Ten-year trends in cigarette smoking among young adults, 1986-1996: the CARDIA study. Coronary Artery Risk Development In Young Adults

Oral cancer patients achieve comparable survival at high safety-net burden hospitals

PURPOSE

To evaluate the impact of hospital safety-net burden and social demographics on the overall survival of patients with oral cavity squamous cell carcinoma.

MATERIALS AND METHODS

We identified 48,176 oral cancer patients diagnosed between the years 2004 to 2015 from the National Cancer Database and categorized treatment facilities as no, low, or high safety-net burden hospitals based on the percentage of uninsured or Medicaid patients treated. Using the Kaplan Meier method and multivariate analysis, we examined the effect of hospital safety-net burden, sociodemographic variables, and clinical factors on overall survival.

RESULTS

Of the 1269 treatment facilities assessed, the median percentage of uninsured/Medicaid patients treated was 0% at no, 11.6% at low, and 23.5% at high safety-net burden hospitals and median survival was 68.6, 74.8, and 55.0 months, respectively (p < 0.0001). High safety-net burden hospitals treated more non-white populations (15.4%), lower median household income (<$30,000) (23.2%), and advanced stage cancers (AJCC III/IV) (54.6%). Patients treated at low (aHR = 0.97; 95% CI = 0.91-1.04, p = 0.405) and high (aHR = 1.05; 95% CI = 0.98-1.13, p = 0.175) safety-net burden hospitals did not experience worse survival outcomes compared to patients treated at no safety-net burden hospitals.

CONCLUSION

High safety-net burden hospitals treated more oral cancer patients of lower socioeconomic status and advanced disease. Multivariate analysis showed high safety-net burden hospitals achieved comparable patient survival to lower burden hospitals.

A Complex Systems Model of Breast Cancer Etiology: The Paradigm II Conceptual Model

BACKGROUND

The etiology of breast cancer is a complex system of interacting factors from multiple domains. New knowledge about breast cancer etiology continues to be produced by the research community, and the communication of this knowledge to other researchers, practitioners, decision makers, and the public is a challenge.

METHODS

We updated the previously published Paradigm model (PMID: 25017248) to create a framework that describes breast cancer etiology in four overlapping domains of biologic, behavioral, environmental, and social determinants. This new Paradigm II conceptual model was part of a larger modeling effort that included input from multiple experts in fields from genetics to sociology, taking a team and transdisciplinary approach to the common problem of describing breast cancer etiology for the population of California women in 2010. Recent literature was reviewed with an emphasis on systematic reviews when available and larger epidemiologic studies when they were not. Environmental chemicals with strong animal data on etiology were also included.

RESULTS

The resulting model illustrates factors with their strength of association and the quality of the available data. The published evidence supporting each relationship is made available herein, and also in an online dynamic model that allows for manipulation of individual factors leading to breast cancer (https://cbcrp.org/causes/).

CONCLUSIONS

The Paradigm II model illustrates known etiologic factors in breast cancer, as well as gaps in knowledge and areas where better quality data are needed.

IMPACT

The Paradigm II model can be a stimulus for further research and for better understanding of breast cancer etiology.

Patterns in first and daily cigarette initiation among youth and young adults from 2002 to 2015

This study’s objective was to describe long-term trends and patterns in first cigarette use (cigarette initiation) and daily cigarette use (daily initiation) among youth and young adults in the U.S. We used cross-sectional survey data from the National Survey on Drug Use and Health, 2002–2015, to estimate annual incidence of first cigarette use (N = 270,556) and first daily cigarette use (N = 373,464) for each year by age groups, race/ethnicity and gender, examining trends over time and the average annual change in initiation for each group. Several clear patterns emerged: 1) cigarette initiation and daily initiation significantly decreased over time among those aged 12–14 and 15–17 and these trends were consistent among nearly all racial/ethnic and gender subgroups; 2) among 18–21 year olds, cigarette initiation sharply increased through 2009, surpassing rates among 15–17 year olds, and sharply declined through 2015 while remaining higher than rates among the younger group, and this trend was consistent for almost all racial/ethnic subgroups; 3) daily initiation for those aged 18–21 significantly declined, and this was significant among most subgroups 4) there was no change in cigarette initiation and daily initiation for 22–25 year olds overall and most subgroups; 5) there was a significant increase in cigarette initiation for 22–25 year old Hispanics males and daily initiation for 22–25 year old males. This study provides a comprehensive look at trends in cigarette and daily initiation among U.S. youth and young adults. Despite notable declines in smoking initiation among youth and young adult populations over the last two decades, targeted prevention and policy efforts are needed for subgroups at higher risk, including young adults and Hispanic males.

Trends and timing of cigarette smoking uptake among US young adults: survival analysis using annual national cohorts from 1976 to 2005

AIMS

To measure changes over time in cigarette smoking uptake prevalence and timing during young adulthood (ages 19-26 years), and associations between time-invariant/-varying characteristics and uptake prevalence/timing.

DESIGN

Discrete-time survival modeling of data collected from United States high school seniors (modal age 17/18) enrolled in successive graduating classes from 1976 to 2005 and participating in four follow-up surveys (to modal age 25/26).

SETTING

The longitudinal component of the Monitoring the Future study.

PARTICIPANTS

A total of 10 758 individuals reporting no life-time smoking when first surveyed as high school seniors.

MEASUREMENTS

Smoking uptake (any, experimental, occasional and regular); socio-demographic variables; marital, college and work status; time spent socializing.

FINDINGS

The percentage of young adults moving from non-smoker to experimental smoking [slope estimate 0.11, standard error (SE) = 0.04, P = 0.005] or occasional smoking (slope estimate 0.17, SE = 0.03, P < 0.001) increased significantly across graduating classes; the percentage moving from non-smoker to regular smoker remained stable. All forms of smoking uptake were most likely to occur at age 19/20, but uptake prevalence at older ages increased over time [e.g. cohort year predicting occasional uptake at modal age 25/26 adjusted hazard odds ratio (AHOR) = 1.05, P = 0.002]. Time-invariant/-varying characteristics had unique associations with the timing of various forms of smoking uptake (e.g. at modal age 21/22, currently attending college increased occasional uptake risk (AHOR = 2.11, P < 0.001) but decreased regular uptake risk (AHOR = 0.69, P = 0.026).

CONCLUSIONS

Young adult occasional and experimental smoking uptake increased in the United States for non-smoking high school seniors graduating from 1976 to 2005. Smoking uptake for these cohorts remained most likely to occur at age 19/20, but prevalence of uptake at older ages increased.

Women and smoking—prices and health warning messages: evidence from Spain

OBJECTIVE

In Spain, fewer men are smoking every year yet the number of women smokers remains relatively high. This paper examines the impact of two anti-smoking policies (increased prices and obligatory pictorial health warning labels) on womens smoking decisions; generation cohorts are used to elucidate the determinants of those decisions.

DATA SOURCE

We have drawn 48,755 observations of women living in Spain from the Spanish National Health Surveys of 2001, 2003, 2006 and 2011.

DATA SYNTHESIS

Among the main results, we highlight that belonging to a particular generation modulates the manner in which individual characteristics and tobacco policies determine smoking decisions. For example, women's smoking was not considered as socially acceptable until the 1960s and therefore older women have lower smoking rates. However, for the younger female cohorts (generations X and Y) smoking was seen as an act of rebellion and modernity, so women belonging to these groups, irrespective of educational level, are more likely to smoke.

CONCLUSIONS

The price of cigarettes and pictorial health warning labels on cigarette packets also influence the smoking behaviour of Spanish women.

The effects of residential proximity to bars on alcohol consumption

A person's decision to drink alcohol is potentially influenced by both price and availability of alcohol in the local area. This study uses longitudinal data from 1985 to 2001 to empirically assess the impact of distance from place of residence to bars on alcohol consumption in four large U.S. cities from 1985 to 2001. Density of bars within 0.5 km of a person's residence is associated with small increases in alcohol consumption as measured by: daily alcohol consumption (ml) drinks per week, and weekly consumption of beer, wine, and liquor. When person-specific fixed effects are included, the relationship between alcohol consumption and the number of bars within a 0.5 km radius of the person's place of residence disappears. Tests for endogeneity of the number of bars within the immediate vicinity of respondents' homes fail to reject the null hypothesis that the number of bars is exogenous. We conclude that bar density in the area surrounding the individuals' homes has at most a very small positive effect on alcohol consumption.

An overview of the emergence of disparities in smoking prevalence, cessation, and adverse consequences among women

This report reviews epidemiologic findings demonstrating the emergence of disparities in smoking prevalence against the backdrop of general declines in smoking over time among women in the United States. In addition to socioeconomic differences in overall smoking prevalence, this report examines evidence of emerging disparities for specific stages of smoking, including progression to heavy smoking, smoking cessation, and lung cancer mortality. Findings from population-based studies indicate that social disadvantage signals higher likelihood of involvement with each stage of smoking and the gap by level of disadvantage is increasing over time. Disparities in smoking outcomes have been observed for both men and women but in many cases appear to be greater for women. This pattern of results in which disparities emerge in a dynamic system of change in smoking are consistent with Link and Phelan's theory of social conditions as a fundamental cause of disease, and has important implications for approaches to reduce the public health burden of smoking.

Life course socioeconomic conditions, passive tobacco exposures and cigarette smoking in a multiethnic birth cohort of U.S. women

Low socioeconomic status (SES) and exposure to passive tobacco smoke are associated with increased risk of smoking in adults, but the influences of these factors in earlier life periods on adult smoking behavior are not well understood. We investigated the relationship of SES and passive tobacco exposure over the lifecourse with adult smoking status in a multiethnic cohort of U.S. women (n = 262, average age = 41.8), using prospective data on maternal smoking during pregnancy and childhood SES, and follow-up data on current smoking, adult SES and household tobacco exposure. Low adolescent and adult SES consistently increased the risk of current smoking, but most associations were not statistically significant in multivariable models. Blue collar parental occupation at birth increased the risk of smoking, particularly for current smoking relative to former smoking (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.2-5.9). After adjusting for SES, current and former smokers were more likely than never smokers to have exposures to prenatal tobacco (OR = 4.4, 95% CI = 2.1-9.4 and OR = 2.0, 95% CI = 1.0-4.2, respectively) and adult household tobacco (OR = 2.7, 95% CI = 1.3-5.8 and OR = 2.4, 95% CI = 1.2-4.8, respectively). Our results show that early life conditions have enduring influences on women's smoking behavior in middle adulthood, even after considering similar types of conditions in later life periods.

Socioeconomic and drug use determinants of smoking status in an urban adult population of Black African descent

We examined the influence of socioeconomics and drug use on current smokers (N = 137) and nonsmokers (N = 143) from an urban adult population of Black African descent. Median participant age was 33 years (range = 20-59). Smokers consumed a median of eight cigarettes/day (range = 0-35). Interestingly, 86% smoked fewer than 15 cigarettes/day and only 8% smoked menthol cigarettes. Socioeconomic and drug use variables significantly associated with smoking status in univariate analyses were included in a multiple logistic regression model that controlled for gender and age. Compared with nonsmokers, smokers were less likely to be university educated, more likely to be divorced, separated, or widowed, more likely to be current alcohol users, and more likely to be current marijuana users. Unexpectedly, household income and employment status were not associated with smoking status. Among current alcohol users, smokers consumed three times the number of drinks per month that nonsmokers consumed (p<.001). Among current marijuana users, smokers consumed more than five times the number of joints per month that nonsmokers consumed (p<.001). Overall, lower education levels, divorce, and alcohol and marijuana use were significantly associated with increased likelihood of smoking among this population.

Tobacco-use prevalence in special populations taking advantage of electronic medical records

BACKGROUND

It is difficult and expensive to use surveys to obtain the repeatable information that is needed to understand and monitor tobacco prevalence rates and to evaluate cessation interventions among various subgroups of the population. Therefore, the electronic medical record database of a large medical group in Minnesota was used to demonstrate the potential value of that approach to accomplish those goals.

METHODS

The relevant variables for all medical group patients aged 18 and over were extracted from the record from a 1-year period. Rates of smoking prevalence were computed for the entire population as well as for those with various characteristics and combinations of characteristics of interest to tobacco-cessation advocates. These prevalence rates were also adjusted to control for the other characteristics in the analysis.

RESULTS

From March 2006 to February 2007, there were 183,982 unique patients with at least one office visit with a clinician, and a record of their tobacco-use status (90%). Overall, 19.7% with recorded status were tobacco users during this year, as were 24.2% of those aged 18-24 years, 16.0% of pregnant women, 34.3% of those on Medicaid, 40.0% of American Indians, 9.5% of Asians, and 8.5% of those whose preferred language was other than English. Combining characteristics allowed greater understanding of those differences.

CONCLUSIONS

Although there are limitations in these data, the level of detail available for this large population and the ease of repeat analysis should greatly facilitate targeted interventions and evaluation of the impact.

Trends in smoking in Sweden from 1968 to 2002: age, period, and cohort patterns

OBJECTIVE

Smoking is related to many later life health outcomes. We examined age, period, and cohort patterns in smoking between 1968 and 2002.

METHODS

A nationally representative panel study allowed repeated cross-sectional comparisons of ages 18-75 (5 waves n approximately 5000), and ages 77+ at later waves (2 waves n approximately 500). Cross-sectional 10-year age group differences in 5 waves, time-lag differences between waves for age groups, and within-cohort differences between waves for 10-year birth cohorts were evaluated using graphs and ordered logistic regressions.

RESULTS

Age-period-cohort models suggested that period and age effects dominated smoking patterns, showing decreases over time and age. The 1935-44 and 1945-54 cohorts, however, showed lesser period decline. Moreover, men showed a period reduction of smoking rates but no age related decrease, while women showed an age related decrease but no period effect. The genders' cohort patterns were similar, with higher smoking rates in the last waves for some cohorts, for men the 1945-54 cohort and women the 1935-44 cohort.

CONCLUSIONS

Cross-sectional studies of cohorts must be aware of age effects. Due to the coming of age of the 1940s' cohorts smoking may increase among women in the oldest age groups.

The application of household expenditure data in the development of anti‐smoking campaigns

Purpose

Despite widespread anti‐smoking campaigns, prevalence and the consequent damage to the community remains high and are therefore of concern to health educators. Several studies have identified a clear socio‐economic status gradient in smoking prevalence. One purpose of this paper is to re‐examine this gradient to assist in the more accurate targeting of anti‐smoking campaigns. Another purpose of this paper is to examine the financial cost of smoking from a household perspective and also to compare survey data with data compiled by other means to test whether smokers are accurately reporting their smoking behaviour. This can assist in the refining of anti‐smoking message strategies.

Design/methodology/approach

Data from a large‐scale survey of Australian households – the Household Expenditure Survey – was analysed and compared with data from other sources to examine demographic correlates and self‐reported estimates of smoking behaviour.

Findings

Approximately one third of households reported expenditure on tobacco. Expenditure is more prevalent among households with a female head and among lower status occupations. Young people are continuing to take up smoking. Smoking households appear to underestimate their expenditure on tobacco by more than 40 percent.

Research limitations/implications

Data are drawn from households, not individuals; therefore exact estimations of smoking prevalence and individual smoking behaviour are not possible.

Originality/value

The findings provide important guidance for health educators developing anti‐smoking campaigns. The findings provide assistance in the development of targeting and message strategy guidelines.

Adolescent and young adult tobacco prevention and cessation: current status and future directions

OBJECTIVE

To summarise the evidence on adolescent and young adult prevention and cessation, and provide future directions for research.

DATA SOURCES

Data were collected from published literature. Searches for adolescent prevention were conducted using PubMed, PsycInfo, and ERIC; and for cessation, PubMed, and two major reviews that span January 1978 to May 2002. PubMed, PsychInfo, and SCCI were searched for young adults from January 1990 to May 2002.

STUDY SELECTION

Data included smoking prevention studies published from January 1990 to May 2002 and conducted in the USA; all identified smoking cessation studies for adolescents. Young adult data were limited to initiation and cessation studies.

DATA EXTRACTION

Extraction of data was by consensus of the authors.

DATA SYNTHESIS

Results of the review are qualitative in nature using a consensus approach of the authors.

CONCLUSIONS

School based curricula alone have been generally ineffective in the long term in preventing adolescents from initiating tobacco use but are effective when combined with other approaches such as media and smoke-free policies. Prevention research should consider multiple approaches and the social conditions that influence the development of youth problem behaviours including tobacco use. Because youth smoking cessation has been understudied to date, scientifically rigorous adolescent smoking cessation studies need to be conducted with attention to high risk smokers and less than daily smokers. Tobacco prevention and cessation for young adults needs focused attention. Prevention and cessation programmes need to address other tobacco products in addition to cigarettes.

Development of overweight associated with childbearing depends on smoking habit: The Coronary Artery Risk Development in Young Adults (CARDIA) Study

OBJECTIVE

To prospectively evaluate whether childbearing leads to development of overweight in women and to evaluate the role of other known risk factors.

RESEARCH METHODS AND PROCEDURES

A prospective, multicenter observational study, the Coronary Artery Risk Development in Young Adults (CARDIA) Study from 1986 to 1996, examined subjects at baseline and in follow-up years 2, 5, 7, and 10. Included were 998 (328 black and 670 white) nulliparous women, age 18-30 years, who were not overweight at baseline. Relative odds for incident overweight (BMI > or = 25 kg/m2) associated with parity change (0, 1, or 2+) and risk factors were estimated using discrete-time survival models adjusted for baseline and time-dependent covariates.

RESULTS

Parity change-association with development of overweight depended on smoking habit (interaction, p < 0.001). In multivariate adjusted models, 1 and 2+ births vs. 0, respectively, were associated with increased risk for development of overweight among never smokers [odds ratio (OR) = 2.66; 95% confidence interval (CI): 1.80, 3.93, and 2.10, 95% CI: 1.24, 3.56] and decreased risk among current smokers (OR = 0.41; 95% CI: 0.17, 0.96, and 0.36, 95% CI: 0.08, 1.65). Risk was increased for black vs. white race (OR = 3.49; 95% CI: 2.59, 4.69), frequent weight cycling (OR = 1.45; 95% CI: 1.03, 2.04), and high school education or less (OR = 2.21; 95% CI: 1.50, 3.26) and was decreased for highest physical activity quartile (OR = 0.62; 95% CI: 0.43, 0.90).

DISCUSSION

Childbearing contributes to development of overweight in nonsmokers but not in smokers, where development of overweight is less likely in women who bear children. Race, education, and behaviors are important factors in development of overweight in young women.

Disparities in smoking cessation between African Americans and Whites: 1990-2000

OBJECTIVES

We examined disparities in smoking cessation rates between African Americans and Whites from 1990 through 2000.

METHODS

We performed an analysis of smoking cessation with data from the National Health Interview Surveys of 30660 African Americans and 209828 Whites, 18 to 64 years old, with adjustment for covariates in multiple logistic regression models.

RESULTS

Whites were significantly more likely than African Americans to be former smokers, and this disparity in the quit ratio persisted from 1990 through 2000. After adjustment for covariates, disparities were substantially reduced especially among women. Among former smokers, African Americans were significantly more likely than Whites to have quit successfully within the past 10 years.

CONCLUSIONS

Statistical adjustment for covariates reduces African American-White disparities in quit ratios, and recent cessation patterns suggest possible future reductions in disparities.

Opportunities for oral cancer screening among older African-American women

BACKGROUND

Older persons with smoking histories are important targets for oral cancer screening. Although older persons in low-income communities often lack regular dental care, little is known about the characteristics of groups at greatest risk for poor screening.

METHODS

Survey data from 576 African-American women aged 45-93 were used to identify predictors of smoking and recency and type of dental care.

RESULTS

Fifty-nine percent of respondents were current or former smokers, and 62% reported dental care within the past 3 years. Among smokers, no recent dental care was associated with older age, worse health, not working, no regular medical provider, and no recent mammography.

CONCLUSIONS

These results suggest that episodic visits to non dentist providers offer opportunities for oral screening in high-risk populations.

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.

Reduction of primary and secondary smoke exposure for low-income black pregnant women

Cigarette smoking by women during pregnancy continues to be a substantial contributor to poor perinatal outcomes in the United States. Decreasing tobacco smoke exposure for women and children is a lifestyle change that will improve perinatal health. A study was conducted with a sample of 74 low-income black women to evaluate the effectiveness of the Smoke Free Families intervention in moving pregnant women forward in the stages of change toward becoming a non-smoker and reducing exposure to second-hand smoke. Transtheoretical model variables were measured at intake, postintervention, and during the last month of pregnancy. There were no statistically significant differences between treatment and control group in movement forward in the stages of change. The findings raise questions about the conceptual fit of the transtheoretical model with pregnant women. We discuss additional interventions and suggest types of studies that would provide new insight into tobacco exposure issues for pregnant women.

Oral contraceptive use and association with glucose, insulin, and diabetes in young adult women: the CARDIA Study. Coronary Artery Risk Development in Young Adults

OBJECTIVE

We studied the associations between 1) current use of oral contraceptives (OCs) and 2) glucose levels, insulin levels, and diabetes in young women.

RESEARCH DESIGN AND METHODS

Subjects were women (n = 1,940) in the Coronary Artery Risk Development in Young Adults (CARDIA) study, a prospective observational study of African-Americans and whites aged 18-30 years at enrollment in 1985-1986. We analyzed the cross-sectional associations between 1) current use of OCs and 2) fasting glucose, fasting insulin, and presence of diabetes using generalized estimating equations to adjust for repeated measures. We also examined the effect of current use of OCs on incident diabetes at year 10 of the study.

RESULTS

In unadjusted analyses, current use was associated with lower fasting glucose levels [-3.1 mg/dl, 95% CI (-3.7, -2.5)] and reduction in the odds of diabetes [odds ratio 0.56 (0.32, 0.97)], but not lower fasting insulin levels [-0.01 microU/ml (-0.03, 0.02)], compared with nonuse in both African-American and white women. After adjustment for covariates, current use of OCs was still associated with lower fasting glucose levels [-1.8 mg/dl (-2.4, -1.3)] and lower odds of diabetes [odds ratio 0.56 (0.33, 0.95)], although the associations were attenuated. After adjustment, current use of OCs was associated with higher insulin levels [0.12 microU/ml (0.006, 0.23)]. No association existed between pattern of use of OCs and incident diabetes at year 10, although the total number of new persons with diabetes at year 10 was small (n = 17).

CONCLUSIONS

Current use of OCs is associated with lower glucose levels in young African-American and white women and may be associated with lower odds of diabetes.

Ten-year changes in smoking among young adults: are racial differences explained by socioeconomic factors in the CARDIA study?

OBJECTIVES

This study investigated whether socioeconomic factors explain racial/ethnic differences in regular smoking initiation and cessation.

METHODS

Data were derived from the CARDIA study, a cohort of 5115 healthy adults aged 18 to 30 years at baseline (1985-1986) and recruited from the populations of 4 US cities. Respondents were followed over 10 years.

RESULTS

Among 3950 respondents reexamined in 1995-1996, 20% of Whites and 33% of African Americans were smokers, as compared with 25% and 32%, respectively, in 1985-1986. On average, African Americans were of lower socioeconomic status. Ten-year regular smoking initiation rates for African American women, White women, African American men, and White men were 7.1%, 3.5%, 13.2%, and 5.1%, respectively, and the corresponding cessation rates were 25%, 35.1%, 19.2%, and 31.3%. After adjustment for socioeconomic factors, most 95% confidence intervals of the odds ratios for regular smoking initiation and cessation in African Americans vs Whites included 1.

CONCLUSIONS

Less beneficial 10-year changes in smoking were observed in African Americans, but socioeconomic factors explained most of the racial disparity.

Cigarette use in adolescents: the Cardiovascular Health in Children and Youth Study

Tobacco is the leading cause of preventable death in the United States, and its use is increasing in adolescents. To determine the interventions needed to prevent the initiation of smoking, it is important to know the factors related to tobacco use by adolescents. In this study the following factors related to cigarette use were examined: age, gender, ethnicity, self-esteem, physical activity, parental smoking, and socioeconomic status. Participants were 1,207 youth completing a written survey for the Cardiovascular Health in Children and Youth Study (CHIC II). Participants ranged in age from 10 to 15 years, with a mean age of 12.2 years; 64.2% were White, 24.0% Black, 5.8% Hispanic, and 6.0% other races. White and Hispanic youth and youth of other races had significantly higher rates of smoking than did Black youth. Significant risk factors for smoking were: higher grade in school, White race, and for girls only, lower self-esteem. In White youth those in the lowest socioeconomic status were most likely to be current and experimental smokers. Smoking was as common in girls as in boys at these ages. Multivariate analysis showed that neither physical activity nor parental smoking were significant predictors of smoking behaviors. These results suggest that smoking prevention programs for adolescents should specifically target White and Hispanic youth and those from families with low socioeconomic status. In addition, these interventions should include ways to increase self-esteem in girls.