Why children start smoking cigarettes: predictors of onset

Motivational Influences on Cigarette Smoking

Cigarette smoking is a leading cause of mortality and morbidity and a particularly common and intractable addictive disorder. Research shows that nicotine is a sine qua non of tobacco addiction and that it produces the hallmark effects of addictive drugs: sensitization, tolerance, physical dependence, and euphoria/elation. Research on the development of smoking reveals that although smoking prevalence has declined from a peak in the mid-1990s, close to 30% of twelfth graders still smoke. Smoking in adolescents is related to development of physical dependence, ethnicity, impulsivity, affective disorder, and peer influences. However, which of these exerts the greatest causal effects is unknown, and their influence no doubt varies across individuals and across development. Once dependence on tobacco smoking is established, evidence suggests that tobacco motivation is strongly influenced by a reduction in withdrawal symptoms, an expectation of stress reduction, and conditioned reinforcement. Nicotine motivation may also be influenced by modulation in stimulus incentive value.

Integrating four theories of adolescent smoking

The ability of the Theory of Planned Behavior, Social Learning Theory, Social Attachment Theory, and Problem Behavior Theory to predict smoking at Grade 10 was tested against an integrated model incorporating predictors from all the theories. The integrated model also tested whether constructs from each theory contribute distinct variance to the prediction of smoking. Predictors measured at Grade 7 (in 1985) were used to model smoking 3 years later (in 1988) among 4186 youth, using logistic regression. Constructs emphasized by each theory were important, independent predictors of later smoking. The integrated model was superior to all of the theory-based models. A few predictors varied for current vs. frequent smoking outcomes. Results emphasize the need for a multifaceted approach to understanding and preventing adolescent smoking.

Smoking and adolescence: narratives of identity

The purpose of this study was to understand the identities that youth hold in relation to smoking, as revealed in narrative accounts of their smoking experiences. The analysis was a narrative inquiry, a qualitative approach based on the propensity of people to narrate or tell stories about the experiences in their daily lives. A purposeful sample of 35 youths ages 14-18 years with a variety of smoking histories (all had tried smoking) participated in in-depth interviews. A detailed analysis of the transcripts revealed the key identities communicated by the youths including the confident nonsmoker, the vulnerable nonsmoker, the ardent nonsmoker, the accepting nonsmoker, the in-control smoker, the confirmed smoker, and the contrite smoker. Tobacco control interventions for youth must be designed to respond to and incorporate multiple smoking identities.

The alcohol-tobacco relationship: a prospective study among adolescents in six European countries

AIM

This study examined the earliest stages in drug involvement, in terms of the relationship between alcohol and tobacco use, among adolescents from six European countries (Denmark, Finland, the Netherlands, Portugal, Spain and the United Kingdom). International, gender and age differences were studied.

DESIGN, SETTING AND PARTICIPANTS

A large international sample of European adolescents (n = 10170, mean age = 13.3 years) was followed longitudinally. Data were gathered in the autumn terms of 1998 and 1999 by means of self-administered questionnaires.

MEASURES

Adolescents' self-reports on smoking and alcohol behaviour were used. Both behaviours were classified into two categories, that of adolescents who had never used the substance and that of those who had used the substance at least once in their lives. Logistic regression was used to determine which substance was the best predictor of the subsequent use of the other substance.

FINDINGS

Alcohol use and tobacco use were found to be associated with each other reciprocally. Results revealed that in Europe as a whole, tobacco use predicted subsequent alcohol use better than the converse. However, for Dutch girls, alcohol use predicted subsequent smoking behaviour better than the converse.

CONCLUSION

The findings suggest that the development of alcohol and tobacco use patterns are closely related, but the order of progression is not universal and may reflect cultural factors.

Smoking behavior among urban and rural Native American adolescents in California

BACKGROUND

Previous studies have documented a high prevalence of tobacco use among Native American adolescents. However, little is known about the smoking behavior of Native American adolescents who live in urban areas. This study used statewide data from California to examine the smoking behavior and related psychosocial risk factors among Native American adolescents living in urban and rural counties.

METHODS

The Independent Evaluation of the California Tobacco Control Program conducted three population-based statewide surveys of 10th-grade California public school students in 1996, 1998, and 2000. Past-month smoking and psychosocial correlates were examined among 22,440 respondents, including 1060 Native Americans.

RESULTS

Native Americans had a 32% excess risk of past-month smoking compared with other ethnic groups. Smoking prevalence did not differ between urban (27.7%) and rural (29.3%) Native Americans. Native Americans reported higher access to cigarettes and exposure to smoking peers than other groups. Those psychosocial variables explained some, but not all, of the excess risk of smoking among Native Americans.

CONCLUSIONS

Effective smoking prevention and cessation interventions are needed for Native American adolescents in urban and rural areas of California.

The role of genes in tobacco smoking during adolescence and young adulthood: a multivariate behaviour genetic investigation

AIMS

To incorporate a psychosocial model of tobacco smoking into a behaviour genetic design to examine genetic and environmental influences on variation in smoking involvement.

DESIGN

Longitudinal twin study.

SETTING AND PARTICIPANTS

Twins initially aged between 13 and 18 years and registered with the Australian Twin Registry were surveyed three times between 1988 and 1996. A total of 414 pairs of identical and same-sex fraternal twin pairs participated in all three surveys, aged between 20 and 25 at wave 3. Biometric modelling estimated the influence of genetic and environmental factors in determining variation in smoking at each wave, both before and after adjusting for perceived smoking behaviours of peers and parents.

MEASUREMENTS

Twins answered a questionnaire on their own smoking status and reported on the use of tobacco by parents and friends as they perceived it, at each survey wave.

FINDINGS

At all three surveys, current smokers were more likely to have parents who smoked and to have smokers among their peers. Genes and environmental factors, both common and unique, contributed to variation in smoking behaviours. However, after controlling for the smoking behaviours of peers and parents, the role of genes in determining variation in smoking involvement was reduced by 100% at wave 1 and by 30% at wave 2. Friends' smoking reduced the magnitude of the common environment variance by 11%, 30% and 40% at waves 1, 2 and 3, respectively. Parents' smoking behaviours explained part of the common environment. Biometric modelling of the covariation between smoking involvement and peer smoking suggested that genes might influence smoking involvement at wave 1 by influencing choice of peers.

CONCLUSION

Environmental factors play the greatest role in determining variation in tobacco smoking among adolescents and young adults. Among adolescents, genes may influence variation in smoking behaviours indirectly by influencing choice of peers. However, genes seem to have a direct influence on variations in the smoking behaviours of young adults.

Parent's socioeconomic status, adolescents' disposable income, and adolescents' smoking status in Massachusetts

OBJECTIVES

This study examined the association between parental socioeconomic status (SES) and adolescent smoking.

METHODS

We conducted telephone interviews with a probability sample of 1308 Massachusetts adolescents aged 12 to 17 years. We used multiple-variable-adjusted logistic regression models.

RESULTS

The risk of adolescent smoking increased by 28% with each step down in parental education and increased by 30% for each step down in parental household income. These associations persisted after adjustment for age, sex, race/ethnicity, and adolescent disposable income. Parental smoking status was a mediator of these associations.

CONCLUSIONS

Parental SES is inversely associated with adolescent smoking. Parental smoking is a mediator but does not fully explain the association.

Nine-year prospective association between older siblings' smoking and children's daily smoking

PURPOSE

To explore the hypothesis that older siblings' smoking, after controlling for parents' smoking, influences children's smoking.

METHODS

Study participants were 2981 students in the control cohort of a school-based smoking prevention randomized trial for whom parents' smoking and older siblings' smoking data were collected at 3rd grade and daily smoking data was assessed 9 years later through a self-report questionnaire at the 12th grade. Data were analyzed using conditional logistic regression and likelihood ratio tests.

RESULTS

For families in which no parent smoked, the 12th grade prevalence of daily smoking was 31% when at least one older sibling smoked compared to 18% when no older sibling smoked. For families in which at least one parent smoked, the 12th grade prevalence of daily smoking was 41% when at least one older sibling smoked compared to 29% when no older sibling smoked. There was a substantial increase in the odds (OR = 1.60, p =.004) of children's daily smoking at 12th grade when their older siblings smoked, even after adjusting for parents' smoking.

CONCLUSIONS

Older siblings' smoking is associated with increased risk of children's smoking after adjusting for parents smoking. Furthermore, there was no evidence to suggest that the influence of older siblings' smoking was different in families where no parent smoked compared to those where at least one parent smoked. Also, there was no evidence that the influence of older siblings' smoking was different in boys vs. girls.

Explaining racial/ethnic differences in smoking during the transition to adulthood

Using data from a longitudinal panel of nearly 3000 adolescents to predict current smoking among young adults, we test whether adding variables that tap prior social bonds and influences to the model eliminates race/ethnicity as a significant predictor of current smoking. At age 23, African Americans and Asians exhibited substantially lower rates of current smoking than Whites and Hispanics. Controlling for social influences during high school, particularly exposure to siblings and friends who smoked plus parental disapproval of smoking, accounted for these differences. Social bonding variables, in contrast, had a limited mediating effect. Interventions aimed at decreasing adolescent vulnerability to prosmoking influences, reducing overall levels of peer cigarette use, and helping parents better convey their disapproval of smoking should help curb young adult smoking and diminish racial/ethnic differences in tobacco use.

Adolescents’ perceptions of the risks and prevalence of smoking

Abstract. The aims of this study were to assess adolescents’ perceptions of the personal risks and prevalence of smoking, and to examine whether these perceptions were related and how they varied by gender, age and smoking status. A questionnaire survey was conducted among 3657 11-16 year olds from a sample of 138 secondary schools in England. The results showed a large false consensus effect: smokers gave higher estimates of the prevalence of smoking among their peers than non-smokers. The gap between smokers and non-smokers decreased between 11 and 16 but was still apparent among 15 and 16 year olds. Smokers of different ages showed little difference in their estimates of prevalence. Smokers were substantially less optimistic in their risk perceptions than non-smokers. Even the youngest smokers acknowledged that their risks were higher than non-smokers’. Smokers nevertheless showed unrealistic optimism. There was little evidence for the idea that the false consensus effect may contribute to unrealistic optimism. The findings raise the question of whether giving children accurate information about smoking prevalence would reduce their likelihood of taking up smoking. The demonstration of optimism bias in teenage smokers highlights the need for innovative education campaigns focused on the health risks of smoking.

Family attention and tobacco smoking among adolescents in Central America, Panama, and the Dominican Republic

This study examined the association between family attention and tobacco use among 5549 adolescent students in five Central American countries, Panama, and the Dominican Republic who participated in a survey of drug use in 1994. Drug use and other variables were assessed using an adapted version of the Drug Use Screening Inventory (DUSI) in Spanish. Students with the highest level of family attention had a lower occurrence of tobacco smoking than students with the lowest level of family attention. Country-specific analyses show similar associations. These findings underscore the need to understand tobacco use in Central America and neighboring countries and to test whether interventions aimed at enhancing parental-child attention, communication, and monitoring reduce the incidence of tobacco use among youths.

Employed adolescents and beliefs about self-efficacy to avoid smoking

This paper examines self-efficacy to avoid cigarette smoking and its association with smoking and quitting behavior, peer and worksite influences, nicotine dependence, and socio-demographic variables among employed adolescents. A cross-sectional survey was used to collect data from employed adolescents ages 15-18 who worked in 10 participating grocery stores in Massachusetts. Eighty-three percent of workers (n=379) completed the survey. Results from the multivariate model indicate that daily smokers were less confident in their ability to avoid smoking than those who smoked less frequently. As nicotine dependence increased, self-efficacy beliefs decreased. In addition, as friends' encouragement to quit increased, self-efficacy beliefs also increased. Work-related variables were not associated with self-efficacy beliefs among smokers. This study suggests that smoking frequency, nicotine dependence, and friends' encouragement to quit are associated with self-efficacy to avoid smoking. Researchers may tailor interventions for daily and less-than-daily smokers, build on peer networks that encourage quitting and help smokers resist pressures to smoke, and enhance strategies for coping with nicotine dependence in high-risk situations.

Familial influences on adolescent smoking

The family unit is the primary source of transmission of basic social, cultural, genetic, and biological factors that may underlie individual differences in smoking. Existing information on the role of familial factors in tobacco use is characterized by two separate, but somewhat overlapping, lines of research: genetic epidemiological studies and risk-factor research. The present paper summarizes and evaluates studies assessing the association between adolescent smoking and parent and sibling smoking behaviors. A review of 87 studies reveals that methods are limited by a lack of standardized instruments, failure to measure important confounding and mediating factors, reliance on cross-sectional designs and the use of inconsistent definitions of tobacco-related behavior and assessment procedures. Moreover, there are no systematic family studies of the acquisition and continuation of smoking that have employed contemporary methodological standards for examining familial aggregation of tobacco behaviors among adolescents. Findings across studies show weak and inconsistent associations between parent and adolescent smoking; inconsistent findings may be attributed to methodological issues or associated factors that may complicate the relation between parent and adolescent smoking. Sibling and peer smoking show greater associations with adolescent smoking. Suggestions for future research include contemporary family studies that delineate meaningful phenotypes of tobacco use and prospective work on the later stages of tobacco use and the timing of the influence and valence of parent and family factors. Integration of the risk factor approach within the family study design may enrich both approaches to elucidate familial influences on smoking.

Concurrent use of tobacco products by California adolescents

BACKGROUND

To describe patterns and correlates of tobacco product use other than cigarettes in adolescents 12-17 years of age.

METHODS

Adolescent respondents (N = 6090) to the 1999 California Tobacco Survey provided estimates of ever and current use (in last 30 days) of smokeless tobacco, cigars, and bidis, which were examined by cigarette smoking experience, demographics, and known predictors of cigarette use.

RESULTS

Only 3% of adolescents who never smoked cigarettes experimented with other tobacco products. Among ever smokers who were not current smokers, the rate was 35%. Nearly 60% of current cigarette experimenters had tried another tobacco product, but almost 90% of current established smokers had experimented with one. Over 40% of current established smokers used another tobacco product in the last 30 days. Factors predictive of cigarette smoking were also highly associated with other tobacco use. In ever cigarette smokers, having peers who used other tobacco products was most highly associated with other tobacco use. Problem or risky behaviors, beliefs that cigarettes are safe or beneficial, and receptivity to tobacco promotions were also independently associated with other tobacco product use.

CONCLUSIONS

Adolescent smokers who use other tobacco products may be prone to risky behavior and such use may hasten the development of nicotine tolerance.

Parental, family, and home characteristics associated with cigarette smoking among adolescents

PURPOSE

This study examines the relationship between smoking-related parental, family, and home factors with adolescents' cigarette use.

DESIGN

Cross-sectional surveys of adolescents, via a self-administered questionnaire in classrooms, and their parents, via a telephone interview, were conducted.

SETTING

Fifteen suburban and rural communities within Minnesota.

SUBJECTS

The study sample included 8th, 9th, and 10th grade public school students and their parents.

MEASURES

The dependent variable was monthly tobacco use among students. The independent measures were parental, family, and home smoking-related characteristics. There were 1343 parent-child dyads with completed surveys.

RESULTS

The final, multivariate logistic regression model found the following variables to be independently related to higher smoking rates among adolescents: child's grade (odds ratio [OR] = 3.03 for 10th vs. 8th), parents' permissiveness of adult smoking (OR = 1.80), parents' having higher normative estimates of how many people smoke (OR = 1.70), parents' decreased likelihood of punishing their teenager for smoking (OR = 1.65), smoking by an adult living in the home (OR = 1.99), and sibling smoking (OR = 8.95). Lack of communication about consequences for breaking family smoking rules was associated with lower smoking rates among adolescents (OR = .49).

CONCLUSION

The results of this study highlight the importance of parental smoking norms and attitudes and smoking role models in the home. It is important that smoking prevention strategies target and include the entire family. Limitations of the study are its cross-sectional design and that the sample was primarily white.

Peers and adolescent smoking

There is a considerable body of empirical research that has identified adolescent peer relationships as a primary factor involved in adolescent cigarette smoking. Despite this large research base, many questions remain unanswered about the mechanisms by which peers affect youths' smoking behavior. Understanding these processes of influence is key to the development of prevention and intervention programs designed to address adolescent smoking as a significant public health concern. In this paper, theoretical frameworks and empirical findings are reviewed critically which inform the current state of knowledge regarding peer influences on teenage smoking. Specifically, social learning theory, primary socialization theory, social identity theory and social network theory are discussed. Empirical findings regarding peer influence and selection, as well as multiple reference points in adolescent friendships, including best friendships, romantic relationships, peer groups and social crowds, are also reviewed. Review of this work reveals the contribution that peers have in adolescents' use of tobacco, in some cases promoting use, and in other cases deterring it. This review also suggests that peer influences on smoking are more subtle than commonly thought and need to be examined more carefully, including consideration of larger social contexts, e.g. the family, neighborhood, and media. Recommendations for future investigations are made, as well as suggestions for specific methodological approaches that offer promise for advancing our knowledge of the contribution of peers on adolescent tobacco use.

Theory, measurement, and methods in the study of family influences on adolescent smoking

This paper discusses three dilemmas faced by researchers interested in family influences in substance use: the transitional nature of adolescent smoking, the complexity and multi-dimensionality of family forms and influences, and the inter-relationship of family influences with other key developmental contexts. Methodological and conceptual issues stemming from these dilemmas are discussed with regard to understanding why previous reviews have found the correlations between family predictors and adolescent smoking to be relatively low. In particular, the importance of understanding time, the transitional nature of the phenomenon, and within- and between- family processes are emphasized. More appropriate conceptual and statistical models for analyzing family influences are suggested, including both mixed models and person-centered approaches.

Rapid progression to regular cigarette smoking among nonsmoking adolescents: interactions with gender and ethnicity

BACKGROUND

While the correlates and predictors associated with transition through the stages of smoking acquisition have received substantial attention, the identification of factors associated with the time course of progression remain generally unexplored.

METHODS

We identified adolescents escalating from nonsmoking to regular smoking in 1 year as rapid progressors (n = 98) and those escalating from nonsmoking to experimental smoking in 1 year as slow progressors (n = 555). We entered demographic and psychosocial variables, initial reactions to smoking variables, and their interactions with gender and ethnicity into a logistic regression analysis comparing rapid progressors to slow progressors.

RESULTS

At baseline, rapid progressors reported more friends who smoked regularly. Girls who reported more concern with dieting and less social success were more likely to progress to regular smoking within 1 year; these variables did not influence progression in boys. Those who associated positive feelings with their initial smoking experience were more likely to progress to regular smoking. Differences between white and African American youth emphasize the importance of physiological interpretations of initial smoking experiences.

CONCLUSIONS

Our findings suggest that even as nonsmokers, adolescents likely to progress quickly to regular smoking can be identified. Researchers designing prevention programs should take these factors into account.

Smoking among American adolescents: a risk and protective factor analysis

Cigarette smoking remains a substantial threat to the current and future health of America's youth. The purpose of this study was to identify the risk and protective factors for cigarette smoking among US adolescents. Data from the National Longitudinal Study of Adolescent Health was used, comparing the responses of all non-smokers at Time 1 for their ability to predict the likelihood of smoking at Time 2, one year later. Data was stratified into four gender by grade group cohorts. Cross-cutting risk factors for smoking among all four cohorts were: using alcohol, marijuana, and other illicit drugs; violence involvement; having had sex; having friends who smoke and learning problems. Having a higher grade point average and family connectedness were protective across all cohorts. Other gender and grade group specific risk and protective factors were identified. The estimated probability of initiating smoking decreased by 19.2% to 54.1% both in situations of high and low risk as the number of protective factors present increased. Of the factors that predict or protect against smoking some are influential across all gender and grade group cohorts studied, while others are specific to gender and developmental stage. Prevention efforts that target both the reduction of risk factors and enhancement of protective factors at the individual, family, peer group and community are likely to reduce the likelihood of smoking initiation.

Intervention to reduce intentions to use tobacco among pediatric cancer survivors

PURPOSE

In this randomized controlled trial, we sought to determine whether a risk counseling intervention would increase knowledge and perceived vulnerability to tobacco-related health risks and decrease future intentions to use tobacco among preadolescents and adolescents previously treated for cancer.

PATIENT AND METHODS

Participants included 103 cancer survivors between the ages of 10 and 18 years who were randomly assigned to either a standard care control (SCC) group or a tobacco intervention (TI) group. Patients in the SCC group received standard advice about the risks of tobacco use. Patients in the TI group received more intensive late effects risk counseling in addition to an educational video, goal setting, written physician feedback, smoking literature, and follow-up telephone counseling. The effect of our intervention was assessed by self-reported knowledge, perceived vulnerability, and intentions at baseline, 6, and 12 months.

RESULTS

Compared with the SCC group, patients who received our intervention had significantly higher knowledge scores, higher perceived vulnerability scores, and lower intention scores at 12 months. No significant differences between the SCC and TI groups at 6 months, across all measures, were found.

CONCLUSION

Pediatric survivors' knowledge, perceived vulnerability to health risks, and intentions to use tobacco can be modified by a risk counseling intervention. The delayed effect of our intervention indicates that these changes may evolve over time. Implications for health care providers who engage in tobacco counseling with young cancer survivors are discussed. Additional longitudinal studies are needed to determine definitive long-term intervention effects on actual tobacco use in this high-risk population.

Tobacco counter-advertising: a review of the literature and a conceptual model for understanding effects

The tobacco counter-advertising literature is reviewed as it relates to basic process questions concerning what makes counter-advertisements effective. Limitations in addressing (a) counter-advertisement content and the psychological mediators targeted, (b) counter-advertisement style and the affective reactions targeted, (c) prior smoking experience, and (d) other audience factors are enumerated. A theoretical model based on alcohol advertising research is presented to address those limitations. The model addresses the practical research question of predicting when tobacco counter-advertising will work by examining the independent influence of each of these enumerated factors, as well as how these factors operate in concert, qualifying each other. The model also addresses the process question of explaining how counter-advertising works by identifying affective and cognitive processes as mediators. By understanding the processes that underlie the qualified findings, one can better advise the designers of tobacco counter-advertisements how to be more effective.

Ethnic differences in adolescent smoking behaviors, sources of tobacco, knowledge and attitudes toward restriction policies

The purpose of this study was to examine racial/ethnic differences in adolescent smoking behavior, sources of tobacco, knowledge of and attitudes toward youth tobacco restriction policies, and perceptions of tobacco availability by adolescents. The study is important as it will add to the growing body of literature regarding tobacco use by minors, and will help policymakers and public health professionals develop efficacious policies and interventions to prevent and reduce tobacco use among adolescents. Minors obtain tobacco from social and commercial sources. Previous studies have emphasized rural homogeneous populations and so the present study addresses the need to determine these sources of tobacco to youth in a large urban, heterogeneous population, such as Philadelphia. A stratified multistage purposive sampling procedure was used to ensure an ethnically/racially sample. A 68-item questionnaire was administered to 645 students in Grades 8-10 in five public and nonpublic funded schools in a culturally diverse part of Philadelphia. Correlations between selected independent variables and smoking behavior were determined. Results from this study indicate that rates of smoking are high among students, with 50% of students ever having smoked, 19% within the last month, 17% weekly, and 15% smoke daily. Further, there were differences in rates of smoking between ethnic/racial groups. Social sources were the most common sources of tobacco reported, with friends being the most frequent source. There were differences in social and commercial ever sources of cigarettes between ethnic/racial groups and in perceived school and parental sanctions for tobacco use. The results of this study suggest that more financial and educational resources should be committed to prevent and reduce smoking behaviors among adolescents. Educational prevention programs, especially parenting programs should be employed to reduce smoking.

The risk of smoking in relation to engagement with a school-based smoking intervention

Health promotion interventions cannot work if people do not engage with them. The aim of this study was to examine whether disengagement from an adolescent smoking prevention and cessation intervention was an independent risk factor for regular smoking 1 and 2 years later. The data were taken from a cluster randomised controlled trial, in the West Midlands, UK, based on the transtheoretical or stages of change model. In this trial, 8,352 13-14-year old school pupils enrolled, and the data in this report were based on the 7,413 and 6,782 pupils present at 1 and 2 years follow-ups, respectively. The intervention group undertook three sessions using an interactive computer programme. At the end of the programme, pupils recorded their responses to it. Pupils were classed as engaged if they thought the intervention was both useful and interesting; all others were classed as disengaged. Random effects logistic regression related the number of times engaged to regular smoking at 1 and 2 years follow-up, adjusted for school absences and 11 potential confounders. The majority of pupils were engaged by the intervention. For participants using the intervention three times but not engaging once, the odds ratios (95% confidence intervals) for smoking at 1 and 2 years relative to the controls were 1.83 (1.41-2.39) and 1.70 (1.38-2.11). For those engaging three times, they were 0.79 (0.60-1.03) and 0.96 (0.75-1.21). There was no interaction with baseline intention to smoke, classified by stage of change, but there was a borderline significant interaction with baseline smoking status, with disengagement acting as a stronger risk factor among baseline never-smokers. We conclude that disengagement from interventions is a risk factor for smoking independently of experimentation with cigarettes. The best explanation is that disengagement from school, an established risk factor for smoking, generalises to disengagement from didactic school-based health promotion programmes.

Psychosocial determinants of cigarette smoking among college students

Although the prevalence of cigarette smoking among adolescents and adults consistently declined in the past decade, smoking among college students rose sharply. To reduce the morbidity and premature mortality caused by smoking, antismoking interventions need to target this vulnerable population. Anonymous self-report data were collected from a convenience sample of 224 college students who voluntarily completed a Web-based survey developed to assess the relation of risk-taking tendency, depression, social normative beliefs, and smoking resistance self-efficacy to cigarette smoking behavior. Employing structural analysis using LISREL (Jöreskog & Sörbom, 1996), all 4 factors were confirmed as determinants of smoking. Resistance self-efficacy, the only direct antecedent, mediated the link to risk-taking tendency, depression, and social normative beliefs. Antismoking interventions that focus on enhancing refusal skills and are delivered to homogeneous groups are proposed as an effective approach to reducing cigarette smoking among college students.

Greek students' attitudes toward physical activity and health-related behavior

A three-wave study over one year with 882 adolescents, aged 10 to 16 years at the initial testing, examined psychosocial variables regarding four health-related behaviors: exercise, eating fruit, smoking, and drug use. Analysis showed that during the stages of the study, high school students' exercise behavior decreased and their smoking behavior increased as well as their willingness to use drugs. It seems that study of physical education and health education during adolescence must take into account the possible differences in psychosocial variables associated with health-related behaviors as well as the different stages of adolescence.

Can the school make a difference? A multilevel analysis of adolescent risk and health behaviour

The main aim of this article is to assess the relationship between the structural and (health) policy variables of the school and characteristics of the individual on the risk and health behaviour of adolescents. Individual and school level effects on seven health-related behaviours are simultaneously estimated, using multilevel modelling. The data are from the Flemish health behaviour in school-aged children study in Belgium. Data are used from 29 Flemish schools in which students (N=3225), school administrators (N=29) and teachers (N=1132) were surveyed with anonymous written questions. The analysis confirms previous findings concerning individual level effects. Although differences between schools in risk and health behaviour were found to originate mainly from differences in pupil characteristics, substantial variation between schools remained with regard to regular smoking, drinking habits and tooth brushing after controlling for individual effects. A wide range of school structure and policy variables were taken into account, but only few of them were found to influence the health and risk behaviour of young people. Moreover, the study could not detect an effect of health promotion policy at school. The analysis therefore only partially confirms the hypothesis that the school has an impact on the health behaviour of young people. The findings demonstrate the need for a more thorough examination of the paths by which schools can influence the health behaviour of their pupils.

Which adolescents are most receptive to tobacco industry marketing? implications for counter-advertising campaigns

This study sought to identify adolescents most receptive to tobacco advertising based on individual differences in novelty-seeking personality and other key variables. Confidential self-report surveys were completed by 1,071 high school freshmen at 5 public high schools. The survey included validated measures of novelty-seeking personality, smoking habits, peer and family smoking, and tobacco advertising receptivity. Multiple logistic regression analysis was used to evaluate the independent associations of these variables and demographics with receptivity to tobacco advertising. Of the ninth graders, 44% had moderate to high levels of advertising receptivity and 54% had minimal to low levels of receptivity. Higher levels of receptivity were associated with ever smoking (odds ratio [OR] = 2.59, confidence interval [CI] = 1.99-3.39) and novelty-seeking personality (OR = 2.14, CI = 1.57-2.93). The association of novelty-seeking personality and tobacco advertising receptivity was most pronounced among adolescents who had never had a puff of a cigarette. Counter-advertising messages should consider individual differences in novelty-seeking, because novelty-seekers may be most receptive to tobacco industry promotional campaigns.

Adolescent smoking and family structure in Europe

This paper examines the relationship between family structure and smoking among 15-year-old adolescents in seven European countries. It also investigates the association between family structure and a number of known smoking risk factors including family socio-economic status, the adolescent's disposable income, parental smoking and the presence of other smokers in the adolescent's home. Findings are based on 1998 survey data from a cross-national study of health behaviours among children and adolescents. Family structure was found to be significantly associated with smoking among 15-year-olds in all countries, with smoking prevalence lowest among adolescents in intact families and highest among adolescents in stepfamilies. Multivariate analysis showed that several risk factors were associated with higher smoking prevalences in all countries, but that even after these other factors were taken into account, there was an increased likelihood of smoking among adolescents in stepfamilies. Further research is needed to determine the possible reasons for this association.

Prospective analysis of peer and parent influences on smoking initiation among early adolescents

The nature and relative importance of psychosocial influences on smoking initiation among early adolescents are topics of substantial research interest. Students (n = 1081) from four middle schools were surveyed at the beginning and end of the sixth grade. Baseline predictors were regressed on smoking initiation at end of sixth grade. In bivariate, logistic regression analyses association with problem behaving peers, perceived prevalence, and depression were positively associated and adjustment to school, perceived social competence, parent expectations, parental monitoring, and parental involvement were negatively associated with smoking initiation. In multivariate logistic regression analyses controlling for sex, race, and school, peer affiliation and perceived prevalence were positively associated, whereas social competence and parental monitoring were negatively associated with smoking initiation. A significant interaction between parental involvement and peer affiliation indicated that among teens with problem behaving friends only those with parents who were relatively uninvolved were are at increased risk for smoking initiation. This finding held for boys, girls, Whites, Blacks, and teens living in single parent families. These findings provide evidence that antecedent parenting behaviors may protect early adolescents against smoking even in the context of negative peer affiliation.

Self-reported school difficulties and tobacco use among fourth- to seventh-grade students

This study examined the relationship between academic and behavioral difficulties at school, and tobacco use in students. Participants included 1,219 students in fourth to seventh grade at the time of enrollment. Interviews were repeated eight months later with 85% of baseline participants. Telephone interviews assessed use of cigarettes, cigars, and chewing tobacco; students also were asked if they liked school, how often they got in trouble at school, and how well they were doing in school. At baseline, students reporting school difficulties were 1.4-5.6 times more likely to report a lifetime history of cigarette, cigar, and chewing tobacco use relative to students who did not report these difficulties. Average to below-average academic performance at baseline was predictive of new cigarette use at the eight-month follow-up (Relative Risk = 3.35; 95% Confidence Interval = [1.36, 8.22]). Self-reported school difficulties are associated with lifetime use of all major forms of tobacco and are predictive of future cigarette use in fourth- to seventh-grade students.

Applying genetic approaches to the treatment of nicotine dependence

To advance the science of tobacco control, an enhanced understanding of the bio-behavioral basis of nicotine addiction is needed. In this study, we provide an overview of data from investigations of genetic factors in smoking behavior, discuss potential bio-behavioral mechanisms and effect modifiers, and suggest avenues for pharmacogenetics research in the area of smoking cessation treatment. The evidence to date is very consistent with respect to the significance of genetic contributions to smoking behavior. However, attempts to elucidate the role of specific genetic variants have met with mixed success. Explanations for the lack of consistency in the results of genetic association studies include biases in ascertainment, ethnic admixture, lack of attention to co-variates or modifiers of genetic risk, and the need for more refined phenotypes. As the field of genetics and smoking research progresses, increasing attention is being devoted to gene-environment interactions, with particular attention to the identification of genetic variants that may modify the effects of pharmacological treatment for smoking. With advances in molecular biology and genomics technology, individualized tailoring of smoking cessation therapy to genotype is within our grasp. Such research has the potential to improve treatment outcome, thereby reducing morbidity and mortality from smoking-related disease.

Is smoking a communicable disease? Effect of exposure to ever smokers in school tutor groups on the risk of incident smoking in the first year of secondary school

OBJECTIVE

To estimate the effect of joining a first year secondary school tutor group with a high prevalence of ever smoking on the risk of incident smoking in schoolchildren.

DESIGN

Cross-sectional questionnaire survey.

SETTING

10 randomly selected secondary schools in Nottinghamshire, UK.

PARTICIPANTS

Pupils in years (grades) 7-11 (aged 11-16 years).

MAIN OUTCOME MEASURE

Incident smoking in the first year of secondary education, defined as pupils who reported smoking their first cigarette during year 7.

RESULTS

Of 6522 pupils (75% of those eligible) who completed the questionnaire, 17% were current smokers and 49% had ever smoked, of whom 23% had started smoking in year 7. Incident smoking in year 7 was more common in girls, in children with parents or siblings who smoke, and in more deprived children, and was independently increased in relation to the proportion of ever smokers in the year 7 tutor group joined by the child (adjusted odds ratio of incident smoking for a child joining a year 7 tutor group in the highest relative to the lowest quartile of ever smoking prevalence 1.45, 95% confidence interval (CI) 1.11 to 1.89). Exposure to ever smokers in year 7 tutor groups also accounted for most of the increased risk of incident smoking associated with socioeconomic deprivation.

CONCLUSIONS

The risk of incident smoking in children entering secondary education is independently increased by exposure to other ever smokers in school tutor groups. Incident smoking in adolescents is thus to some extent a communicable disorder, and may be partly preventable by policies that reduce exposure to smoking at school.

Effectiveness of the "Smoke-Free Class Competition" in delaying the onset of smoking in adolescence

BACKGROUND

This paper examines the effectiveness of the "Smoke-Free Class Competition" in delaying the onset of smoking in adolescence. Each participating class must decide if they want to be a "smoke-free class" for the 6-month period from fall to spring. Classes monitor their (non-)smoking behavior and report it to the teacher regularly. Classes in which pupils refrain from smoking for this period of time participate in a prize draw, in which they can win a number of attractive prizes.

METHODS

To evaluate the effectiveness of the competition, a sample of 131 participating and nonparticipating classes (number of pupils 2,142; mean age 12.9 years, SD = 0.98) was compared with regard to their smoking behavior. Smoking status was determined by self-assessment on three occasions: (a) prior to the beginning of the competition, (b) 1 month after the competition, and (c) 1 year after the start of the competition.

RESULTS

From pretest to posttest smoking increased by 7.5% in the comparison group, while it decreased by 0.2% in the intervention group (OR = 2.19; P < 0.001). In the follow-up measurement, a clear increase in smoking prevalence occurs in all groups; however, the pupils in the intervention condition still have a significant lower increase of smoking (OR = 1.45; P < 0.01). Moreover, with regard to the nonsmokers at baseline, pupils in the comparison group showed significantly higher prevalences in smoking than the intervention group in the postmeasurement, 7.8 versus 13.9% (OR = 1.98; P < 0.001), as well as in the in the follow-up-measurement, 17 versus 21.3% (OR = 1.36; P < 0.05).

CONCLUSIONS

The results suggest that the participation in the competition could delay the onset of smoking in adolescence.

Exposure to teachers smoking and adolescent smoking behaviour: analysis of cross sectional data from Denmark

OBJECTIVE

To determine whether adolescent smoking behaviour is associated with their perceived exposure to teachers or other pupils smoking at school, after adjustment for exposure to smoking at home, in school, and best friends smoking.

DESIGN

Logistic regression analysis of cross sectional data from students in Denmark.

SUBJECTS

1515 grade 9 students (mean age 15.8) from 90 classes in 48 Danish schools.

OUTCOME MEASURE

Self reported smoking behaviour; daily smoking and heavy smoking, defined as those smoking more than 20 cigarettes per week.

RESULTS

Of the students in this study, 62% of boys and 60% of girls reported being exposed to teachers smoking outdoors on the school premises. The proportion of boys and girls reporting to have been exposed to teachers smoking inside the school building were 86% and 88%, respectively. Furthermore, 91% of boys and 92% of girls reported that they had seen other students smoking outdoors on the school premises. Adolescents' perceived exposure to teachers smoking outdoors on the school premises was significantly associated with daily smoking, having adjusted for sex, exposure to teachers smoking indoors at school and pupils smoking outdoors at school, as well as the smoking behaviour of mother, father, and best friend (odds ratio (OR) 1.8, 95% confidence interval 1.2 to 2.8). Adolescents' perceived exposure to teachers smoking inside the school building was not associated with daily smoking (OR 0.9, 95% CI 0.5 to 1.6) and perceived exposure to pupils smoking outdoors was not associated with daily smoking (adjusted OR 1.5, 95% CI 0.5 to 4.4). There were similar findings with heavy smoking as the outcome variable.

CONCLUSIONS

Teachers smoking during school hours is associated with adolescent smoking. This finding has implications for future tobacco prevention strategies in schools in many countries with liberal smoking policies where it might provide support for those working to establish smokefree schools.

Differentiating stages of smoking intensity among adolescents: stage-specific psychological and social influences

Researchers' understanding of the impact of sociocultural and psychological factors on the various stages of adolescent smoking uptake is limited. Using national data, the authors examined transitions across smoking stages among adolescents (N = 20,747) as a function of interpersonal, familial, and peer domains. Peer smoking was particularly influential on differentiating regular smoking, whereas alcohol use was most influential on earlier smoking. Although significant, depression and delinquency were attenuated in the context of other variables. Higher school grade was more likely to differentiate regular smoking from earlier smoking stages, whereas African American ethnicity and connectedness to school and family were protective of smoking initiation. Results lend support for an interactional approach to adolescent smoking, with implications for stage-matched prevention and intervention applications.

Does tobacco marketing undermine the influence of recommended parenting in discouraging adolescents from smoking?

OBJECTIVE

The tobacco industry contends that parenting practices, not marketing practices, are critical to youth smoking. Our objective was to examine whether tobacco-industry marketing practices undermine the protective effect of recommended authoritative parenting against adolescent smoking.

DESIGN AND SETTING

Receptivity to tobacco advertising and promotions was assessed in 1996 from a representative sample of California adolescent never-smokers aged 12 to 14 years. A follow-up survey of 1641 of these adolescents was conducted in 1999 that included measures of the key components of authoritative parenting: parental responsiveness, monitoring, and limit setting.

MAIN OUTCOME MEASURE

Smoking initiation in adolescents.

RESULTS

Adolescents in families with more-authoritative parents were half as likely to smoke by follow-up as adolescents in families with less-authoritative parents (20% vs 41%, p <0.0001). In families with more-authoritative parents, adolescents who were highly receptive to tobacco-industry advertising and promotions were significantly more likely to smoke (odds ratio=3.52, 95% confidence interval =1.10-11.23), compared to those who were minimally receptive. This effect was not significant in adolescents in families with less-authoritative parents. The overall attributable risk (adjusted for exposure to peer smokers) of smoking from tobacco-industry advertising and promotions was 25%. However, an estimated 40% of adolescent smoking in families with more-authoritative parents was attributable to tobacco-industry advertising and promotions; this was five times the attributable risk seen in families with less-authoritative parents (8%).

CONCLUSION

The promotion of smoking by the tobacco industry appears to undermine the capability of authoritative parenting to prevent adolescents from starting to smoke.

Effects of gender in social control of smoking cessation

This study of 93 men and 117 women smokers during an ongoing quit attempt examined the roles of gender and social network influences on quitting. For men, social influences appeared to positively affect their ability to reduce their smoking but were less effective for women. Specifically, increased reports of a spouse or partner's influence, and family and friends' influence, were associated with greater reductions in men's smoking 2 days and 4 months post quit date, respectively. In contrast, for women, greater reports of spouse or partner influence and of family and friends' influence were associated with smaller reductions in smoking. Sex differences in social control strategies and perceived autonomy supportiveness of those strategies are discussed as possible explanations for these results.

Association of attention-deficit/hyperactivity disorder symptoms with levels of cigarette smoking in a community sample of adolescents

OBJECTIVE

Research on the association of attention-deficit/hyperactivity disorder (ADHD) with cigarette smoking has primarily occurred within samples of clinically referred youths. This paper reports the association of ADHD symptoms with smoking practices in a community sample of adolescents.

METHOD

Confidential self-report surveys were completed by 1,066 tenth-grade students enrolled in five public high schools who were taking part in a longitudinal study of biobehavioral predictors of adolescent smoking adoption. A well-standardized measure of ADHD inattention and hyperactivity-impulsivity symptoms, as well as demographic and social risk factors, were examined in relation to three levels of cigarette smoking: (1) never having smoked, (2) ever having smoked, and (3) current smoking (having smoked a cigarette within the past 30 days).

RESULTS

Regarding lifetime cigarette use, approximately 43% of students had ever smoked. Among those who had ever smoked, approximately 31% of students were current smokers. Ever having smoked was associated with family (odds ratio [OR] = 2.49, confidence interval [CI] = 1.85, 3.36) and peer smoking (OR = 4.05, CI = 3.07, 5.33) and clinically significant ADHD inattention symptoms (OR = 3.39, CI = 1.53, 7.54). Current smoking was also associated with peer smoking (OR = 2.99, CI = 1.72, 5.20) and clinically significant ADHD inattention symptoms (OR = 2.80, CI = 1.20, 6.56).

CONCLUSION

Clinically significant ADHD symptoms should be taken into account when identifying adolescents at risk to smoke, since those with problematic inattention may be more likely to experiment with smoking and to become regular tobacco users.

Influences on adolescent smoking behaviour: siblings' smoking and norms in the social environment do matter

The prevalence of smoking among adolescents has stopped declining in spite of all preventative efforts. There is a need for further knowledge and understanding of why adolescents initiate and continue tobacco use. The aim of the present study was to investigate important facets of adolescents' tobacco use, such as their reasons for smoking, and their smoking patterns in relation to smoking habits in the family and the social environment. This study was part of a larger one that used a descriptive, cross-sectional design with questionnaires to 216 pupils in grade 5 (11 years of age) and 225 pupils in grade 8 (14 years of age) in a south-western county in Sweden. Thirteen per cent of the pupils in grade 8 were regular tobacco users. Smoking habits by relatives, especially siblings, influenced tobacco use by adolescents. An association was found between smoking by adolescents and mother's employment, and between the smoking status of girls and family status. The pupils valued their parents' opinions, and wanted parents and other adults to take a clear stand against tobacco. The present study reinforces the importance of norm setting by parents and siblings for adolescents' tobacco use. Preventive measures may be more appropriately directed towards those with the highest risks, i.e. pupils with smoking siblings and smoking peers.

Short-term effects of a randomized computer-based out-of-school smoking prevention trial aimed at elementary schoolchildren

BACKGROUND

Smoking prevention programs usually run during school hours. In our study, an out-of-school program was developed consisting of a computer-tailored intervention aimed at the age group before school transition (11- to 12-year-old elementary schoolchildren). The aim of this study is to evaluate the additional effect of out-of-school smoking prevention.

METHODS

One hundred fifty-six participating schools were randomly allocated to one of four research conditions: (a) the in-school condition, an existing seven-lesson program; (b) the out-of-school condition, three computer-tailored letters sent to the students' homes; (c) the in-school and out-of-school condition, a combined approach; (d) the control condition. Pretest and 6 months follow-up data on smoking initiation and continuation, and data on psychosocial variables were collected from 3,349 students.

RESULTS

Control and out-of-school conditions differed regarding posttest smoking initiation (18.1 and 10.4%) and regarding posttest smoking continuation (23.5 and 13.1%). Multilevel logistic regression analyses showed positive effects regarding the out-of-school program. Significant effects were not found regarding the in-school program, nor did the combined approach show stronger effects than the single-method approaches.

CONCLUSIONS

The findings of this study suggest that smoking prevention trials for elementary schoolchildren can be effective when using out-of-school computer-tailored interventions.

Parenting style and adolescent smoking

PURPOSE

To investigate whether parenting style is an independent risk factor of smoking initiation and experimentation among adolescents, and whether there is a relationship between parenting style and readiness to quit, or nicotine dependence among smokers.

METHODS

The 84-item Health and Smoking Questionnaire, which assesses demographics, smoking status and smoking history, perceptions of risk and risk reduction, risk factors for tobacco use, and parenting style, was administered to 816 adolescents in grades 7 to 12 (mean age, 15.1 years) of whom 22.6% (n = 182) were smokers. Parenting style was measured by the brief, non-retrospective version of the Family of Origin Scale (FOS). Higher scores on the FOS indicated more positive perceived parenting style with high levels of intimacy and autonomy, characteristics of healthy parent-child relationships. Data were analyzed using a model-building approach to logistic regression with demographic and other psychosocial variables in the first two steps, and with parenting style as the last step.

RESULTS

Results from two logistic regression models indicate that although parenting style is not a significant risk factor for smoking experimentation [odds ratio (OR) =.998; confidence interval (CI) =.977-1.019; p =.820], it is a significant independent risk factor for smoking initiation (OR =.950; CI =.930-.970; p =.000). Smokers who were more ready to quit had higher parenting style scores than those who were not ready to quit, and smokers who had made a serious quit attempt (an indicator of nicotine addiction) had higher parenting style scores than those who had not made a quit attempt. Moreover, nonsmokers who reported they would smoke a cigarette if their best friend offered had significantly lower parenting style scores than those who reported they would not smoke a cigarette.

CONCLUSIONS

Additional research on parenting style and its impact on adolescent smoking with a more economically and ethnically diverse sample is warranted. If future research confirms the strength of the relationship between parenting style and adolescent smoking, teaching positive parenting, including facilitating intimate yet autonomous relationships, may be considered as part of smoking prevention and cessation programs.

Early predictors of daily smoking in young women: the national heart, lung, and blood institute growth and health study

BACKGROUND

Smoking is highly prevalent in young women and little is known about early multilevel independent risk or protective factors that are predictive of daily smoking in young women.

METHODS

Multiple logistic regression was conducted on data from NGHS, a 10-year cohort study of Black (1,213) and White (1,166) girls recruited from three clinical centers in the United States, ages 9-10 years on entry to ages 18-19.

RESULTS

Compared with never smokers, White girls were at higher risk than Black girls of being daily smokers at ages 18-19. Early predictors of daily smoking at ages 18-19 years included lower parental education, one parent in the household, drinking alcohol at ages 11-12, higher drive for thinness at ages 11-12, lower behavioral conduct at ages 11-12, and lower stress at ages 10-11 and higher stress at ages 12-13. For both Black and White girls weight-related variables were significant. Stress, behavioral conduct, and one-parent household were also important predictors for White girls.

CONCLUSIONS

There is evidence that childhood and adolescent factors are related to young adult smoking behavior. Body weight concerns as well as family, social environment, and behavioral factors are important issues in determining which girls will become daily smokers.

Ethnicity, gender and risk factors for smoking initiation: an overview

Although the prevalence of cigarette smoking has increased dramatically among youth over the past several years, there are significant ethnic and gender differences in prevalence rates. This paper presents highlights of the research literature on ethnic and gender differences in risk factors for smoking. The effects of peer and family influences may vary by both ethnicity and gender. White youth, especially females, may be more susceptible to the negative influence of friends' smoking than are African-American youth. Although the evidence about the relative importance of parent smoking among ethnic groups is contradictory, recent data suggest that African-American parents provide stronger anti-smoking messages than do white parents. The subgroups also vary in their perceptions of the negative consequences of smoking, with Asian-American and African-American females perceiving stronger negative consequences. Cultural expectations may place white females at increased risk for smoking. The link between depressed mood and smoking also varies by subgroup. Finally, popular media figures may influence the appeal of smoking and be differentially relevant to youth subgroups. We need: (1) specific examinations of ethnic and gender effects with attention paid to identifying protective factors among certain ethnic/gender subgroups; (2) to know more about how family influences may vary by the ethnic/gender subgroups and over the developmental course of smoking; (3) to know more about how youth cope with negative moods and the role of smoking in coping; and (4) to investigate whether the factors that protect youth in some subgroups can be diffused to others.