Relationship of personal tobacco-raising, parental smoking, and other factors to tobacco use among adolescents living in a tobacco-producing region

Randomized controlled trial of the ACTION smoking cessation curriculum in tobacco-growing communities

We conducted a group randomized trial of an interactive, games-based, tobacco cessation program (ACTION) designed to help adolescents who live in tobacco-growing communities to stop using tobacco. More than 260 high school students participated in this study, in 14 schools across three states. We collected self-reported measures of cigarette and smokeless tobacco use and conducted biochemical validation of self-reported use at three time points (pre-test, immediate post-test, and 90-day follow-up). We used multi-level modeling to account for intraclass clustering at the school and classroom levels, and we analyzed our results using an intent-to-treat approach and a per protocol approach. Using the per protocol analytic approach, ACTION participants were more likely than comparison participants to achieve abstinence at 90-day follow-up. We found no program effects on our secondary outcomes or mediating factors. This study suggests that ACTION has promise as a relatively effective adolescent cessation program, although the overall limited effectiveness of cessation programs for adolescents must be acknowledged.

What works to prevent adolescent smoking? A systematic review of the National Cancer Institute's Research-Tested Intervention Programs

BACKGROUND

Cigarette use remains the leading preventable cause of death in the United States. Although school is an ideal setting for antismoking interventions, school-based programs have not been successful in the long term. The purpose of this study was to explore characteristics of programs deemed to be successful short-term Research-Tested Intervention Programs (RTIPs) by the National Cancer Institute (NCI).

METHODS

To identify adolescent smoking prevention programs, 2 independently working researchers applied specified selection criteria to all programs in the NCI's RTIP database. Selected programs were abstracted using a structured form for general information, participants, interventions, outcomes, and quality. Extracted data were then assessed for common themes and contrasts in each category.

RESULTS

As of June 2008, 18 studies met the NCI's standards for RTIPs preventing smoking among adolescents. After selection criteria were applied, only 5 programs remained. Each independently working researcher arrived at the same pool of programs. In chronological order according to date of publication of outcomes evaluation, the 5 programs ultimately included were Project Towards No Tobacco Use, Pathways to Health, Native FACETS, Kentucky Adolescent Tobacco Prevention Project, and Sembrando Salud. The majority of these programs were targeted toward a particular sociodemographic group (eg, American Indians, Hispanic migrant communities).

CONCLUSIONS

New school-based programs are needed to address current issues in tobacco control. To improve chances of success, these programs may wish to target certain specific high-risk demographic groups, use professional health educators and/or trained community members, and build in methods of updating material.

Youth smoking, cigarette prices, and anti-smoking sentiment

In this paper, we develop a new direct measure of state anti-smoking sentiment and merge it with micro-data on youth smoking in 1992 and 2000. The empirical results from the cross-sectional models show two consistent patterns: after controlling for differences in state anti-smoking sentiment, the price of cigarettes has a weak and statistically, insignificant influence on smoking participation, and state anti-smoking sentiment appears to have a potentially important influence on youth smoking participation. The cross-sectional results are corroborated by results from the discrete time hazard models of smoking initiation that include state-fixed effects. However, there is evidence of price-responsiveness in the conditional cigarette demand by youth and young adult smokers.

The tobacco epidemic in the United States

Tobacco use, primarily in the form of cigarettes and exposure to tobacco smoke pollution, has caused the premature deaths of more than 14 million Americans since 1964. The major diseases caused by tobacco and tobacco smoke include lung cancer, other cancers, coronary heart disease, other cardiovascular diseases, chronic respiratory diseases, pregnancy complications, and respiratory diseases in children. Per capita consumption of various tobacco products has declined substantially since 1950, with current consumption at approximately 3.7 pounds per capita. Whereas approximately two in five adults smoked cigarettes in 1965, approximately one in five did so in 2005. Several factors can influence initiation and cessation, including product factors (e.g., ventilation holes, additives, and flavorings); host factors (intention to use, level of dependence); tobacco company activities (e.g., marketing strategies, efforts to undermine public health activities); and environmental factors (e.g., peer and parental smoking, smoke-free air laws and policies). Efforts to prevent initiation, promote quitting, and protect nonsmokers should reduce exposure to pro-tobacco marketing and increase (1) the price of tobacco products, (2) protection from tobacco smoke pollution, (3) effective mass media strategies, (4) provision of effective cessation support, (5) effective regulation, and (6) litigation that holds the industry responsible for its misdeeds. Adequate implementation of effective tobacco-control strategies and useful scientific advances will help to ensure that per capita consumption decreases to the lowest level possible. The economic benefits of tobacco in our society are replaceable and they pale in comparison to the extent of human life lost.

The California Tobacco Control Program's effect on adult smokers: (3) Similar effects for African Americans across states

OBJECTIVE

To compare trends in African-American (AA) and non-Hispanic white (NHW) smoking between states categorised as having three different levels of tobacco control practice in the 1990s.

SETTING AND PARTICIPANTS

Analysis of 1992-3 to 2001-2 Tobacco Use Supplements to the Current Population Survey for differences in adult (20-64 years) daily smoking prevalence for AAs and NHWs across states: California (CA; high cigarette price/comprehensive programme), New York (NY) and New Jersey (NJ; high cigarette price/no comprehensive programme), and tobacco growing states (TGS; low cigarette price/no comprehensive programme).

RESULTS

From 1992-3 to 2001-2, there were large declines in AA smoking across states (2.7-3.8% decrease/year, adjusted for age, income, education, gender; p<0.05). Adjusted NHW smoking prevalence declined significantly only in CA. AA prevalence declined significantly and did not differ across state groups. In all years, in all state groups, adjusted prevalence was either not significantly different or was lower for AAs than for NHWs. More recent cohorts of AAs appeared to have taken up smoking at lower rates than older cohorts.

CONCLUSION

There were uniformly large declines in AA smoking from 1992-3 to 2001-2 across states, independent of type of tobacco control strategy. Further research is needed into factors associated with smoking declines among AAs.

The California Tobacco Control Program's effect on adult smokers: (1) Smoking cessation

OBJECTIVES

To estimate national population trends in long-term smoking cessation by age group and to compare cessation rates in California (CA) with those of two comparison groups of states.

SETTING

Retrospective smoking history of a population sample from the US: from CA, with a comprehensive tobacco-control programme since 1989 with the goal of denormalising tobacco use; from New York and New Jersey (NY & NJ), with similar high cigarette prices but no comprehensive programme; and from the tobacco-growing states (TGS), with low cigarette prices, no tobacco-control programme and social norms relatively supportive of tobacco use.

PARTICIPANTS

Respondents to the Current Population Survey-Tobacco Use Supplements (1992-2002; n = 57 918 non-Hispanic white ever-smokers).

MAIN OUTCOME MEASURES

The proportion of recent ever-smokers attaining long-term abstinence (quit > or = 1 year) and the successful-quit ratio (the proportion of all ever-smokers abstinent > or = 1 year).

RESULTS

Nationally, long-term cessation rates increased by 25% from the 1980s to the 1990s, averaging 3.4% per year in the 1990s. Cessation increased for all age groups, and by > 40% (p<0.001) among smokers aged 20-34 years. For smokers aged < 50 years, higher cigarette prices were associated with higher quitting rates. For smokers aged < 35 years, quitting rates in CA were higher than in either comparison group (p<0.05). Half of the ever-smokers had quit smoking by age 44 years in CA, 47 years in NY & NJ, and by age 54 years in TGS.

CONCLUSION

Successful smoking cessation increased by 25% during the 1990s in the US. Comprehensive tobacco-control programmes were associated with greater cessation success than were with high cigarette prices alone, although both effects were limited to younger adults.

Cigarette smoking among Greek adolescents: behavior, attitudes, risk, and preventive factors

This study was produced in the context of the first author's thesis at Athens University and was a collaboration between the Department of Clinical Care Medicine, Athens University, and Attiki Child Psychiatric Hospital. It was supported by a project grant from the THORAX Foundation, Greece.

OBJECTIVE

To study the smoking behavior, attitudes, and beliefs of Greek adolescents, as well as the risk and preventive factors for the onset of smoking and to obtain data to serve in the planning of comprehensive antismoking campaigns tailored to the Greek adolescent's specific profile.

SAMPLE AND METHOD

A stratified, nationwide, representative, school-based sample of 3827 Greek adolescents was surveyed during the academic year 2001-2002, using a questionnaire on smoking and Achenbach's Youth Self-Report.

RESULTS

Cigarette smoking is a serious problem among Greek youth. Family and peers play a primary role in shaping smoking attitudes and habits. Adolescents who smoke regularly have increased rates of psychopathology as indicated by higher scores on the Externalising and Attention Problem scales of Achenbach's Youth Self-Report, compared to adolescents who are non-smokers. The data obtained can indeed guide smoking prevention strategies in Greece.

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

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

School tobacco policies in a tobacco-growing state

This study examined factors associated with tobacco-free policies and tobacco cessation in schools serving children in grades 6 to 12 in a tobacco-growing state using a cross-sectional telephone survey of school administrators from public and private middle and high schools (N = 691), representing 117 of the 120 Kentucky counties. Trained health department staff contacted 1028 schools; 691 (67%) participated in a phone survey, which lasted an average of 19 minutes. Variables of interest were indoor and outdoor smoking policies, fund-raising in Bingo halls, provision of cessation and prevention programs, owning or leasing a tobacco base, if the school received money from tobacco companies, type of school (public vs private), and school setting (urban vs rural). Only 20% of Kentucky schools reported comprehensive tobacco-free policies. Urban area schools were nearly twice as likely to have a tobacco-free campus than rural schools. Schools that did fund-raising in smoky Bingo halls were 30% less likely to have tobacco-free school policies. While few schools had a tobacco affiliation, those that received money from tobacco companies or grew tobacco were nearly 3 times as likely to provide cessation resources, compared to schools without tobacco affiliation. Rural schools were less likely to be tobacco free and provide cessation services. School-related, off-campus, extracurricular events might be considered as an element of tobacco-free school policy. Schools with tobacco affiliation may provide more cessation resources due to the increased prevalence of tobacco use in these areas.

The impact of anti-tobacco industry prevention messages in tobacco producing regions: evidence from the US truth campaign

BACKGROUND

Adolescents who live in tobacco producing regions may not respond favourably to anti-industry ads.

OBJECTIVE

To examine whether state level involvement in tobacco production appears to limit the effectiveness of anti-industry ads to prevent tobacco use among adolescents in the USA.

DESIGN

Time trend analyses were done using repeated cross sectional data from six waves of the Legacy Media Tracking Survey, which were collected between 1999 and 2003.

SETTING AND PARTICIPANTS

28,307 adolescents, ages 12-17 years, were classified as living in: tobacco producing states (TPS) (n = 1929); non-tobacco producing states (non-TPS) with low tobacco control funding comparable to TPS (n = 5323); non-TPS with relatively high funding (n = 15,076); and non-TPS with established anti-industry ad campaigns (n = 5979).

MAIN OUTCOME MEASURES

Reactions to anti-industry ads; strength of anti-industry attitudes/beliefs; changes in anti-industry attitudes/beliefs over time.

RESULTS

Ad reactions did not differ by state type. Multivariate adjusted time trend analyses indicated significant, comparable increases in anti-industry attitudes/beliefs since the onset of the truth campaign, in both TPS and non-TPS. Mediation analyses indicated that these increases were due, in part, to campaign exposure.

CONCLUSIONS

Adolescents who live in tobacco producing regions appear to be as responsive to anti-industry ads as their counterparts in non-tobacco producing regions. This study provides further evidence for the effectiveness of such ads.

Tobacco cessation in adolescent females in Appalachian communities

Adolescents who live in tobacco-growing areas use tobacco at earlier ages and more frequently than other youth. These adolescents, like all tobacco users, have many health risks. To be successful, cessation efforts targeting these youth must reflect the cultural, social, and economic import of tobacco in their communities. Six focus groups with girls aged 12 to 14 who lived in tobacco-growing communities in Appalachian Ohio, Tennessee, and Virginia and 20 interviews with key informants were conducted. Barriers identified by informants included community norms around tobacco use, family use of tobacco, school practices and policies, peer influences, youth attitudes, and logistical difficulties with cessation program efforts. Key findings indicated: (1) the social community in tobacco-growing communities is a significant influence in tobacco use; (2) family is important among young people in tobacco-growing communities and influences cessation positively and negatively; (3) parental smoking was an influence to smoke (4) some parents condone and even facilitate tobacco use by their children, but others actively discourage use; and (5) concern for the health of younger brothers and sisters elicits a strongly protective reaction from youth in discussions of health risks related to secondhand smoke. Youth in tobacco-growing regions have many similarities to others, but they also have unique cultural characteristics pertinent in the development and delivery of tobacco cessation programs.

Design and analysis of group-randomized trials: a review of recent practices

We reviewed group-randomized trials (GRTs) published in the American Journal of Public Health and Preventive Medicine from 1998 through 2002 and estimated the proportion of GRTs that employ appropriate methods for design and analysis. Of 60 articles, 9 (15.0%) reported evidence of using appropriate methods for sample size estimation. Of 59 articles in the analytic review, 27 (45.8%) reported at least 1 inappropriate analysis and 12 (20.3%) reported only inappropriate analyses. Nineteen (32.2%) reported analyses at an individual or subgroup level, ignoring group, or included group as a fixed effect. Hence increased vigilance is needed to ensure that appropriate methods for GRTs are employed and that results based on inappropriate methods are not published.

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.

Epidemiology of tobacco use in the United States

Efforts to understand trends in and patterns of lung cancer are well served by studies of trends in and patterns of tobacco use. In the United States, the manufactured cigarette emerged as the tobacco product of choice shortly after the turn of the twentieth century. Lung cancer emerged after years of inhalation of cigarette smoke, first among men and then among women. The massive public health education campaign that began after scientists recognized the dangers of cigarette smoking has contributed to large reductions in cigarette use and subsequent smoking-attributable morbidity and mortality. Since 1965, the prevalence of cigarette smoking among US adults has declined by almost half, with positive trends observed among persons in almost all sociodemographic groups and efforts to reduce disparities recognized as an important goal in public health. An epidemiologic approach to understanding and controlling patterns of tobacco use is proposed. The model focuses on the agent (tobacco products), host (consumer or potential consumer), vector (tobacco companies and other users), and environment (with influences from families, social sources, culture, history, politics, law, and media). Accelerating progress in reducing tobacco use will accelerate reductions in tobacco-attributable morbidity and mortality.

Determinants of youth tobacco use in West Virginia: a comparison of smoking and smokeless tobacco use

PURPOSE

To identify and compare the determinants of different types of tobacco use among rural youths and discuss the implication of these differences for youth tobacco use cessation.

METHODS

Ninth grade participants (n = 883) were 95% white, between 13 and 19 years old with a mean age of 14.6 years. Students were classified into four exclusive groups: non-tobacco use, smoking only, smokeless tobacco (ST) use only, and conjoint smoking and ST use. The influences of 14 specific risk factors on tobacco use were investigated for each group using separate multiple logistic regression analyses.

RESULTS

Among participants, 20% were smokers only, 6% were ST users only, and 10% were conjoint users. Students who had more friends (odds ratio [OR] =] 2.75) and siblings (OR = 1.96) who smoke, family problems (OR = 1.70), and favorable attitudes toward tobacco use (OR = 1.12) were more likely to smoke than were other students. Among students who used only ST, gender was a primary determinant (95% were male). Excluding gender, sibling ST use (OR = 4.28), friends' ST use (OR = 1.71), and favorable attitudes (OR = 1.11) were the most significant risk factors. Male students were also more likely to use both cigarettes and ST (OR = 8.62). In addition, among students who used both tobacco products, siblings' and friends' ST use were significant (OR = 3.09 and 2.13, respectively), as well as family problems (OR = 2.41) and attitude (OR = 1.15). Unlike smokers only or ST users only, lack of knowledge about tobacco was a significant determinant among conjoint users (OR = 1.39).

CONCLUSIONS

Findings revealed that 7 of 14 factors were significant predictors of tobacco use. Some factors predicted smoking only, ST only, and conjoint use; however, the pattern of predictors varied for these three categories. Implications for these findings as they relate to tobacco use interventions are discussed.

The effectiveness of a tobacco prevention program with adolescents living in a tobacco-producing region

OBJECTIVES

This study investigated the efficacy of a social-influences tobacco prevention program conducted with adolescents living in a high tobacco production area.

METHODS

Students in 10 experimental schools completed the tobacco prevention program and a booster intervention. Control students received health education as usual.

RESULTS

After 2 years of treatment, smoking rates in the treatment group (vs the control group) were lower for 30-day, 7-day, and 24-hour smoking. The intervention had more of an impact on those who were involved in raising tobacco than it did on those not involved in raising tobacco.

CONCLUSIONS

Although modest, effects were achieved with minimal intervention time in a high-risk group, indicating that social-influences prevention programs may be effective in such groups.