Tobacco-refusal skills and tobacco use among high-risk adolescents

Psychological and Familial Factors of Depression in Relation to Adolescent Smoking Behavior

BACKGROUND

Several common factors have been identified for smoking and depression. The The present study explores the relation of psychological and familial factors with depression, by student smoking behavior.

MATERIALS AND METHODS

A total of 5500 middle- and high-school students were selected in Isfahan province in 2010. A self-administered questionnaire collected data on background characteristics, smoking status, depression, and risk factors. Univariate analysis multiple logistic regressions were conducted to compare between depressed and nondepressed people by adolescent smoking status. Odds ratios and the corresponding 95% confidence intervals (CIs) were reported.

RESULTS

Fathers lower education attainment was accompanied adolescents higher depression prevalence. Parental smoking and sibling smoking increased the depression likelihood by 1.41 (95% CI: 1.18, 1.68) and 1.43 folds (95% CI: 1.04-1.94) for never-smokers. Positive attitude toward smoking increased the probability of depression by 1.18 among never-smokers. Never-smokers lacking refusal skill had 1.23 (1.03-1.47) higher chance of depression. A higher level of self-efficacy related to lower chance of depression. Taking risky behavior, increased the depression likelihood by 1.56 (95% CI: 1.29-1.89) in never-smokers, by 1.85 (95% CI: 1.37-2.44) in experimental smokers, and by 1.14 times (95% CI: 1.01-1.72) in current smokers. Family conflict increased depression chance by 2.25 times (95% CI: 1.89-2.66) in never-smokers, by 1.95 (95% CI: 1.46-2.61) in experimental smokers, and by 2.06 times (95% CI: 1.38-3.08) in current smokers.

CONCLUSIONS

Targeting self-efficacy level, risky behavior, and family conflict can drop the comorbidity of smoking and depression simultaneously. This may help public health practitioners and policymakers to develop common strategies in reducing adolescents smoking and depression comorbidity.

Influence of Parent-Adolescent Communication About Anabolic Steroids on Adolescent Athletes' Willingness to Try Performance-Enhancing Substances

BACKGROUND

Performance-enhancing substances are used by adolescent athletes to help improve performance. Anabolic steroids (AS) are performance-enhancing substances that pose significant health problems when used by adolescents.

OBJECTIVES

Objectives were to: (1) examine the extent to which parents and adolescents discuss AS and (2) test whether parent-adolescent communication about AS can generalize to, and influence, decisions to use other types of performance-enhancing substances.

METHOD

Adolescent athletes (n = 244) completed an anonymous questionnaire that assessed the extent to which the adolescents discussed with their parents the performance outcomes and protective factors associated with AS, their intentions to use AS, and their willingness to try a newly developed, potentially illegal performance-enhancing substance. Data were collected during 2009-2010.

RESULTS

Adolescents reported relatively low levels of communication with their parents about anabolic androgenic steroids (AAS). Communication with parents about the performance outcomes associated with AS was a positive predictor of willingness to try a newly developed performance-enhancing substance (b = 0.31, p < .01) and intentions to use AS (b = 0.54, p < .01). Communication with parents about protective factors predicted willingness to try a new performance-enhancing substance (b = -0.24, p < .01), but not intentions (b = -0.20, p > .77). Conclusions/Importance: Parents should highlight the protective factors and avoid emphasizing the performance outcomes associated with AS in discussions with their adolescents. Discussions about AS may influence adolescents' decisions to use other types of performance-enhancing substances.

School-based programmes for preventing smoking

BACKGROUND

Helping young people to avoid starting smoking is a widely endorsed public health goal, and schools provide a route to communicate with nearly all young people. School-based interventions have been delivered for close to 40 years.

OBJECTIVES

The primary aim of this review was to determine whether school smoking interventions prevent youth from starting smoking. Our secondary objective was to determine which interventions were most effective. This included evaluating the effects of theoretical approaches; additional booster sessions; programme deliverers; gender effects; and multifocal interventions versus those focused solely on smoking.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Tobacco Addiction Group's Specialised Register, MEDLINE, EMBASE, PsycINFO, ERIC, CINAHL, Health Star, and Dissertation Abstracts for terms relating to school-based smoking cessation programmes. In addition, we screened the bibliographies of articles and ran individual MEDLINE searches for 133 authors who had undertaken randomised controlled trials in this area. The most recent searches were conducted in October 2012.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) where students, classes, schools, or school districts were randomised to intervention arm(s) versus a control group, and followed for at least six months. Participants had to be youth (aged 5 to 18). Interventions could be any curricula used in a school setting to deter tobacco use, and outcome measures could be never smoking, frequency of smoking, number of cigarettes smoked, or smoking indices.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies for inclusion, extracted data and assessed risk of bias. Based on the type of outcome, we placed studies into three groups for analysis: Pure Prevention cohorts (Group 1), Change in Smoking Behaviour over time (Group 2) and Point Prevalence of Smoking (Group 3).

MAIN RESULTS

One hundred and thirty-four studies involving 428,293 participants met the inclusion criteria. Some studies provided data for more than one group.Pure Prevention cohorts (Group 1) included 49 studies (N = 142,447). Pooled results at follow-up at one year or less found no overall effect of intervention curricula versus control (odds ratio (OR) 0.94, 95% confidence interval (CI) 0.85 to 1.05). In a subgroup analysis, the combined social competence and social influences curricula (six RCTs) showed a statistically significant effect in preventing the onset of smoking (OR 0.49, 95% CI 0.28 to 0.87; seven arms); whereas significant effects were not detected in programmes involving information only (OR 0.12, 95% CI 0.00 to 14.87; one study), social influences only (OR 1.00, 95% CI 0.88 to 1.13; 25 studies), or multimodal interventions (OR 0.89, 95% CI 0.73 to 1.08; five studies). In contrast, pooled results at longest follow-up showed an overall significant effect favouring the intervention (OR 0.88, 95% CI 0.82 to 0.96). Subgroup analyses detected significant effects in programmes with social competence curricula (OR 0.52, 95% CI 0.30 to 0.88), and the combined social competence and social influences curricula (OR 0.50, 95% CI 0.28 to 0.87), but not in those programmes with information only, social influence only, and multimodal programmes.Change in Smoking Behaviour over time (Group 2) included 15 studies (N = 45,555). At one year or less there was a small but statistically significant effect favouring controls (standardised mean difference (SMD) 0.04, 95% CI 0.02 to 0.06). For follow-up longer than one year there was a statistically nonsignificant effect (SMD 0.02, 95% CI -0.00 to 0.02).Twenty-five studies reported data on the Point Prevalence of Smoking (Group 3), though heterogeneity in this group was too high for data to be pooled.We were unable to analyse data for 49 studies (N = 152,544).Subgroup analyses (Pure Prevention cohorts only) demonstrated that at longest follow-up for all curricula combined, there was a significant effect favouring adult presenters (OR 0.88, 95% CI 0.81 to 0.96). There were no differences between tobacco-only and multifocal interventions. For curricula with booster sessions there was a significant effect only for combined social competence and social influences interventions with follow-up of one year or less (OR 0.50, 95% CI 0.26 to 0.96) and at longest follow-up (OR 0.51, 95% CI 0.27 to 0.96). Limited data on gender differences suggested no overall effect, although one study found an effect of multimodal intervention at one year for male students. Sensitivity analyses for Pure Prevention cohorts and Change in Smoking Behaviour over time outcomes suggested that neither selection nor attrition bias affected the results.

AUTHORS' CONCLUSIONS

Pure Prevention cohorts showed a significant effect at longest follow-up, with an average 12% reduction in starting smoking compared to the control groups. However, no overall effect was detected at one year or less. The combined social competence and social influences interventions showed a significant effect at one year and at longest follow-up. Studies that deployed a social influences programme showed no overall effect at any time point; multimodal interventions and those with an information-only approach were similarly ineffective.Studies reporting Change in Smoking Behaviour over time did not show an overall effect, but at an intervention level there were positive findings for social competence and combined social competence and social influences interventions.

Adolescent preventive health and team-games-tournaments: five decades of evidence for an empirically based paradigm

The problematic behaviors of teenagers and the subsequent negative consequences are extensive and well documented: unwanted pregnancy, substance abuse, violent behavior, depression, and social and psychological consequences of unemployment. In this article, the authors review an approach that uses a cooperative learning, empirically based intervention that employs peers as teachers. This intervention of choice is Teams-Games-Tournaments (TGT), a paradigm backed by five decades of empirical support. The application of TGT in preventive health programs incorporates elements in common with other prevention programs that are based on a public health orientation and constitute the essential components of health education, that is, skills training and practice in applying skills. The TGT intervention supports the idea that children and adolescents from various socioeconomic classes, between the ages of 8 and 18 and in classrooms or groups ranging in size from 4 to 17 members, can work together for one another. TGT has been applied successfully in such diverse areas as adolescent development, sexuality education, psychoactive substance abuse education, anger control, coping with depression and suicide, nutrition, comprehensive employment preparation, and family intervention. This article reviews the extensive research on TGT using examples of successful projects in substance abuse, violence, and nutrition. Issues are raised that relate to the implementation of preventive health strategies for adolescents, including cognitive aspects, social and family networks, and intervention components.

Short-term impact of cognition-motivation-emotional intelligence-resistance skills program on drug use prevention for school students in Wuhan, China

Drug abuse continues to be a serious public health threat worldwide. Most drug abuse prevention research has been conducted with predominantly American or European adolescent populations. Little is known about approaches that work best to prevent the initiation of Chinese adolescent drug use. For targeting risk factors of drug initiation in Chinese adolescents, a school-based health intervention program named "Cognition-Motivation-Emotional Intelligence-Resistance Skills" (CMER) was developed to enhance cognition upon drug use, to decrease motivation of drug use and to improve emotional adjusting and drug resistance skills in this study. A total of 798 students from 3 senior high schools in Wuhan, a city in central China, were assigned randomly to intervention and control groups. The intervention group received the CMER program in which knowledge, development of positive attitude and motivation towards drugs and training of peer resistance skills were basic elements. The immediate impact was compared by measuring the above mentioned elements prior to and three-month after the training session. Students from both groups were asked to complete a self-administered questionnaire. The questionnaire included demographic items, self-reported drug use behavior, cognition, attitude, and motivation associated with the initiation of drug use and resistance skills. Three months after the intervention, significant effects were found on "illegal substance use at least once" (P<0.05) between the intervention and control groups. Immediate effects of the intervention were also found on knowledge, motivation and peer resistance skills (P<0.05), but there was no clear evidence for any effects on attitude towards substance use (P>0.05). It was concluded that the CMER program, which significantly increased the knowledge of drugs and peer resistance skills, was effective in the drug abuse prevention in a sample of school students in Wuhan, China.

Stay away from tobacco: a pilot trial of a school-based adolescent smoking prevention program in Beijing, China

A quasiexperimental study was conducted to explore the efficacy of the program Stay Away from Tobacco (SAFT). Participants-from 11 classes with 381 students total in grades 7, 8, 10, and 11-were assigned by class to three groups (intervention group T with school teachers delivering the program, intervention group R with researchers delivering the program, and comparison group C). Data were collected at baseline, immediately after the intervention, and 6 months after the intervention. Self-reported smoking was the outcome measure. The 30-day smoking prevalence in group C increased from 4% at baseline to 10% at the 6-month follow-up, whereas this rate declined from 11% to 6% in group T, and from 9% to 1% in group R. For group T, the odds ratio (for 30-day smoking) and the regression coefficient (for indexed number of cigarettes smoked) assessing interactions between intervention and time were 0.20 (p < .001) and -.1605 (p < .05), respectively. The same statistics for group R were 0.09 (p < .001) and -.2406 (p < .01), respectively. The predicted smoking rate declined by 19% from baseline to 6-month follow-up in group T (11.5% vs. 9.3%), and the same rate declined by 26% in group R (11.1% vs. 8.2%). The results from this pilot trial suggest that SAFT can reduce cigarette smoking among middle and high school students through its effect on improving these students' refusal skills and changing their perceived mental and physical values from smoking. A full-scale evaluation is recommended.

School-based programmes for preventing smoking

BACKGROUND

Smoking rates in adolescents are rising in some countries. Helping young people to avoid starting smoking is a widely endorsed goal of public health, but there is uncertainty about how to do this. Schools provide a route for communicating with a large proportion of young people, and school-based programmes for smoking prevention have been widely developed and evaluated.

OBJECTIVES

To review all randomized controlled trials of behavioural interventions in schools to prevent children (aged 5 to12) and adolescents (aged 13 to18) starting smoking.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Tobacco Addiction Group's Specialized Register, MEDLINE, EMBASE, PsyclNFO, ERIC, CINAHL, Health Star, Dissertation Abstracts and studies identified in the bibliographies of articles. Individual MEDLINE searches were made for 133 authors who had undertaken randomized controlled trials in this area.

SELECTION CRITERIA

Types of studies: those in which individual students, classes, schools, or school districts were randomized to the intervention or control groups and followed for at least six months.

TYPES OF PARTICIPANTS

Children (aged 5 to12) or adolescents (aged 13 to18) in school settings. Types of interventions: Classroom programmes or curricula, including those with associated family and community interventions, intended to deter use of tobacco. We included programmes or curricula that provided information, those that used social influences approaches, those that taught generic social competence, and those that included interventions beyond the school into the community. We included programmes with a drug or alcohol focus if outcomes for tobacco use were reported. Types of outcome measures: Prevalence of non-smoking at follow up among those not smoking at baseline. We did not require biochemical validation of self-reported tobacco use for study inclusion.

DATA COLLECTION AND ANALYSIS

We assessed whether identified citations were randomized controlled trials. We assessed the quality of design and execution, and abstracted outcome data. Because of the marked heterogeneity of design and outcomes, we computed pooled estimates only for those trials that could be analyzed together and for which statistical data were available. We predominantly synthesized the data using narrative systematic review. We grouped studies by intervention method (information; social competence; social influences; combined social influences/social competence; multi-modal programmes). Within each group, we placed them into three categories (low, medium and high risk of bias) according to validity using quality criteria for reported study design.

MAIN RESULTS

Of the 94 randomized controlled trials identified, we classified 23 as category one (most valid). There was one category one study of information-giving and two of teaching social comeptence. There were thirteen category one studies of social influences interventions. Of these, nine found some positive effect of intervention on smoking prevalence, and four failed to detect an effect on smoking prevalence. The largest and most rigorous study, the Hutchinson Smoking Prevention Project, found no long-term effect of an intensive eight-year programme on smoking behaviour. There were three category one RCTs of combined social influences and social competence interventions: one provided significant results and one only for instruction by health educators compared to self-instruction. There was a lack of high quality evidence about the effectiveness of combinations of social influences and social competence approaches. There was one category one study providing data on social influences compared with information giving. There were four category one studies of multi-modal approaches but they provided limited evidence about the effectiveness of multi-modal approaches including community initiatives.

AUTHORS' CONCLUSIONS

There is one rigorous test of the effects of information-giving about smoking. There are well-conducted randomized controlled trials to test the effects of social influences interventions: in half of the group of best quality studies those in the intervention group smoke less than those in the control, but many studies failed to detect an effect of the intervention. There are only three high quality RCTs which test the effectiveness of combinations of social influences and social competence interventions, and four which test multi-modal interventions; half showed significant positive results.

The impact of self-control indices on peer smoking and adolescent smoking progression

OBJECTIVE

To determine the direct impact of self-control variables on baseline smoking and smoking progression and determine whether self-control had indirect effects on smoking practices through effects on peer smoking.

METHODS

Study participants were 918 adolescents who were followed from 9th through the 12th grade and completed self-report measures of peer smoking, self-control, and cigarette smoking. An exploratory factor analysis (EFA) was conducted to assess the factor structure of a 41-item self-control measure. The EFA indicated a six-factor structure comprising of impulsive control, planning, hostile blaming, attentional disregulation, conscientiousness, and physical aggression.

RESULTS

The results of a latent growth model indicated that conscientiousness (OR = 0.81, CI = 0.73-0.90), hostile blaming (OR = 0.89, CI = 0.81-0.99), and physical aggression (OR = 1.16, CI = 1.06-1.27) had direct effects on baseline smoking, whereas planning (OR = 0.90, CI = 0.82-0.99) and impulse control (OR = 1.15, CI = 1.02-1.28) had indirect effects on adolescent smoking at baseline through baseline peer smoking. There were no significant direct or indirect effects of the self-control indices on smoking progression. There was a direct effect of peer smoking progression (number of peers who smoked) on adolescent smoking progression, such that increases in the number of peers who smoked across time increased the odds that an adolescent would progress to a higher level of smoking.

CONCLUSIONS

Youth smoking prevention and intervention program outcomes may potentially improve by addressing self-control behaviors as they appear to have direct effects on smoking and indirect effects through peers who smoke.

School-based programmes for preventing smoking

BACKGROUND

Smoking rates in adolescents are rising. Helping young people to avoid starting smoking is a widely endorsed goal of public health, but there is uncertainty about how to do this. Schools provide a route for communicating with a large proportion of young people, and school-based programmes for smoking prevention have been widely developed and evaluated.

OBJECTIVES

To review all randomised controlled trials of behavioural interventions in schools to prevent children (aged 5 to12) and adolescents (aged 13 to18) starting smoking.

SEARCH STRATEGY

We searched The Cochrane Controlled Trials and Tobacco Review group registers, MEDLINE, EMBASE, Psyclnfo, ERIC, CINAHL, Health Star, Dissertation Abstracts and studies identified in the bibliographies of articles. Individual MEDLINE searches were made for 133 authors who had undertaken randomised controlled trials in this area.

SELECTION CRITERIA

Types of studies: those in which individual students, classes, schools, or school districts were randomised to the intervention or control groups and followed for at least six months.

TYPES OF PARTICIPANTS

Children (aged 5 to12) or adolescents (aged 13 to18) in school settings. Types of interventions: Classroom programmes or curricula, including those with associated family and community interventions, intended to deter use of tobacco. We included programmes or curricula that provided information, those that used social influences approaches, those that taught generic social competence, and those that included interventions beyond the school into the community. We included programmes with a drug or alcohol focus if outcomes for tobacco use were reported. Types of outcome measures: Prevalence of non-smoking at follow-up among those not smoking at baseline. We did not require biochemical validation of self-reported tobacco use for study inclusion.

DATA COLLECTION AND ANALYSIS

We assessed whether identified citations were randomised controlled trials. We assessed the quality of design and execution, and abstracted outcome data. Because of the marked heterogeneity of design and outcomes, we did not perform a meta-analysis. We synthesised the data using narrative systematic review. We grouped studies by intervention method (information; social competence; social influences; combined social influences/social competence and multi-modal programmes). Within each category, we placed them into three groups according to validity using quality criteria for reported study design.

MAIN RESULTS

Of the 76 randomised controlled trials identified, we classified 16 as category one (most valid). There were no category one studies of information giving alone. There were fifteen category one studies of social influences interventions. Of these, eight showed some positive effect of intervention on smoking prevalence, and seven failed to detect an effect on smoking prevalence. The largest and most rigorous study, the Hutchinson Smoking Prevention Project, found no long-term effect of an intensive 8-year programme on smoking behaviour. There was a lack of high quality evidence about the effectiveness of combinations of social influences and social competence approaches. There was limited evidence about the effectiveness of multi-modal approaches including community initiatives.

REVIEWER'S CONCLUSIONS

There is no rigorous test of the effects of information giving about smoking. There are well-conducted randomised controlled trials to test the effects of social influences interventions: in half of the group of best quality studies those in the intervention group smoke less than those in the control, but many studies showed no effect of the intervention. There is a lack of high-quality evidence about the effectiveness of combinations of social influences and social competence interventions, and of multi-modal programmes that include community interventions.

Investing in youth tobacco control: a review of smoking prevention and control strategies

OBJECTIVE

To provide a comprehensive review of interventions and policies aimed at reducing youth cigarette smoking in the United States, including strategies that have undergone evaluation and emerging innovations that have not yet been assessed for efficacy.

DATA SOURCES

Medline literature searches, books, reports, electronic list servers, and interviews with tobacco control advocates.

DATA SYNTHESIS

Interventions and policy approaches that have been assessed or evaluated were categorised using a typology with seven categories (school based, community interventions, mass media/public education, advertising restrictions, youth access restrictions, tobacco excise taxes, and direct restrictions on smoking). Novel and largely untested interventions were described using nine categories.

CONCLUSIONS

Youth smoking prevention and control efforts have had mixed results. However, this review suggests a number of prevention strategies that are promising, especially if conducted in a coordinated way to take advantage of potential synergies across interventions. Several types of strategies warrant additional attention and evaluation, including aggressive media campaigns, teen smoking cessation programmes, social environment changes, community interventions, and increasing cigarette prices. A significant proportion of the resources obtained from the recent settlement between 46 US states and the tobacco industry should be devoted to expanding, improving and evaluating "youth centred" tobacco prevention and control activities.

Stress-coping and temptation-coping as predictors of adolescent substance use

The stress-coping model of addiction posits that stress-coping and temptation-coping skills each make an independent contribution to the likelihood of substance use. Despite the popularity of this model, this proposition has never been examined empirically. The current study tested this proposition using a sample of public high school students (n = 332). Results supported the model, as stress-coping and temptation-coping each accounted for statistically unique and significant variance in teenagers' substance use. In addition, substance-abusing adolescents reported engaging in significantly more avoidance stress-coping and significantly less temptation-coping than demographically-matched nonsubstance-abusing adolescents. Our results replicate and expand previous findings from the stress-coping literature and have implications for future research and intervention efforts in the adolescent substance abuse field.

Why do effective smoking prevention programs work? Student changes in social cognitive theory constructs

Psychosocial smoking prevention programs can decrease adolescent smoking initiation. This study determined if the theoretical variables targeted in a psychosocial smoking prevention program can be improved significantly by participation in a smoking prevention program. The Social Cognitive Theory constructs examined included behavioral capability to resist positive images of smoking, refusal skill-efficacy, total positive refusal expectations and importance, and total negative refusal expectations and importance. The smoking prevention program had a significant impact on student refusal skill-efficacy and total positive refusal expectations and importance. However, the program did not affect behavioral capability to resist positive images of smoking and total negative refusal expectations and importance. Results from the study can be used to improve the impact of psychosocial prevention programs on targeted Social Cognitive Theory constructs and support the continued practice of cigarette refusal strategy role-plays, addressing various types of pressure and emphasizing positive outcomes from cigarette refusals.

One-year predictors of smoking initiation and of continued smoking among elementary schoolchildren in multiethnic, low-income, inner-city neighbourhoods

OBJECTIVE

To identify one-year predictors of smoking initiation among never-smokers, and of continued smoking among ever-smokers.

DESIGN

Two sequential cohorts of grade 4 and 5 children. Data were collected as part of Coeur en sante St Louis du Parc, a non-randomised controlled trial to evaluate the impact of a school-based heart health promotion programme.

SETTING

24 inner-city elementary schools located in multiethnic, low-income neighbourhoods in Montreal.

SUBJECT

1824 schoolchildren aged 9-12 years with baseline and one-year follow-up data.

MAIN OUTCOME MEASURES

Changes in smoking behaviour over a year; the ability of baseline data to predict smoking initiation and continued smoking a year later was investigated in logistic regression analyses.

RESULTS

The prevalence of ever-smoking was 21.1% at baseline and 30.2% at one-year follow up. One in six never-smokers initiated smoking; one in three ever-smokers continued smoking. Predictors of initiation included age (odds ratio (OR) = 1.6, 95% confidence interval (CI) = 1.3 to 2.0), male gender (OR = 1.5 (95% CI = 1.1 to 2.0)), friends who smoke (OR = 2.3 (95% CI = 1.7 to 3.3)), sibling(s) who smoke (OR = 1.9 (95% CI = 1.2 to 3.1)), father/mother who smokes (OR = 2.2 (95% CI = 1.6 to 3.0)), and frequent high fat/"junk food" consumption (OR = 1.6 (95% CI = 1.1 to 2.1)). Age and friends who smoke were also independent predictors of continued smoking in both genders. In addition, in boys, current smokers at baseline were 2.6 times (95% CI = 1.4 to 5.0) more likely to continue smoking than past smokers. In girls, being overweight was associated with continued smoking (OR = 3.5 (95% CI = 1.6 to 7.6)).

CONCLUSIONS

Smoking prevention programmes should address parental and sibling influences on smoking, in addition to refusal skills training. Among girls, weight-related issues may also be important.

Prevalence, patterns, and correlates of spit tobacco use in a college athlete population

We surveyed varsity athletes (N = 1,328) in 16 California colleges about their patterns of spit (smokeless) tobacco (ST) use, related habits, reasons for use, and preferred methods for quitting. Prevalence of use was analyzed by sport and demographic characteristics, and patterns of use in players using snuff exclusively, using chewing tobacco exclusively, and those using both were compared. Odds ratios and 95% confidence intervals were calculated, adjusting for ethnic group. Prevalence was highest in Whites (44%) and Native Americans (48%) and lowest in African Americans (11%), and higher in varsity baseball (52%) than varsity football players (26%), in players attending rural colleges, and among those who ever smoked cigarettes or used alcohol. Forty-one percent of ST users initiated regular use during their high school years. Athletes who used snuff exclusively used it more intensively and for more years than those who used chewing tobacco exclusively. Snuff users indicated a greater perceived need for ST, but also were more ready to quit. These data suggest ST programs with prevention and cessation components are appropriate for high school as well as college athletes. Such interventions should focus on baseball players, distinguish snuff from chewing tobacco users in planning quit strategies, integrate intervention programs for cigarette smoking and alcohol consumption, provide training in refusal skills, and attempt to change social norms in support of ST use by integrating popular peers and significant others (e.g., wives/girlfriends) to endorse nonuse of ST.