similarity of smoking behaviour. Sibling smoking behaviour was a more important predictor of adolescent smoking behaviour than parental smoking behaviour.

CONCLUSIONS

Social selection and social influence both promote similarity of smoking behaviour, and the impact of each process differs with the degree of reciprocity of friendships. These insights may contribute to further refinement of smoking prevention strategies.

Perceived peer influence and peer selection on adolescent smoking

Despite advances in tobacco control, adolescent smoking remains a problem. The smoking status of friends is one of the highest correlates with adolescent smoking. This homophily (commonality of friends based on a given attribute) may be due to either peer pressure, where adolescents adopt the smoking behaviors of their friends, or peer selection, where adolescents choose friends based on their smoking status. This study used structural equation modeling to test a model of peer influence and peer selection on ever smoking by adolescents. The primary analysis of the model did not reach significance, but post hoc analyses did result in a model with good fit. Results indicated that both peer influence and peer selection were occurring, and that peer influence was more salient in the population than was peer selection. Implications of these results for tobacco prevention programs are discussed.

Cognitions about smoking and not smoking in adolescence

The theory of planned behavior identifies important proximal determinants of behavior, including attitude toward the behavior, perception of subjective norms exerted by significant others, and perception of perceived control over performance of the behavior. Because research in the planned behavior tradition has focused on desirable target behaviors, it is not clear how these determinants can best be conceptualized to account for adolescents' acquisition of health risk behaviors such as smoking. This cross-sectional study compared the explanatory power of planned behavior constructs assessed in relation to "smoking" and "not smoking" in a sample of 248 Dutch secondary students (aged 12 to 17 years; 56% girls). The results indicated that four variables--attitude toward smoking, perceived subjective norm, and perceived behavioral control over both smoking and not smoking--best explained the adolescents' smoking intentions and smoking behavior. Methodological and practical implications for smoking interventions are discussed.

Correlates of smoking initiation among young adults in Ukraine: a cross-sectional study

Background

Aim: To estimate the impact of smoking restrictions in homes and schools, and tobacco advertising and information on smoking initiation by young people in Ukraine.

Methods

Data of 609 young people aged 15–29 was taken from the national representative survey conducted in June 2005. Outcome measures: The reported age of cigarette initiation was used to characterize the start of smoking experimentation, and the reported age of daily smoking initiation was considered to be a characteristic of established smoking.

Analysis: survival analysis Cox proportional hazard regression models were used.

Results

Age of smoking initiation was reported by 87% of young men and 61% of young women, the beginning of daily smoking by 71% and 33% respectively. Being frequently exposed to second-hand smoke and having no household smoking restrictions was associated with a higher risk of earlier smoking initiation both for men and women. For women, this risk was associated with age, HR = 0.95, (95% CI 0.91–0.98), that is, younger girls were more likely to smoke their first cigarette earlier in their lifetime. Those women had a higher risk of early smoking initiation who reported to receive tobacco-related information from magazines, HR = 1.40 (1.01–1.92), and outdoor tobacco advertising, HR = 1.99 (1.45–2.75). With both men and women, the risk of establishing daily smoking was higher in those with lower levels of tobacco-related knowledge and less household smoking restrictions. For women, the risk was higher in those who live in larger cities HR = 1.77 (1.10–2.86), and who received information about tobacco smoking from colleagues or friends HR = 1.83 (1.13–2.95).

Conclusion

Encouraging people to eliminate their homes of tobacco smoke and tobacco advertising bans can be effective measures in preventing the initiation of smoking among young people. Young female smoking initiation is of special concern in Ukraine, since they are more responsive to tobacco marketing and pro-smoking peer influence.

The neighbourhood they live in: does it matter to women's smoking habits during pregnancy?

Socioeconomic factors in the neighbourhood are associated with smoking habits in various populations. We studied a 10-year cohort to determine whether women's smoking behaviour during pregnancy can similarly be determined by neighbourhood economic and ethnic factors. The cohort included 127,074 primiparous pregnant women in 592 Swedish neighbourhoods during the years 1992-2001. Multilevel technique was used to regress pregnancy smoking on socioeconomic individual-level variables and neighbourhood characteristics. Seven percent of the variation in pregnancy smoking was at the neighbourhood level and the odds of smoking during pregnancy were doubled in poorer areas. Health education and smoking cessation interventions should be directed at maternity care units in deprived neighbourhoods.

Predictors of smoking stage transitions for adolescent boys and girls

BACKGROUND

Aim of this study was to identify predictors of transition from never smoking to smoking monthly or more often in a European sample of adolescents. To show whether predictors differed between genders, analyses were run for boys and girls separately.

METHODS

From six European countries, 4055 never smokers participated at baseline (1998). One year later, respondents were asked to indicate their smoking status. Respondents were categorized as smoker (smoking monthly or more) or non-smoker (smoking less than monthly). The predictive qualities of predisposing, motivational and intentional concepts were assessed using logistic regression analyses.

RESULTS

Girls were more likely to be a smoker at follow-up. More spending money, modeling from parents and a higher intention to start smoking were predictive of smoking uptake in both genders. Boys were more likely to start smoking when perceiving less cons of smoking, drinking more alcohol and perceiving a social norm towards not smoking from parents. Girls experiencing higher social pressure to smoke from friends were more likely to start smoking.

CONCLUSIONS

Separate uptake prevention interventions for boys and girls do not seem warranted. Boys may benefit from a program also addressing other deviant behaviors. Girls should continue to be supplied with specific skills to resist social pressure.

Which dimensions of impulsivity are related to cigarette craving?

Cigarette smoking is a very important health problem and represents the largest preventable risk factor for premature death in developed countries. A considerable body of research indicates that impulsivity is a central etiological concept in many theoretical models of tobacco addiction. The aim of this study is to analyse which dimensions of impulsivity are related to cigarette craving. To this end, 40 undergraduate psychology students were screened using the revised Questionnaire on Smoking Urges (QSU-12) and the French adaptation of the UPPS Impulsive Behavior Scale (UPPS). This scale identifies four distinct components associated with impulsive behaviour: urgency, lack of premeditation, lack of perseverance, and sensation seeking. The results showed that urgency is a significant predictor of tobacco cravings, while depression and anxiety are not.

Psychometric properties of brief indexes designed to measure social-cognitive predictors of smoking initiation

BACKGROUND

Constructing indexes which measure factors that may predict smoking initiation is essential for planning prevention programs. Our aim was to examine the criterion-related construct validity of brief psychological indexes of attitude, social influence and self-efficacy to be used in future studies for predicting smoking initiation in adolescents.

METHODS

Five indexes were evaluated using cross-sectional data on 4819 adolescents age 13 in a random sample of schools in six Danish counties. Item analyses were performed with the graphical log-linear Rasch model, a modification of the Rasch model that allows for differential item functioning and positive local dependence.

RESULTS

The three indexes social influence-norms, social influence-pressure and attitude showed acceptable deviations from the Rasch model, while the two indexes self-efficacy and social influence-behavior were invalidated by negative local dependence.

CONCLUSION

Of the five tested indexes, three (social influence-norms, social influence-pressure and attitude) showed acceptable criterion-related construct validity and may be considered unbiased representations of the theory-based factors if statistical analyses are appropriately adjusted. The results of this population-based study show that the graphical log-linear Rasch model is useful for evaluating health-related behavior indexes and identifying problems, which can be dealt with when using the indexes in future studies.

Social influences, and attitudes and beliefs associated with smoking among border Latino youth

BACKGROUND

Adolescent smoking rates have declined among all ethnic groups since the late 1990s. However, despite the recent declines and intervention efforts, today smoking remains a serious problem among youth, with a quarter of adolescents being current smokers by the time they complete 12th grade. This problem is particularly prevalent among Latino youth, who have among the highest rates of lifetime and past-30-day use. The purpose of this study was to examine the association between psychosocial factors and the smoking behavior of Latino youth living along the Mexico-US border.

METHODS

A convenient sample of 2471 middle and high school Latino students was surveyed in fall 2000. Logistic regression analysis was used to examine the association between study risk factors and youth smoking behavior.

RESULTS

The strongest predictor of lifetime and past-30-day smoking was peer influence; however, the strength of the association was greater with recent use. There were also differences in the influence of family and attitudes and beliefs between the 2 groups.

CONCLUSIONS

These differences need to be taken into consideration to guide development of tailored prevention and control interventions aimed at this specific group. These efforts should address social influences to smoke, particularly those from peers; promote changes in attitudes and beliefs toward smoking; increase understanding of the addictive nature of nicotine; and provide development of skills young people need to resist social and environmental pressures to smoke. Strict control and enforcement measures are needed to completely eliminate the sale of cigarettes to minors.

Psychosocial factors related with smoking behaviour in Portuguese adolescents

Few studies describe the factors associated with smoking behaviour in Portuguese adolescents. Hence, smoking prevention activities are not based on research findings. This study analyses the differences between smokers and nonsmokers and factors associated with smoking behaviour in a sample of Portuguese adolescents. A questionnaire was administrated to seventh grade students of 25 schools from five municipalities near Lisbon (n=3064). The majority of them were never smokers (71.3%), 21.9% smoked less than monthly, 2.1% monthly and 4.7% weekly or more frequently. Smokers were older, had lower school achievement, had more money available to spend, preferred less to be together with nonsmoking people and were more likely to be allowed to smoke at home, to use alcohol and to perform various risky behaviours. Nonsmokers were less convinced of the advantages and more convinced of the disadvantages of smoking, encountered more social norms against smoking, perceived less smoking in others, felt less pressure to smoke from peers, were more confident to refuse cigarettes and had a lower intention to smoke next year. Intention to smoke, self-efficacy expectations to refuse smoking, social influence and alcohol consumption were the most relevant variables associated with smoking behaviour. Consequently, Portuguese smoking prevention programmes should include activities aimed to help adolescents to deal with pressure to smoke from peers and to improve self-efficacy expectations to refuse cigarettes. Our findings also confirm the link between smoking and alcohol use suggesting that the prevention of these two behaviours should be complementary.

Parental Smoking and Adolescent Smoking Stages: The Role of Parents’ Current and Former Smoking, and Family Structure

This study examined the role of parents' current and former smoking in predicting adolescent smoking acquisition stages. Participants were 7,426 students from 33 schools in the Netherlands. Participants' survey data were gathered at baseline and at two-year follow-up. Logistic regression models showed that parental smoking status was not only predictive of transitions from never smoking to trying smoking, monthly smoking, or daily smoking, but also of the progression from trying smoking to daily smoking. Further, although parental former smoking was weaker associated with progressive adolescent smoking transitions than current parental smoking, however absence of parental smoking history was most preventive. Compared to the situation in which both parents had never smoked, cessation of parental smoking after the child was born was associated with an increased risk for children to smoke. Adolescents living in a single-parent family were at greater risk of smoking than adolescents living in an intact family with both mother and father. In sum, the role of parental smoking is not restricted to smoking onset and is present throughout different phases of the acquisition process. Results support the delayed modeling hypothesis that parental smoking affects the likelihood for children to smoke even when parents quit many years before. Children living in single-parent families are only exposed to the behaviour of one parent; in two-parent families the behaviour from one parent may magnify or buffer the behaviour of the other parent.

Peer and parental influences on longitudinal trajectories of smoking among African Americans and Puerto Ricans

The purpose of this study was to identify distinct trajectories of smoking behavior during a period extending from adolescence (mean age = 14 years) to young adulthood (mean age = 26 years) among African American and Puerto Rican adolescents/young adults, to examine ethnic and gender differences in group membership, and to assess the ability of peer and parental smoking to distinguish among trajectory groups. A community-based sample of 451 African American and Puerto Rican adolescents was interviewed four times during adolescence and in early adulthood, covering a span of 12 years. For both ethnic/racial groups, four distinct trajectories were identified: Nonsmokers, maturing-out smokers, late-starting smokers, and early-starting continuous smokers. Compared with Puerto Ricans, African Americans were over-represented in the nonsmoking group, whereas Puerto Ricans were over-represented in the early-starting continuous group. Females were more likely than males to be early-starting continuous smokers than late starters. Adolescents who were exposed to peer and parental smoking in early adolescence were more likely to belong to trajectory groups characterized by higher levels of smoking. These findings show that exposure to peer and parental smoking in early adolescence constitutes a risk factor for engaging in elevated levels of smoking behavior at an early age and for continued smoking into adulthood for urban African Americans and Puerto Ricans. To be most effective, smoking prevention programs should address peer group and family influences on adolescent smoking.

Using classification trees to profile adolescent smoking behaviors

The purpose of this study was to explore the interactive nature of various predictor variables in profiling adolescent smoking behaviors characterized by intention to smoke, current, situational, and established smoking using classification trees. The data (n = 3610) were obtained from cross-sectional telephone surveys of the Florida Anti-Tobacco Media Evaluation Program. Three classification trees were constructed, namely, intention versus no intention to smoke among non-smokers, current smokers versus non-smokers, and established versus situational smokers. The tree model for the intention model revealed that social and health risks are important in the context of peer smoking. Certain variables such as peer smoking and alcohol consumption retained their relative importance across the tree classifiers demonstrating that smoking intention may be predictable using some of the same variables as in current or more dependent smoking.

Beliefs about the risks of smoking mediate the relationship between exposure to smoking and smoking

OBJECTIVE

Peer and family smoking are key predictors of adolescent smoking. Yet, it is unclear whether the effect of these variables is direct or indirect through the effects of mediating mechanisms. One possible mechanism is smoking risk beliefs. We hypothesized an indirect effect such that exposure to peer and family smoking may affect adolescents' smoking through two sets of risk beliefs; beliefs about the personal harm of smoking, and beliefs about the general immediate harm of smoking, and these beliefs may in turn affect smoking.

METHODS

Our sample was 963 participants taking part in a longitudinal study of the biobehavioral determinants of smoking. We measured exposure to peer and household smoking in grade 10, smoking risk beliefs in grade 11, and modeled the effects of these variables prospectively on smoking one year post high school graduation in a Structural Equation Model (SEM).

RESULTS

Beliefs about the personal harm and general immediate harm of smoking had significant and negative direct effects on smoking one year post high school. However, controlling for 10th grade smoking, only personal harm beliefs mediated the relationship between household smoking exposure and smoking behavior. Specifically, personal harm beliefs mediated the effect of having a household member who smokes on smoking one year post high school graduation.

CONCLUSIONS

The findings are consistent with the hypothesized mediation model and suggest that exposure to household smoking may affect adolescent smoking through its effects on beliefs about the personal harm of smoking, beyond the effects of previous smoking.

Effects of a single-lesson tobacco prevention curriculum on knowledge, skill identification and smoking intention

One in five students report experimenting with tobacco before the age of 13 and most prevention efforts take place in the school setting. This study measures the effect of a single-lesson tobacco prevention curriculum, conducted by a health education center, focusing on knowledge of tobacco, ability to identify refusal techniques, and intent not to smoke. Data were collected, via electronic keypads, from students visiting a non-school, health education center in Michigan (n = 704 intervention and 85 comparison). Contingency table Chi-squared tests and t-tests demonstrated that a single lesson can improve general knowledge and ability to identify appropriate refusal techniques. Improvement in intent not to smoke was not significant because both groups had very high intent prior to implementation. Similar to results from other programs, multivariate logistic regression of gender, general knowledge, and skill identification revealed that only the skill variable was associated with intent not to smoke at pretest. Recommendations are given for further research and for designing more effective curricula or programs.

Peer contagion of aggression and health risk behavior among adolescent males: an experimental investigation of effects on public conduct and private attitudes

Peer contagion of adolescent males' aggressive/health risk behaviors was examined using a computerized "chat room" experimental paradigm. Forty-three 11th-grade White adolescents (16-17 years old) were led to believe that they were interacting with other students (i.e., "e-confederates"), who endorsed aggressive/health risk behaviors and whose ostensible peer status was experimentally manipulated. Adolescents displayed greater public conformity, more internalization of aggressive/health risk attitudes, and a higher frequency of actual exclusionary behavior when the e-confederates were high in peer status than low. Participants' level of social anxiety moderated peer contagion. Nonsocially anxious participants conformed only to high-status peers, whereas socially anxious participants were equally influenced by low- and high-status peers. The role of status-maintenance motivations in aggression and risk behavior, and implications for preventive intervention, are discussed.

Early dating predicts smoking during adolescence: A prospective study

AIM

To examine the relationship between dating and smoking behaviour.

DESIGN

A 5-year prospective study.

SETTING

Thirty-six schools in South London, England.

PARTICIPANTS

A socio-economically and ethnically diverse sample of students (n = 4319 at baseline) took part in the study, providing annual assessments from age 11-16 years.

MEASUREMENTS

Questionnaire items assessed dating status, smoking status, friends and family smoking, psychological wellbeing, popularity and conduct, pubertal status, gender, ethnicity and deprivation. Cotinine assays provided biochemical verification of smoking status.

FINDINGS

At age 11-12, 18% [corrected] of girls and 29% [corrected] of boys reported having a boyfriend or girlfriend. Logistic regressions showed being an early 'dater' to be a strong predictor of later smoking uptake at each study year, with odds ratios ranging from 3.03 to 8.96 among girls and 1.87 to 5.85 among boys. These associations remained significant after controlling for potential confounding factors, including past smoking and pubertal stage. There was minimal evidence that having smoked by age 11-12 predicted later dating.

CONCLUSIONS

The association between early dating and later smoking is strong, and not explained by obvious confounders or dependent on the influence of past smoking experience. The use of smoking to maintain a popular image, and the link between both behaviours and aspirations towards maturity, are potential explanations for the effect. Identification of adolescents dating early could help to target prevention of later smoking uptake.

Can home smoking restrictions influence adolescents' smoking behaviors if their parents and friends smoke?

Research suggests that the presence of a total ban on smoking in the home is associated with a reduced likelihood of tobacco experimentation among adolescents. While the influence of parental smoking on this association is examined in this work, no study has examined the influence of friends' smoking behavior. In this study, we use data from a statewide survey of students (n=4125) from the Australian State of Victoria to examine the association between home smoking bans and stage of smoking uptake after controlling for parental smoking and smoking among friends. Logistic regression revealed that students residing in homes with a total ban on smoking were least likely to be susceptible to smoking or to have experimented with smoking. While there was an interaction between parental smoking status and home bans on smoking uptake stage, indicating that the effect of home bans was strongest when neither parent smoked, there was no interaction between home bans and friends' smoking. The results suggest that home smoking bans reduce the likelihood of an adolescent trying tobacco regardless of their friends' smoking behavior. By adopting strong home smoking bans, parents can reduce some of the influence friends' smoking can have on the smoking behavior of their adolescent.

Age-related smoking progression among adolescents in China

PURPOSE

This study examined the differences in smoking progression between middle and upper school students.

METHODS

The China Seven Cities Study (CSCS) is a longitudinal cohort study. The current sample consists of subjects with both baseline and one-year follow-up measures collected between October 2002 and December 2003. There were 4842 students from 62 middle schools and 5806 students from 83 upper schools. Multilevel random-coefficient modeling techniques were applied.

RESULTS

Among male never or lifetime ever smokers, middle school students were susceptible to transitioning more rapidly than upper school students (never--RR: 1.272, 95% confidence interval [CI]: .985-1.642; lifetime ever--RR: 1.497, 95% CI: .979-2.290). Among female lifetime ever smokers, middle school students were more likely to progress than upper school students (RR: 1.353, 95% CI: 1.038-1.763).

CONCLUSION

This longitudinal study is the first to explore differences in smoking progression among adolescents in China. The results revealed that over a one-year interval, there was greater progression across smoking trajectories during early adolescence (corresponding to middle school) than later adolescence (upper school). This is consistent with the neurological development hypothesis, but does not rule out alternative explanations. These findings are important to consider relative to the content and timing of prevention interventions in China where smoking rates approach 70% in adult males and are increasing rapidly in women.

Close friends', parents', and older siblings' smoking: reevaluating their influence on children's smoking

A number of longitudinal studies have explored the role of friends', parents', and older siblings' smoking in children's smoking acquisition. A reasonable implication of this previous research is that intervention efforts could be beneficially directed toward countering the potential influence of friends' and possibly older siblings' smoking but not parents' smoking. However, methodological limitations of this previous research motivated our reevaluation of the role of friends', parents', and older siblings' smoking in children's smoking. Close friends' smoking status was assessed when children were in 5th grade, whereas parents' and older siblings' smoking status was assessed when children were in 3rd grade. The outcome, children's daily smoking status, was assessed in 12th grade. The setting was 40 Washington state school districts that participated in the long-term Hutchinson Smoking Prevention Project. Participants were the 4,576 families for whom close friends', parents', and older siblings' smoking status as well as children's smoking status were available. The probability that each close friend's smoking influenced the child to smoke daily was 9% (95% CI = 6%-12%), the probability that each parent's smoking influenced the child to smoke daily was 11% (95% CI = 9%-14%), and the probability that each older sibling's smoking influenced the child to smoke daily was 7% (95% CI = 1%-13%). These results suggest that close friends', parents', and siblings' smoking were similarly important influences on children's smoking. Family-focused interventions could be a valuable future direction of prevention research.

Predicting perceived vulnerability to tobacco-related health risks and future intentions to use tobacco among pediatric cancer survivors

OBJECTIVE

To examine predictors of perceived vulnerability to tobacco-related health risks and future intentions to use tobacco among pre-adolescents and adolescents previously treated for cancer.

METHODS

Written self-report measures of tobacco knowledge, perceived vulnerability, perceived positive value of tobacco use, past and present tobacco use, and intentions to use tobacco were completed by 103 cancer survivors, 10-18 years of age (51.5% males, 78.6% Caucasians). Patient reports of peer and parent tobacco use were also obtained.

RESULTS

Perceived vulnerability was influenced by demographic variables, knowledge, and gender-related past tobacco use. Fifty-seven percent of non-smoking survivors reported some intention to use tobacco. Survivors who perceived some positive value associated with tobacco use and who used tobacco in the past reported greater intentions for future tobacco use.

CONCLUSION

Modifiable cognitive-motivational variables directly associate with smoking-related outcomes among pediatric survivors of childhood cancer.

PRACTICE IMPLICATIONS

Preventive tobacco interventions with this vulnerable cohort are warranted and should inform about tobacco-related health risks and attempt to modify misperceptions of the positive value associated with tobacco use.

Smoking rates and the state of smoking interventions for children and adolescents with chronic illness

Engaging in smoking is particularly risky for children and adolescents with chronic illness whose health status is already compromised because of disease- and treatment-related complications. Yet, some of these youngsters smoke at rates at least comparable to those of their healthy peers. To date, few randomized smoking-prevention and cessation trials have been conducted in children with chronic medical problems. In this review we report on the smoking rates among youngsters with chronic illness, identify specific disease- and treatment-related complications that can be exacerbated by smoking, examine risk factors associated with tobacco use among medically compromised youngsters, and review smoking interventions that have been conducted to date with pediatric populations in the health care setting. The following chronic illnesses are included in this review: asthma, cystic fibrosis, cancer, sickle cell disease, juvenile-onset diabetes, and juvenile rheumatoid arthritis. Objectives for a tobacco-control agenda and recommendations for future tobacco studies in chronically ill pediatric populations are provided. Finally, tobacco counseling strategies are suggested for clinicians who treat these youngsters in their practices.

Perceptions of Tobacco Use in Early Adolescents

In an effort to strengthen tobacco use prevention programs, this study explores early (9- to 13-year-old) adolescent motivations for and perceptions of use. Data were collected, via electronic keypads, from students visiting 12 health education centers in the U.S. (N=1433). Multivariate logistic regression showed that perceptions of frequent peer tobacco use and popularity of adolescent smoking, in addition to absence of family discussion of tobacco use, were associated with greater likelihood for smoking and of reporting past smoking. Even though most participants thought adolescents who smoke are very unpopular, more than 60% said the primary reason for adolescent smoking was that smokers believe it will make them popular. Participants thought the best way to prevent use was to give kids "other fun things to do instead." Recommendations are given for customizing curricula or programs.

Family and peer influences on tobacco use among adolescents with psychiatric disorders

The purpose of this study was to examine family and peer influences on smoking behaviors among 239 (191 smokers; 48 nonsmokers) psychiatrically hospitalized adolescents. Participants were queried using scales to measure parental supervision and monitoring, parenting style, adolescent-parent communication, family conflict and relations with parents, and the importance placed on life goals. The results of this study are consistent with previous findings from general population studies. Psychiatrically hospitalized adolescents' smoking status were also correlated with their siblings', peers', and girlfriends'/boyfriends' smoking status. In addition, we found that parental monitoring, closeness to parents, and ambitious life goals were protective factors against smoking. As a result, peer and family influences strongly impact the initiation and maintenance of adolescent smoking and should be considered when designing smoking cessation interventions for adolescents with psychiatric disorders.

Over time relationships between early adolescent and peer substance use

Peer and adolescent substance use are highly correlated, but this relationship is not fully understood. In particular, the relative contributions of selection and socialization to substance use progression have not been established. Students (n=2453) in the seven middle schools in one school district were assessed at school at the beginning and end of the sixth, seventh, eighth grade and beginning of the 9th grade. Self-reported smoking and drinking and the number of substance using friends were assessed 5 times over 3 years. The relationship between peer and adolescent substance use were assessed in parallel processes as part of an autoregressive latent trajectory model. Substance use and the number of substance using friends increased in linear fashion from T1 to T5. Initial substance use predicted an increase in the number of substance using friends over time, indicating an effect of selection, and the initial number of substance using friends predicted substance use progression, providing evidence of socialization. The magnitudes of these relationships were similar. Bivariate, lagged autoregressive analyses of the successive relationships from one assessment to the next showed consistent, significant associations from peer use to adolescent substance use. The association from adolescent to peer use was significant only from 7th to 8th grade. The findings provide evidence of reciprocal influences, but socialization was a more consistent influence than selection.

Health inequalities among adolescents: the impact of academic orientation and parents' education

BACKGROUND

Traditionally, the socio-economic position of adolescents has been measured using information about parents' occupation, parents' level of education, or household income. Since the adolescence is a developmental stage characterised by a search for and a move into individual life tracks a shift of focus from socio-economic position of origin to socio-economic position of destination is justified. Academic orientation may be used as a rough indicator of future social position. The purpose of the study was to elucidate the link between academic orientation and parents' education on the one hand and subjective health and health-related behaviour among adolescents on the other.

METHODS

The study was based on cross-sectional questionnaire data collected in 1999 and 2003 among 1828 18-year-old students in year 2 of upper secondary school in a Swedish city. The data were analysed using contingency tables and logistic regression.

RESULTS

Subjective health and health-related behaviour was strongly linked to academic orientation but not directly to parents' education. The pattern is unambiguous, poor health and health-damaging behaviour being significantly higher among students in non-theoretical programmes than among students in theoretical programmes.

CONCLUSION

Academic orientation is a useful concept in order to detect health inequalities and a powerful way of identifying adolescents at higher risk. The unequal distribution of health and health-damaging behaviour according to academic orientation among adolescents turns out to be an important challenge for public health work.

Could the peer group explain school differences in pupil smoking rates? An exploratory study

Schools differ in the proportion of their pupils who smoke. Such differences transcend pupil intake characteristics and relate to the internal life of the school. Although adolescents' smoking behaviour has been associated with that of their peers, little consideration has been given to whether peer structures and processes contribute to school differences in pupil smoking rates. In two relatively deprived Scottish schools, one with a higher and one with a lower rate of pupil smoking, 13 and 15 year-olds were surveyed. Sociometric data and information on pupils' smoking behaviour and views were gathered. Twenty-five single-sex discussion groups were then held with a sub-sample of the 13 year-olds in order to explore in detail their views on smoking, smokers and fellow pupils. Findings showed that in the higher smoking school, pupils were more often in groups, smokers were identified as popular, and attitudes (especially among non-smoking females) were more pro-smoking. In the lower smoking school, by contrast, there were more isolates and dyads, there were no popular smokers and attitudes (especially among non-smoking females) were much less pro-smoking. Thus, evidence suggests peer group structures and related influences could be one explanation for school differences in smoking, and that the popularity of smokers together with the views of non-smoking females may be particularly important in creating such differences.

Racial disparities in tobacco use and social influences in a rural southern middle school

This study investigated racial differences of tobacco use and social exposure to tobacco products in a sample of middle school students. Questionnaires were administered in January 2005 to 290 students in a Mississippi Delta-area middle school. The participants were 51.0% female and 56.6% African American. Unadjusted odds ratios revealed that Caucasian students were statistically more likely than were African American students to (1) have ever tried smoking, (2) have ever been a daily smoker, (3) have smoked in the past 30 days, (4) live with someone who smokes, (5) have seen a parent or guardian smoke, and (6) have friends who smoke. In contrast, African Americans were more likely to report "no one is allowed to smoke" in their home. Caucasian females had the highest rates of smoking, as well as the highest exposure to social smoking behaviors. This study not only showed that Caucasians were indeed smoking more but also that African American adolescents do not have the same exposure to social smoking, particularly African American females. Of particular interest was why the differences eventually dissipate and smoking rates are virtually the same in adulthood. A greater understanding of the impact of exposure to tobacco use on an adolescent's own tobacco use is vital to prevention efforts, especially in regard to racial differences. Future research on youth tobacco prevention and cessation programs should focus on sociocultural and racial differences in the development of tobacco use in adolescents.

Influences affecting adolescent smoking behavior in China

This study examined multiple influences on the use of tobacco by adolescents in China. Using the theory of triadic influences as a guide, we selected interpersonal, attitudinal/cultural, and intrapersonal constructs from baseline data to predict adolescent smoking 1 year later. We used prospective data from middle and high school students (N = 11,583) and their parents from the China Seven Cities Study, a longitudinal study that is evaluating the effects of changing economic and social factors on health behaviors including tobacco use. A multilevel regression analysis provided some support that each of the influences in the theory of triadic influences affects adolescent smoking in China. After adjusting for important confounders including age, gender, socioeconomic status, and smoking behaviors (lifetime and past 30-day) at baseline, we found significant risk factors within each of the three categories, including interpersonal influences (parental monitoring, good friend smoking, and peer smoking), attitudinal/cultural influences (school academic ranking, initial liking of smoking, and the meaning of smoking), and intrapersonal influences (susceptibility to smoking, and low self-confidence to quit smoking). Results suggest that the etiology of smoking among adolescents in China might be similar to that observed in western countries and that some of the techniques used successfully in prevention programs in those countries might be useful guides when developing prevention programs in China.

Perceived smoking norms, socioenvironmental factors, personal attitudes and adolescent smoking in China: a mediation analysis with longitudinal data

PURPOSE

To gather information on inter-relationships among risk factors affecting adolescent smoking for tobacco control in China, the world's largest tobacco producer and consumer.

METHOD

Longitudinal data were collected six months apart in 2003 from 813 students in grades 7, 8, 10, and 11 from two schools in Beijing, China. Linear regression was used to assess both the direct effect from predictor variables (smoking among influential others, pro-tobacco media, and attitudes toward smoking) on cigarette use and the indirect effect mediated through the perceived smoking norms (percentage of smokers among peers).

RESULTS

Among the 803 subjects (mean age of 15.5 years, SD = 1.7; 52.1% female), 18.3% of males and 1.7% of females smoked in the past 30 days. Smoking among influential others (best friends, father, mother, male teachers, female teachers, and adults in general) and perceived positive psychological and social rewards from smoking at baseline were associated with number of cigarettes smoked at follow-up, whereas exposure to pro-tobacco media was not significantly associated with smoking. The mediated effect was greater for adult smoking (70% to 90%) than for best friend smoking (11% to 16%).

CONCLUSION

Smoking among influential others and attitudes toward smoking influence adolescent smoking both directly and indirectly. The finding of the indirect effect mediated through perceived smoking norms expands our knowledge on smoking etiology. Effective adolescent smoking intervention programs in China need to include a component targeting adult smoking to reduce perceived smoking norms.

Seasonal variations in the initiation of smoking among adolescents

Numerous studies have identified a variety of reasons that youths give for starting smoking. Few efforts have been made, however, to identify seasonal variations in initiation. This study was an attempt to fill that void. We examined data from 342 youths participating in a mandated smoking education and cessation program in Texas. Data were collected based on responses to questions in participant workbooks, including an item asking participants about the month in which they started smoking. A total of 47% of the participants indicated that they started smoking in May through August (chi2 = 91.42, df = 3). Post-hoc analyses indicated that significantly more youths than expected began smoking in May and June, whereas significantly fewer youths than expected began smoking in September and November. Unsupervised time out of school during the first months of summer vacation is a period of increased danger for smoking initiation. The significantly lower rates during September seem to be related to the beginning of school.

Normative processes and adolescents’ smoking behaviour in Norway: A multilevel analysis

Currently, smoking prevalence is still high among adolescents. This is of major concern for public health organizations. Factors that influence adolescent smoking behaviour need to be identified and addressed. Research in this area has identified attitudes, subjective norms and perceived behavioural control as some of the contributing factors, but subjective norms have often been the weakest predictor of smoking behaviour. This could be due to inadequate measurement. The current paper suggests that examining different types of norms and their relationship with smoking behaviour could help increase the contribution of norms. The paper set out to identify other normative concepts, such as the subjective estimate of smoking prevalence, and descriptive and desired societal norms that are not captured by subjective norms but that could be related to adolescents' smoking behaviour. Data were collected from 15-year-old students from Norway (n = 1670 in 89 grade 10 school classes). Multilevel logistic regression analysis was used to determine how the various concepts of norms relate to each other and their relationship with adolescent smoking behaviour. The findings of the study showed that an individual's opinion of societal norms, and the expectations of significant others as well as their behaviour all seem significantly related to adolescent smoking behaviour, either as an individual or as a school class predictor. Hence, rather than playing down the role of norms, the addition of a subjective estimate of smoking prevalence, and descriptive and desired societal norms could extend the normative concept as well as increase its predictive power. Future intervention could address different types of norms as well as the effect of shared context to help prevent adolescents from smoking.

Nonresident fathers' involvement and adolescents' smoking

Although prior research has shown that adolescents from divorced and separated households are more likely to smoke than their peers from intact families, few studies have addressed factors that may minimize this risk, such as the role of involvement by nonresident fathers. A sample from the National Longitudinal Study of Adolescent Health (Add Health) is used to examine the longitudinal effects of nonresident fathers 'involvement, changes in involvement, and fathers' modeling of smoking behavior on the probability that adolescents will begin smoking regularly. Results indicate that adolescents who are more involved with their fathers are less likely to begin smoking regularly, that changes in involvement over time predict changes in the probability that adolescents will begin to smoke regularly, and that fathers' smoking also affects this outcome. Implications for theory and public policy are discussed.

Longitudinal analysis of the effect of prenatal nicotine exposure on subsequent smoking behavior of offspring

We explored the influence of maternal smoking during pregnancy on the likelihood of smoking among offspring in adolescence and adulthood using data from two similar British birth cohort surveys, the 1958 National Child Development Study and the 1970 British Birth Survey. Similar information was available in each cohort on maternal age at delivery, offspring sex, maternal smoking during pregnancy, parental and offspring socioeconomic status, and parental smoking at the time offspring smoking was assessed at age 16 years. Offspring smoking at 16 years and at 30/33 years were the primary outcomes of interest. Our data support an association between maternal smoking during pregnancy and an increased risk of offspring smoking later in life among female offspring but not among male offspring. Female offspring of mothers who smoked during pregnancy were more likely to smoke at 16 years than were their male counterparts. Moreover, in this same subgroup, female offspring smoking at 16 years was associated with an increased likelihood of smoking at 30/33 years. Further investigation in larger studies with greater detail of factors shaping smoking in childhood and adulthood and biochemically verified outcome measures would be desirable to clarify the relationship.

Smoking and peer groups: results from a longitudinal qualitative study of young people in Northern Ireland

Previous research has indicated that young people are under considerable social pressure to take up smoking. This study has therefore sought to explore and better understand the mechanisms through which peer-related social factors operate to encourage young people to smoke. Individual qualitative interviews were held with adolescent children aged 11-12 years (N = 102) within youth clubs based in economically deprived areas of Northern Ireland, and then followed up on two occasions during the subsequent 3 years (N = 51/39). The data implied that, although peers influence smoking uptake, this seldom happens through direct persuasion, but rather as the result of the young person striving to conform to the normative behaviour of the peer group with which they identify. The findings are consistent with social identity theory and self-categorization theory in that for both smoking and nonsmoking 14-year-olds smoking activity appears to provide a means through which to define social groups, to accentuate similarity within groups and differences between groups. In-group favouritism was expressed in the sharing of cigarettes within the in-group and in the negative stereotyping of out-group members. There was some evidence that group affiliation may be negotiated differently for boys and girls. These findings imply that successful intervention needs to reconsider the normative processes that encourage young people to smoke.