p,n,&kg Tobacco Use Among Young People onset in this study. McCaul et al. (1982) found no asso- ciation between boys' smoking and participation in ex- tracurricular activities. Among urban black femrales in ~~wic?k and Messeri's (1984) study, those who re p~ecl minimal concern about their health & those who reported a larger appetite were more likely ho begin sm&j.ng; in contrast, black males who had the greatest number of health-related activities and were of normal body weight were more likely to begin smoking than other black males (Brunswick and Messerr 1983). Sussman et al. (1993) found that among you& at the h$vst risk of smoking, those who did not smoke re- p&d that they valued their health. Finally, in Kelder's (19%) longitudmal study of secondary school ,-dents ~JI the north-centi United States, cigarette smoking was found to be related to poor food choices and less exercise after the eighth grade; the correlation betwm these behaviors was stronger with increasing age. Behaviord Skih The final set of behavioral factors comprises the tj&avion3l skills that are necessary to begin smoking tfme that are necessary to resist influences to smoke, and those that are necessary to cope with other social situations that might indirectly encourage cigarette use. Hahn et al. (1990) found that 42 percent of smoking expairnent~ had asked for their first cigarette- In the Sussman et al. (1987) study in southern California, diffi- culty in refusing offers to smoke predicted onset for all four ethnic groups, particularly for whites and blacks, for whom it was the strongest predictive factor found in the study. This difficulty in refusing an offered cigarette appears to be strongly influenced by the offering friend's attitudes and behaviors (e.g., being persistent or critical if refused), particularly for high-risk adolescents (Saiomon et al. 1984; Lawrance and Rubinson 1986; Reardon, Sussrnan, Flay 1989). Conrad, Flay, and Hill (1992) re- viewed three prospective studies and found that refusal or resistance skills against smoking were associated with lower rates of onset. Generally, cigarette use can be viewed as a coping mechanism-a skilled response designed to close the gap between an adolescent's current position and goals (Leventhal et al. 1991). Smoking serves as a coping response if it brings the adolescent closer to a valued goal, such as acceptance in a peer group. Smoking may also serve as a coping response to stress or &tress Wrlls and Shiffman 1985; Castro et al. 1987). These studies suggest that youth need more general social skills, such as being able to cope with various kinds of stress or social pmssures, to help them manage the many devel- opmental demands of adolescence (Franzkowiak 1987). A more comprehensive concept of skills that has been used in prevention efforts is discussed in Chapter 6 (see "lnstiUing Skills for Resisting Social Influences to Smoke" and "ExemplaryPmgrams for ResistingSocialInfluences"). Personal Factors in the Initiation of Smoking Personal factors are those that are inherent in the individual, they include cognitive processes, values, per- sonality constructs, and psychological well-being. These factors can be considered the personal filters through which so&demographic and environmental factors pass as they influence behavior. Personal risk factors also explain differences in behavior among individuals ex- posed to the same or simiIar environments. The per- sonal factors that have been examined in the research literature include levels of knowledge about the health consequences of smoking, the functions or meanings of cigarette use among adolescents, the subjective expected utility C3ELJl of smoking self-esteem, self-image, self- efficacy in refusing offers of cigarettes, personality vari- ables, and emotional well-being. Knowledge of Long-Term Health Consequences Knowledge of the long-term health consequences of smoking has not been a strong predictor of adolescent onset (Collins et al. 1987; Krohn, Naughton, tiuer 1987; Sussman et al. 1987; Conrad, Play, Hill 1992; Royal Col- lege of Physicians of London 1992), perhaps because virtually all U.S. adolescents--smokers and nonsmokers alike-are aware of the long-term health effects of smok- ing and because many adolescents feel inherently invul- nerable in their characteristically short-term view (Gerber and Newman 1989). Belief that smoking has short-term effects on health appears to be a more powerful influence than knowledge of long-term health effects (Krohn, Naughton, Lauer 1987; McNeill et al. 1988). Similarly, belief in personally relevant nega live social consequences of smoking has been associated with a dechne in smok- ing prevalence among secondary school students (Chassin et al. 1987). Botvin et al. (1992) found that lack of concern about the harmful effeds of smoking was associated with intentions to smoke among young, inner-city black adolescents. Similarly, dismissing or rnhimizing the health consequences of smoking has been associated with both initiation of cigarette use and adult smoking levels Wittelmark et al. 1987; Swan, Creeser, Murray 1990). Krohn, Naughton, and Lauer (1987) found that smoking behavior predict& beliefs about the health effects of smoking more than beliefs predicted future cigarette use. Knowledge of the health consequences of smoking may or may not deter some adolescents from begiming to smoke; beginning to smoke appears to ac- centuate adolescents' denial of the health consequences. Psychosocial Risk Factors 101 Surgeon General's Report Functional Meanings of Adolescent Smoking The question of why adolescents begin to smoke has led to multiple examinations of the meanings of cigarette use, the utility of smoking, and the functions that smoking serves in an adolescent's life (Leventhal and Clear-y 1980; Perry, Murray, Klepp 1987). Examin- ing smoking from the perspective of the adolescent is a departure from viewing the onset of smoking exclu- sively as a response to the social environment or as capricious, arbitrary behavior. Since knowledge of the harmful consequences of cigarettes does not appear to deter onset, researchers are examining the social reasons and purposes of smoking. Adolescents who begin to smoke perceive a more functional purpose of smoking than those who are nonsmokers (Gerber and Newman 1989). Adolescent smokers are more likely to view smoking as a way to act mature, be accepted by a peer group, have fun, cope with personal problems and boredom, or be rebellious (Perry, Murray, Klepp 1987). Cigarette smoking has also been shown to be a coping behavior for adolescents who are dealing with disruptive and stressful family events (Castro et al. 1987). Hunter et al. (1987) found that adolescent smokers were significantly more likely than nonsmokers to believe that smoking has psychological and physiological benefits. They were also less likely to believe that others smoked for negative reasons, such as to "show off." In the research of Hahn et al. (1990), regular smok- ers were asked why they first had tried cigarettes arrd why they had most recently smoked. Sixty percent re ported that curiosity was the reason for their first try, 13 percent said that they wanted to fit in with a group, and 10 percent reported that they were pressured into it. For most recent use, 27 percent reported that they smoked for pleasure, 20 percent out of dependence, 17 percent because they were curious, and 10 percent to fit in with the group. These findings are consistent with Chassin et al. (19841, who suggest that positive attitudes toward smoking, such as the idea that smoking is fun or pleasur- abIe, are a better predictor of the transition to regular smoking than they are for first experimentation. In gen- eral, these investigators found that positive attitudes to- ward smoking may increase as a function of age. Botvin, Botvin, and Baker (1983) found that independent of the smoking status of friends, students in the eighth grade (13- and 14-year-olds) were more likely to have a posi- tive social image of smoking than students in the seventh grade (ll- and 12-year-olds). Subjective Expected Utility Carolina. SEU is defined as the extent to which an individual expects the overall consequences of a behav- ior, such as smoking, to be positive or negative. Fishbein (1980) found that behavioral intentions to smoke were related to whether more positive or negative conse quences were expected from smoking. SEU was found to be predictive of the onset of smoking over a one-year interval and of increased smoking levels among baseline smokers (Bauman et al. 1984). In a second study, SEU was found to be mediated by the adolescent's perception of personal control; current smokers with the highest scores for internal locus of control (that is, the belief that they have control over what occurs to them) were more likely to have been influenced by SEU Wunan and Fisher 1985). Therefore, regular smoking appears more likely to be motivated by internal processes than are initiation and trying, which may primarily be products of exposure to a high-risk social environment. Self-Esteem The process of individuation and identity forma- tion is inherent to adolescence. The adolescent's sense of self evolves as she or he interacts with parents, school, and peers and considers options for the future. Self- esteem, or an individual's qualitative self-evaluation, emerges from these contexts (Young and Werch 1990). In several studies, the onset of smoking has been associ- ated with lower self-esteem. Young and Wench (1990) found that young nonsmokers and those with no inten- tion of smoking in the future had higher self-esteem relative to family, school, and peers than frequent users or those who intended to use in the future. Ahlgren et al. (1982) found that low self-esteem within family or school contexts was associated with initiation and continuance of smoking. Self-esteem concerning school predicted intentions to smoke among young, inner-city black ado- lescents (Botvin et al. 1992) but did not predict actual smoking. Stacy et al. (1992) found that general low self- esteem directly predicted smoking onset in a multiracial, southern California sample yet did not significantly mediate friends' social influences. In their review of prospective research, Conrad, Flay, and Hill (1992) conclude, "Self-esteem received fairly consistent support [as a predictor of initiation] from the reviewed longitudi- nal studies. This is better than we would have ex- pected from our reading of previous cross-sectional studies" (p. 20). Self-Image Some adolescents may smoke cigarettes to enhance their low self-esteem by improving their external im- Bauman et al. (1984) have examined the SEU of smoking for adolescents in a longitudinal study in North d I age-that is, by appearing mature & "cool." Smoking onset was seen as a way to improve self-image among 102 Psychosocial Risk Factors preventing Tobacco Use Among Young People whites, blacks, and Hispanics in southern California (Sussman et al. 1987). Role models who smoke am frequently seen to have socially desirable attributes- they seem tough, sociable, and sexually attractive (Chassin, Presson, Sherman 1990). Adolescents who believe that smoking bestows these attributes may see smoking as a powerful mechanism for self-enhancement. These young people may experiment with smoking to try to adopt a perceived positive social image and thereby improve the way others, particularly peers, view them (Chassin, Presson, Sherman 1990; Leventhal et al. 1991). If peers respond favorably to this strategy, these new young smokers may continue to smoke, since the behav- ior has proved functional for them in creating an accept- able self-image. Self-Efficacy An individual's efficacy (or confidence) in perform- ing specified skills and behaviors is a significant media- tor of peer influences to smoke (Bandura 1986). Ellickson and Hays (1990-91) found that low self-efficacy, as mea- sured on a scale of having little or much confidence in resisting offers of drugs, was associated with drug use, including smoking. DeVries, Kok, and Dijkstra (1990) found that self-efficacy in resisting offers to smoke was the best predictor of smoking among adolescents in the Netherlands over a oneyear interval. Similarly, Lawrance and Rubinson (1986) found that young adolescents' per- ceptions of their ability to resist cigarette smoking corre- sponded to their self-reported smoking. Finally, Stacy et al. (1992) found in their cross-sectional study of high school students not only that low self-efficacy in resisting social influence was a significant predictor of smoking but also that high self-efficacy was the only significant mediator of friends' social influences on smoking. There fore, self-efficacy, a personal factor, appears to act as a buffer that protects adolescents from potent peer influ- ences to smoke (Conrad, Flay, Hill 1992). Personality Factors The research on personal factors has also examined many personality factors for their association with onset, in part to assess whether underlying emotional or psycho- logical problems predict adolescent smoking. Personality characteristics that are related to deficiencies in self- control, such as impulsiveness and sensation-seeking tendencies, are important and were discussed earlier in this chapter in connection with behavioral factors. Psychological Well-Being Several studies have associated cigarette smoking and symptoms of depression among adolescents. Covey and Tam (1990) showed an independent relation of depressive mood, friends' smoking behavior, and living in a single-parent home with cigarette smoking among 205 urban 11th~grade males and females. Depression scores correlated with the number of cigarettes smoked. Malkin and Allen (1980) found a significant association between smoking and depression among males in a study of 229 rural Bth- and 11 th-grade students, a fmding that was replicated for both genders by Kaplan et al. (1984). Stein, Newcomb, and Bentler (unpublished data) found that cigarette use was positively associated with being extroverted and negatively associated with having symptoms of depression among junior high school stu- dents in Los Angeles. Cigarette use, however, signifi- cantly predicted symptoms of depression in these young people four and eight years later (Newcomb, McCarthy, Bentler 1989). These findings may reflect the addictive quality of tobacco use beyond the earliest experimental states and the relationship between smoking and de- pression, since depression is a personality factor that usually persists over time. Smoking might be a short- term, self-medicating response to symptoms associated with depression. In the long-term, however, this effect would diminis h; as tolerance to nicotine increases, the possible antidepressant effects of smoking (such as alert- ness, euphoria, and calm) dissipate (Newcomb, M&Whey, Bentler 1989). Similarly, Leventhal, Fleming, and Glynn (1988) found that reported feelings of help lessness were associated with more rapid movement to a second and third experiment with smoking; however, these feelings were not related to the initial experimenta- tion. The association of smoking and suicide attempts, another clearly serious symptom of depression, is pre- sented in Chapter 3 (see "Cigarette Smoking and Other Health-Related Behaviors"). Flay (1993) suggests that symptoms of depression may be a response to distress associated with stress and poor family bonding. He points out that stress and distress have been associated with drug use, including tobacco use (Wills and Shiffman 1985). The research of Kellam, Ensminger, and Simon (1980) suggests that this cycle may begin early in life. In their study of first-graders (aged five through seven) in Chicago, they found that males rated by observers as aggressive or as alternately shy and aggressive had the highest rate of drug use, including cigarette use, 10 years later; no long-term psy- chological predictors were found for females. In another study (Brunswick and Messeri 19841, adolescent males were more likely to begin smoking if they were peSSMS- bc about the likelihood of the world becoming any better or if they held low expectations for their own future; for adolescent females, a shortened time perspective (i.e., a Psychosocial Risk Factors 103 Surgeon General's Rep-t limited ability to conceptualize their future) was the most important psychogenic predictor of initiation. Adolescent Smoking Behavior as a Risk Factor for Subsequent Smoking Intentions to Smoke Since intentions are viewed as proximal to perfor- mance, the research on smoking behavior as a predictive factor of smoking includes behavioral intentions to smoke. In several studies, intentions to smoke have been associ- ated with both the onset and continuation of smoking. Sussman et al. (1987) found in their longitudinal study in southern California that the intention to start smoking was one of 0nIy three factors that predicted onset among all ethnic groups. McNeill et al. (3988) found that future intentions to smoke increased the odds of starting to smoke by a factor of 244 and was the strongest predictor. of change in smoking status after current behavior (hav- ing tried smoking) and gender were entered into the analysis. In the Chassin et al. (1984) longitudinal study, behavioral intentions were "significant predictors of fu- ture smoking transition in all subgroups, accounting for between 1.9 percent and 10.2 percent of the variance in transition. . . . In fact, behavioral intentions were typi- cally the most important single predictor of future tran- sition" (p. 237). Intentions to smoke appear to be a particularly strong predictor of future smoking for those who have already tried smoking. Shean (1991) found that inten-' tions to smoke a "next cigarette" among 14-year-old Western Australians predicted smoking eight years later. Conrad, Flay, and Hill (1992) found that in eight of nine prospective studies of young adolescents, the intention to smoke was significantly associated with onset. Be cause of the strength of this association, severat reseamh- ers have used intentions to smoke as an outcome measure in their studies, especially in populations (such as p* adolescents) where smoking prevalence is low relative to adolescents' intentions to smoke. Intentions to begin smoking seem a much more reliable predictor of future behavior than do intentions to quit smoking (see "Adult Implications of Adolescent Smoking" in Chapter 3). Present Smoking Status Any cigarette use places an adolescent at higher risk for subsequent use and for further progression through the stages of smoking behavior. Conrad, Flay, and Hill (1992) document seven prospective studies in which prior experience with, or exposure to, smoking predicted tobacco use. McNeill et al. (1988) found that the act of having tried smoking was the most predictive factor in initiation and that it more than quadrupled their study participants' odds of taking up smoking. Collins et al. (1987) found that prior smoking behavior was the most important predictor of future smoking over a 2.5- year interval. Even though the physiological effects of the fust tries are mostly adverse (unpleasant taste, cough- ing headache, nausea, dizziness) (Hahn et al. 19901, those who persist report incmasingiy positive reactions (pleas- ant taste, euphoria, alertness, relaxation, curbing of ap petite) and develop tolerance (experience fewer unpleasant sensations) (Flay 1993). Stein, Newcomb, and Bentler (unpublished data) reported a more estab- lished pattern of cigarette use among young adults than among adolescents. In their study, the standardized regression coefficient of prior smoking for smoking be- havior between Year 1 and Year 5 (youth in junior high and high school age groups) was 0.43, yet from Year 9 to Year 13 (young adulthood) it was 0.82. The authors suggest that in early adolescence, some cigarette triers never fully develop a pattern of smoking but by late adolescence, the addictive properties of cigarette use figure prominently in behavior formation. These find- ings underscore the need for antismoking efforts to focus on preventing initial tries, on discouraging transitions to more regular smoking, and on encouraging early cessa- tion (Leventhal, Fleming, Glynn 1988; Kelder 1992). Summary of Psychosocial Risk Factors for Cigarette Smoking Some clear convergence of research findings emerges from this review, a summary of which is high- lighted in Table 1. Table 3 provides a second summary of supportive and unsupportive findings from the Conrad, Play, and Hill (1992) review of 27 prospective studies; for the most part, this summary table is consis- tent with Table 1. Among the so&demographic factors, age is the risk factor consistently linked with onset in early adolescence; ages 11 through 15 (seventh through ninth grades) am the peak age group for first trial and experimentation. Cigarette smoking clearly has social meanings that are attractive to many young and vuhter- able identityseeking adolescents. This age factor is even more pronounced when linked with SES, another im- portant so&demographic risk factor for smoking onset. Altema tive health-enhancing avenues for independence and identity may be less readily available to adolescents from lower SES families, especially those adolescents who live in a single-parent home. Limited by fewer opportunities for healthy development and parental su- pervision, lower-SES youth are generally at greater risk to begin smoking. The gender difference, another major factor, is no longer evident, although the meanings of 104 Psychosocial Risk Factors preventing Tobacco Use Among Young People cigarette use and the pathways to regular use may vary by gender. Finally, differences by ethnic group do not appear to show a consistent pattern across communities, particularly when income level and cigarette availability are considered. The review of so&demographic factors thus concludes that a young adolescent from a low-SES family is at highest risk to begin smoking. Proximal environmental factors, such as the influ- ence of peers, friends, and siblings, play a powerful role in the initiation of adolescent smoking. Smoking initia- tion appears to be a component of peer associations and peer bonding in adolescence, as peer groups establish shared behaviors to differentiate themselves from other adolescents and from adults. Adolescents usually try their first cigarettes with their peers; peer groups may subsequently provide expectations, reinforcement, and opportunities for continuation. The influence of peers seems to be particularly potent in the stages of smoking that precede regular use; in later stages, personal and pharmacological factors appear to predominate. Data on the influence of parental smoking are not as compelling as those on peer influence; only about half of the prospective studies show a clear predictive rela- tionship. The influence of parental smoking appears to be strongest for whites and females, particularly in the early stages of smoking onset. This review suggests that parental influence might include other important fac- tors, such as parents' approval or disapproval of smok- ing, their involvement in freetime supervision, their manner and extent of communication on health-related matters, or their promotion or nonpromotion of aca- demic achievement for their children. Lastly, young people are exposed not only to role models but also to the consequences of the behavior of these role models; having a parent who smokes might even serve to deter an adolescent from smoking if the parent is struggling with cessation or displays the health consequences of tobacco use. How adolescents perceive their social environment also influences their smoking behavior. Adolescents overestimate the number of young people and adults who smoke, and those with the highest estimates are more likely to become smokers. In addition, young people are more likely to smoke if they feel that their peers approve of smoking, and particularly if adults do not seem to disapprove. In each of these cases, the perceived environment could accurately reflect the ac- tual environment. Those who begin to smoke may actu- ally be exposed to more role models who smoke, more peers who approve of smoking, and fewer adults who disapprove than those who never begin to smoke. Families in which parents are considered to be generally concerned and supportive, or in which the children are involved in family decisions, are home environments in which adolescents are less at risk for smoking initiation. Parental strictness and parental approval or disapproval of smoking have indirectly and inconsistently predicted initiation and are there- fore less influential on adolescent smoking behavior than the general family environment. The research on parental skills in coping with adolescent smoking is limited and warrants further investigation. The behavioral factors examined were consistently associated with the initiation of cigarette smoking. Pat- terns of behavior that are associated with smoking in- clude alcohol and drug use, risk-taking and rebellious actions, and involvement in peer groups in early adoles- cence. Patterns of behavior that are associated with les`s risk of smoking include academic achievement, involve- ment in sports (for females), hea$hy eating and physical activity patterns, and the ability to resist offers of ciga- rettes. Thus, encouraging and providing opportunities for health-enhancing activities and academic achieve- ment might, by fulfilling some of the needs that smoking apparently meets for adolescents, prevent some young people from trying their first cigarette. The personal factors-those most proximal to the individual and to the immediate decision to smoke a cigarette-reflect, in part, the adolescent's intemaliza- tion of the social environment. An adolescent's knowl- edge of the health consequences of smoking is a poor predictor of subsequent cigarette use, although smoking risks that are personalized appear to be important. More significant predictors include the meanings, the perceived positive functions, and the expected utility of cigarette use. These aspects are linked to having a positive social image, bonding with peers, and being "mature'`-all of which are particularly socially relevant for adolescents. Compared with nonsmoking adolescents, those who begin to smoke appear to have lower self-images and lower self-esteem; for them, smoking becomes a self- enhancement mechanism. Similarly, self-efficacy toward avoiding cigarettes seems particularly linked with the ability to resist cigarette offers from peers. Of the person- ality variables, symptoms of depression, helplessness, aggression, pessimism, and a limited ability to conceptu- alize the future were all found to be smoking-predictive in a small number of studies. The most predictive per- sonal factors were those linked to the social environ- ment, to peers, and to the meanings of cigarette smoking learned in youth. Intentions to smoke and prior experimentation with cigarettes strongly predict subsequent smoking. The adverse physiological reactions to first tries at smoking wane with repetition, and tolerance levels to nicotine increase. Adolescents who smoke are more likely than nonsmokers to discount the negative health consequences of smoking, report positive functions of smoking, and Psychosocial Risk Factors 105 Surgeon General's Report perceive that their peers are smokers. The shift from social to more personaI reasons for smoking is associated with increasing nicotine dependence and addiction. Several other factors that influence smoking initiation are not covered in this chapter. First, the com- bined influence of tobacco advertising and promotion represents a powerful environmental risk factor (see Chapter 5). Second, cultural or community-level re- search on the causes of smoking onset is decidedly lim- ited. In particular, the effect of taxation, of restrictions to public smoking, of vending machine regulations, and of limiting access to tobacco for underage buyers needs to be addressed prospectively (Chapman and Bloch 1992; Sweanor et al. 1992; see Chapter 6). Third, even at the school level, smoking prevalence rates have been shown to be partly attributable to attendance at a particular school and to school smoking policies (Best et al. 1984; Semmer, Lippert, et al. 1987; Penk et al. 1989; Santi et al. Initiation of Smokeless Tobacco Use 1990-91; see "Smoking Restrictions in the School" in Chapter 6). Still, which aspects of schools contribute to smoking onset-whether their rules, consistency of rule enforcement, grade structure, or discipline procedures- need to be studied. These distal environmental factors partly determine the meaning for, and acceptability of, cigarette use at a community level, determine the ease or difficulty with -which adolescents can obtain tobacco, and reinforce or inhibit the continuation of use into adult- hood. Proximal factors are strong determinants of use once the meaning of-smoking is established and access to cigarettes is possible. Therefore, the more distal risk factors might be considered the proper targets of in- tervention research efforts, which should test the po- tency of these factors and provide the clear community-level message that cigarette smoking among the young is unacceptable. Compared with the research literature on smoking initiation, the knowledge base on smokeless tobacco initiation is modest. Far fewer longitudinal stud- ies have been conducted. For the most part, research efforts on smokeless tobacco have been crosssectional; a few have also been guided by behavioral theory. None- theless, a number of methodologically sound studies provide knowledgeabout the risk factors associated with the initiation of smokeless tobacco use. In parallel with the research on cigarette smoking among young people, sociodemographic, environmental, behavioral, and per- sonal factors have all been explored as correlates of smoke less tobacco use. With only a few exceptions, the consistency of the findings with those found for cigarette smoking suggests that both smoking and the use of smokeless tobacco products share a common causality as well as similar fmctions and meanings for young people. Sociodemographic Factors in the Initiation of Smokeless Tobacco Use National survey data on the demographics of smokeless tobacco Use are presented in detail in Chapter 3 (see "Recent Patterns of Smokeless Tobacco Use") and are only summa rind here. These data clearly indicate that smokeless tobacco use among young people is par- ticularly prevalent among non-Hispanic white males. The three youth surveys that assessed smokeless tobacco prevalence (that is, use during the month preceding the survey) also found that males were 10 to 15 times more likely than females to use smokeless tobacco. Although nationally representative data on American Indian and Alaskan Native youth are not available, community- level studies of these populations have xqorted high rates of weekly smokeless tobacco use among both males (43 percent) and females (34 percent), even at very young ages (Schinke et al. 1987,1989; Bruerd 1990). The Monitoring the Future Project survey, a na- tional survey of high school seniors, indiated that 54 percent of males had used smokeless tobacco. Among those, 23 percent first used smokeless tobacco before or during the sixth grade, and over 53 percent first used it before or during the eighth grade (see "Grade When Smokeless Tobacco Use Beg%&' in Chapter 3). Data from a number of other recent surveys suggest that early adolescence is the peak age for first using smokeless tobacco (Schaefer et al. 1985; US Department of Health and Human Services IUSDHHSI 1986; Ary, Lichtenstein, Severson 1987; Ary et al. 1989; Riley, Barenie, Myers 1989; Brownson et aL 1990; Riley et al. 1990,1991). Limited evidence suggests that the following so&demographic factors may also be related to higher rates of smokeless tobacco use among youth: one or no parenk in the household (Jones and Moberg 1988; Murray et al. 1988; see "So&demographic Risk Factors for 106 Psychosocial Risk Factors Prevedng Tobacco Use Among Young People Smokeless Tobacco Use" in Chapter 3); lower parental education (Bauman, Koch, Lenk 1989; Botvin, Baker, To&u 1989); blue-collar parental occupation (Burke et al. 1989; Elder, Molgaard, Gresham 1988; Novotny et al. 1989); and rural environment (Olds 1988; botvin, baker, Tortu 1989; Rouse 1989; Lisnerski et al. 1991; see "So&demographic Risk Factors for Smokeless Tobacco Use" in Chapter 3). As is reported in Chapter 3 (see "Current Use of Smokeless Tobacco"), prevalence varies among regions and is somewhat lower in the Northeast than in other regions. Environmental Factors in the Initiation of Smokeless Tobacco Use Factors That Influence Acceptability and Availability Ease of access to smokeless tobacco appears to be an important factor in initiation, and young people seem to have little trouble obtaining smokeless tobacco (USDHHS 1992a, CDC 1993). In interviews conducted by the Office of Inspector General WSDHHS 1986),90 percent of smokeless tobacco users in junior and senior high school reported that they purchased their own smokeless tobacco; 94 percent reported that although they were minors, it was either never or only rarely difficult for them to purchase smokeless tobacco. Conve- nience stores were the most frequent purchase site (55 percent); supermarkets and grocery stores accounted for an additional 33 percent of sales. barovich et al. W9.l) found that 50 percent of store personnel were willing to sell to minors. In another study (Leopardi et al. 19891, junior high school students reported that their leading sources of smokeless tobacco were friends (43 percent) and direct store purchase (30 percent); senior high school students' chief sources were direct purchase (62 percent) and friends (25 percent). In a recent study in Texas, minors successfully purchased smokeless tobacco in 59 percent of stores selling the product (CDC 1993). Interpersonal Factors Parental Use As in the research on cigarette smoking, the evi- dence depicts either a modestly positive or no significant association between parental use of smokeless tobacco and adolescent use. The only prospective study that examined parental use found no link to onset or contin- ued use of smokeless tobacco among youth (Ary, Lichtenstein, Severson 1987). However, several cross- sectional studies have reported significant relationships between concurrent use by parents and youth (Cohen et al. 1987; Hall and Dexter 1988; Colbom, Cummings, Michalek 1989; Glover et al. 1989; Brownson et al. 1990). Bauman, Koch, and Lentz (1989) found that an adoles- cent was more likely to use smokeless tobacco if the father did, although there was an interaction with the level of the father's education. Two cross-sectional stud- ies found no significant association between con- current use of.smokeless tobacco by parents and adoles- cent offspring (Chassin et al. 1985; Ary, Lichtenstein, Severson 1987). Sibling Use The evidence from cross-sectional studies gener- ally supports a relationship between a sibling's use of smokeless tobacco and an adolescent's use. However, one prospective study did not fjnd significant sibling relationships (Ary, Lichtenstein, Severson 1987), and an- other study found no effect for "older family members" (Chassin et al. 1985). The sole longitudinal study did not find that sibling use was related to adolescent onset (Ary, Lichtenstein, Severson 1987). Peer Use Although a substantial amount of cross-sectional research has examined the use of smokeless tobacco by peers, only two longitudinal studies have been pub lished. Every cross-sectional study found that peer use was significantly related to adolescent use (Cohen et al. 1987; Hall and Dexter 1988; Lucas and Christen 1988; Glover et al. 1989; Leopardi et al. 1989; Riley, Barenie, Myers 1989; Brownson et al. 1990, Hunter, Vizelberg, berenson 1991). Peer use of smokeless tobacco was related to the onset of adolescent use at the 9-month follow-up in one longitudinal study (Ary et al. 1989) but not in another study (Ary 1989) at the 6- and K&month follow-up times. However, peer use was found to be related to continued use among initial daily users of smokeless tobacco at 6, 9-, and 12-month follow-ups (Ax-y, Lichtenstein, Severson 1987; Ary 1989). Perceived Environmental Factors Norms Current evidence indicates that most adolescents who use smokeless tobacco perceive that this behavior is socially acceptable. The Office of Inspector General (USDHHS 1986) reported the following findings from a survey of male adolescents who used smokeless to- bacco: o 86 percent perceived that most or some students at their school approved of smokeless tobacco use. Psychosocial Risk Factors 107 o 98 percent said their best male friends either approved of, or were neutral toward, their smokeless tobacco use. o 93 percent said their parents knew of their smokeless tobacco use. o 68 percent said their fathers and 45 percent said their mothers approved of, or were neutral toward, their smokeless tobacco use; o 91 percent said their brothers and 71 percent said their sisiers either approved of, or were neutral toward, their smokeless tobacco use. 87 percent listed their home as a setting where they regularly used smokeless tobacco. 43 percent whose dentist knew of their use were not advised by that professional to quit. 51 percent said their coaches either approved of, or were neutral toward, their smokeless tobacco use. These findings were replicated in the 1992 Office of the Inspector General study on Spit Tobacco and Youth (USDHHS 1992b). The adolescents in this study who used smokeless tobacco said that the greatest influences on their trying smokeless tobacco were peer pressure and other family members' use. The majority of these young users felt their parents would agree that their using smokeless tobacco was preferable to smoking ciga- rettes (USDHHS 1992b). In another study, only 14 percent of smokeless tobacco users reported that their father disapproved of their smokeless tobacco use, whereas 60 percent said their mother disapproved (Marty, McDermott, Williams 1986). WilIiams et al. (1986) found that 55 percent of smokeless tobacco users indicated that their parents dis- approved of their use. in a study by Ary et al. (19891, only 13 percent of daily smokeless tobacco users re- ported that their dentist had said anything to them about their use. Brubaker and Loftin (1987) found that smokeless tobacco users reported greater peer accep- tance of, and less parental opposition to, their use than did nonusers. Social Support Chassin, Presson, and Sherman (1988) examined the relationship between family social support and current use of smokeless tobacco. Three cross-sectional analyses found no pattern of relationships between smokeless to- bacco use and perceived parental expectations (for success or academic accomplishment), parental supportiveness, Surgeon Generals Repott parental strictness, agreement between parents, parent- peer agreement, or the adolescent's reported motivation to comply with parents. Similarly, two sets of analyses examining one-year prediction of smokeless tobacco on- set found no statistically significant effects for the same set of factors, although the statisti& Rower to detect such effects was minimal because the sample contained few cases of smokeless tobacco onset. Parental Reaction to Smokeless Tobacco Use Parents appear to be more accepting of smokeless tobacco use than of cigarette smoking. About 40 percent of high school smokers reported that their parents knew about their smoking, whereas smokeless tobacco users reported that 71 percent of their iarents knew of their use (Chassin et al. 1985). Similarly, young people who did not use tobacco reported that their parents and peers were more accepting of smokeless tobacco use than of smoking (Chassin et al. 1985; Ary et al. 1989). These findings suggest that adolescents may begin using smoke- less tobacco partly because they perceive that it is less deviant than smoking or other drug use and therefore is more likely to be accepted by their peers and parents (Hahn et al. 1990). Some research evidence indicates that the antici- pated parental response to an adolescent's use of smoke less tobacco is related to that youth's likelihood of using smokeless tobacco. Riley, Barenie, and Myers (1989) found that high school students' anticipation of their parents' response was highly predictive of the first trial of smokeless tobacco and of the level of continued use. Brubaker and Loftin (1987) found that adolescents who did not currently use smokeless tobacco but who intended to become users reported that it would be unlikely that their parents would respond by taking away their privileges, reprimanding them, becoming an- gry, expressing disappointment, or prohibiting them from continued use. These youth also reported that it was likely that their parents would ignore their smokeless tobacco use. Behavioral Factors in the Initiation of Smokeless Tobacco Use Academic Achievement For males, smokeless tobacco use was related to poor academic performance (Jones and Moberg 1988) and to a low grade point average (Brownson et al. 1990). The NIDA national household survey indicated that for males, the prevalence of daily use of smokeless tobacco was highest among school dropouts (13 percent) and lowest among college students (6 percent) (Rouse 1989). 108 Psychosocial Risk Factors Proven ting Tobacco Use Among Young People Smoking as a Risk Factor for Smokeless Tobacco Five longitudinal studies examined the prospec- tive relationships between cigarette smoking and the onset or continued use of smokeless tobacco Wy, Lichtenstein, Severson 1987; Dent et al. 1987; Murray et al. 1988; Ary 1989; Sussman et al. 1989). (The relation- ship between smokeless tobacco use and subsequent cigarette smoking is reviewed later in this chapter.) In a longitudinal study of eighth graders, Dent et al. (1987) reported that smoking status at baseline predicted the onset of smokeless tobacco use one year later. Twenty- nine percent of regular smokers at baseline-but only 6 percent of those who had never smoked-reported smokeless tobacco onset at follow-up. Ary, Lichtenstein, and Severson (1987) used disaiminant analysis to iden- tify predictors of the onset of smokeless tobacco use nine months after smoking onset among 7th,9th, and 10th graders. The disaim&nt function accounted for .11 percent of the variance, and having tied smoking was an important predictor, correlating at 0.64 with the dis- aiminant function. Jn a similar study using a separate sample of 7th, 9th, and 10th graders in Oregon, smoking did not significantly predict smokeless tobacco onset at 6-month or 12-month follow-ups (Ary 1989). Another longitudinal study found general support for the influ- ence of smoking on seventh graders who had tried smoke less tobacco (Murray et al. 1988). Longitudinal analysis of one-year follow-up data from two other samples of seventh graders indicated that both males and females exhibited a fairly consistent relationship between, the onset of smokeless tobacco use and pretest smoking thsman et al. 1989). Three of the longitudinal studies cited above also examined the prospective relationship between cigarette smoking and continued use of smokeless tobacco among adolescents. Ary, Lichtenstein, and Severson (1987) found that baseline smoking did not predict frequency of later smokeless tobacco use at nine-month foIlow-up. In a separate study, Ary (1989) examined these relationships and found that frequency of smoking was related to continued daily smokeless tobacco use at 1Zmonth follow-up but not at 6month follow-up. A 24month follow-up study of ninth graders also found general support for the infhrence of smoking on later use of smokeless tobacco (Murray et al. 1988). Although the findings from these thr& prospective studies are incon- clusive, numerous studies `&port significant concurrent relationships between smoking and smokeless tobacco use. The degree of statistical power exhibited by these relationships varied widely, but every study found at least one significant association between smokeless to- bacco use and smoking. Other Adolescent Behaviors Twelve studies fairly consistently indicated that smokeless tobacco use is related to concurrent use of alcohol and marijuana Whtenstein et al. 1984; Ary, Lichtenstein, Severson 1987; Burke et al. 1988,1989; Jones and Moberg 1988; Murray et al. 1988; Ary 1989; Riley, Barenie, Myers 1989; Rouse 1989; Sussman et al. 1989; Riley et al. 1991; Stevens et al. 1991). One of these studies CGssman et al. 1989) found that seventh- and eighth- grade females showed no relationship between having tried smokeless tobacco and concurrently using alcohol, but two of four samples with male subjects showed significant relationships. Only three studies examined the prospective relationships between smokeless to- bacco use and the use of alcohol and marijuana. In one study, the onset of smokeless tobacco use among those who had not used at baseline was related to marijuana use but not to alcohol use (Ary, Lichtenstein, Sever-son 1987). In a separate study, initial use of alcohol or mari- jrtana did not predict onset of smokeless tobacco use at 6- month follow-up, but initial alcohol use predicted smokeless tobacco use at 12-month follow-up (Ary 1989). In another 1Zmonth longitudinal study, onset of smoke less tobacco use among those who at baseline had never used smokeless tobacco was predicted by initial alcohol use in one of two samples of seventh-grade females but not in two samples of males (Sussrnan et al. 1989). Taken together, there is some evidence that prior use of either alcohol or marijuana is related to subsequent onset of smokeless tobacco use and to continued useof smokeless tobacco among daily users. Several studies suggest that adolescents who use smokeless tobacco are more likely to use multiple drugs than are adolescents who do not use smokeless tobacco. Ary, Lichtenstein, and Severson (1987) found that among male adolescents who reported use of smokeless to bacco, cigarettes, alcohol, or marijuana in the week pre- ceding the survey, 43 percent (47 percent in Arfs separate study [19891) indicated that they used more than one of these substances during that week The percentage of daily users of smokeless tobacco who reported use of alcohol during the preceding week was particulariy high (76 percent in Ary, Lichtenstein, and Severson's study [1987J and 74 percent in Ary's separate study 119891). Among daily smokeless tobacco users, 83 percent in Ary, Lichtenstein, and Severson's study (1987) (80 percent in Ary's 1989 study) also reported using a drug other than alcohol, a fact suggesting that daily smokeless to- bacco users are particularly likely to be multiple drug users. Psychosocial Risk Factors 109 Surgeon Gem-al's Report Smokeless Tobacco Use as a Risk Factor for Smoking, Alcohol, and Other Drug Use Although the known Literature indicates that the use of cigarettes and other drugs. is a risk factor for smokeless tobacco use, several studies also indicate that the converse is true; that is, smokeless tobacco use is a risk factor for the onset and maintenance of cigarette smoking and for the use of alcohol and marijuana (see "Smokeless Tobacco Use and Other Drug Use" in Chap ter 3). Ary, Lichtenstein, and Severson (1987) examined the prospective relationship between smokeless tobacco use and the onset of the use of cigarettes, alcohol, and marijuana at nine-month follow-up. Smokeless tobacco users were found to be more likely than nonusers to begin using cigarettes (22 percent vs. 7 percent), alcohol (18 percent vs. 7 percent), and marijuana (37 percent vs. 18 percent). These findings were replicated in Ary's. (1989) 12-month follow-up study of a separate sample. Smokeless tobacco users were significantly more likely than nonusers to report smoking cigarettes (6 percent vs. 0.5 percent), drinking alcohol (29 percent vs. 12 percent), and smoking marijuana (12 percent vs. 2 percent). Similarly, smokeless tobacco users were more likely than nonusers to increase their use of other drugs. A greater proportion of smokeless tobacco users than of nonusers reported increased use (in the week preceding the survey) of cigarettes (18 percent vs. 8 percent), alco- hol (34 percent vs. 20 percent), and marijuana (20 percent vs. 8 percent) (Ary, Lichtenstein, Severson 1987). The 1989 study replicated these findings for each substance: cigarettes (7 percent vs. 2 percent), alcohol (25 percent vs. 13 percent), and marijuana (15 percent vs. 2 percent) (Ary 1989). Several studies provide additional evidence for the progression from smokeless tobacco to other drugs. In one, decreases in smokeless tobacco use were accompanied by increases in cigarette smoking (Hunter et al. 1986). In a different longitudinal study, smokeless tobacco users were more likely to report cigarette smok- ing at a two-year follow-up (67 percent) than were non- users (14 percent) (Schinke et al. 1986). A study of undergraduates found that switching from smokeless tobacco to cigarettes was a more Likely progression than the converse (Glover, I.&in, Edwards 1989). Risk Taking and Rebelliousness Although smoking is associated with rebellious- ness and unconventionality, several studies have found no such association for smokeless tobacco use. A signifi- cant but modest relationship has been found between smokeless tobacco use and risk taking. In one of the few longitudinal studies of smokeless tobacco use, Dent et al. (1987) found that among eighth graders, current risk taking predicted the onset of smokeless tobacco use one year later. In another study, a significant relationship was reported between seventh-grade students' smoke- less tobacco use and risk taking (Botvin, Baker, Tortu 1989). Studies with high school students found that risk taking was related to trying smokeless tobacco but not to the level of smokeless tobacco use (Riley, Barenie, Myers 1989; Riley et al. 1991). In two of eight replication samples in another study, risk taking was a significant correlate of trying smokeless tobacco (Sussman et al. 1989). Participation in Athletics Given the number of professional athletes who use smokeless tobacco, and given the associated advertising efforts by smokeless tobacco companies, youth who par- ticipate in athletics would seem likely to be at greater risk of using smokeless tobacco than nonparticipants. Cur- rent studies have mixed findings about this possible relationship. Although 28 percent of predorninantLy white Little League baseball players (aged 12 or less, N = 1,141) in southeast Texas believed that more than half of profes- sional baseball players use smokeless tobacco, this belief was not strongly associated with use of smokeless to- bacco among these youth (Evans, Raines, Getz 1992). Similar findings on a stratified random sample of rumI and urban youth in grades one, three, five, and seven were reported in North Carolina (Lisnerski et al. 1991). In a one-year longitudinal study of seventh graders, sports participation did not predict onset of smokeless tobacco use in two samples of males and in one of two samples of females (Sussman et al. 1989); for the other sample of seventh-grade females, the relationship was positive but modest. Sussman et al. (1990) reported that self-identified "dirts" (i.e., "heavy metal" music enthusi- asts and marijuana users) and "skaters" (i.e., skateboard- ers and surfers) were more likely to be currently using smokeless tobacco than were "jocks/athletes." Another study of high school students yielded inconclusive re- sults (Riley, Barenie, Myers 1989). On the other hand, Ringwalt (1989) found that llth- and 12th~grade athletes (students who played on school teams) were more likely than nonathletes to have used smokeless tobacco, to have used smokeless tobacco in the preceding 30 days, and to perceive fewer (if any) health risks for smokeless tobacco use. Jones and Moberg (1988) found that fre quency of smokeless tobacco use was related to partici- pation in team sports. Glover et al. (1989) found that smokeless tobacco use among U.S. college students was related to participation in organized sports. Taken to- gether, the current evidence is inconclusive and war- rants further investigation that might consider team rules regarding smokeless tobacco use, coaches' use of smoke- less tobacco or attitude toward team members' use, and parents' degree of involvement in the team. 110 Psychosocial Risk Factors preventing Tobacco Use Among Young People Personal Factors in the Initiation of Smokeless Tobacco Use Knowledge of Long-Term Health Consequences Because the long-term health consequences of smokeless tobacco use have not been as widely commu- nicated as those of smoking, knowledge of these conse quences is potentially an important predictive factor for smokeless tobacco use. `Most youth appear to be aware that smokeless tobacco use can be harmful to health, but most smokeless tobacco users do not perceive their own risk to be great. In interviews with smokeless tobacco users, 80 percent of junior high school and 92 percent of senior high school users acknowledged that smokeless tobacco use can be harmful, but about 60 percent of the junior high users and 40 percent of the senior high users believed that there was no risk or only slight risk in regular smokeless tobacco use KJSDHHS 1986). A study of 7th- through 10th~graders found that 31 percent of daily users of smokeless tobacco believed that there was very little health risk associated with this use (Ary, Lichtenstein, Severson 1987). Similarly, only 40 percent of 7th- through 12th-grade students in another sample perceived smokeless tobacco use as very harmful (Schaefer et al. 1985). Marty, McDermott, and Williams (1986) reported that 35 percent of high school students who use smokeless tobacco believed that such use had little or no effect on their health. Many youth appear to believe that smokeless to- bacco use is much safer than cigarette use. Schaefer et al. (1985) found that 77 percent of smokeless tobacco users perceived smoking to be very harmful, whereas only 40 percent perceived smokeless tobacco use as very harmful. Another study reported that 86 percent of fifth- and sixth-grade smokeless tobacco users be- lieved that smoking would hurt their health, but only 33 percent believed this of smokeless tobacco use (Schinke et al. 1986). Ary et al. (1989) found that when smokeless tobacco users were asked why they pre- ferred smokeless tobacco to cigarettes, they most often gave "lower health risk" as the reason. Users of smoke- less tobacco are more likely than nonusers to perceive that smokeless tobacco is a comparatively safe altema- tive to cigarette use (Chassin et al. 1985; McDermott and Marty 1986; Boyle 1989; Glover, Laflin, Edwards 1989; Brownson, DiLorenzo, Van Tuinen 1990; Brownson et al. 1990; Lisnerski et al. 1991). A number of studies have examined the relation- ship between concurrent smokeless tobacco use and health knowledge and beliefs about smokeless tobacco, but none of these studies have examined the prospective relationship. Most of these studies show that youth with more health knowledge of, or greater beliefs in, the risks of smokeless tobacco use are indeed less likely to use smokeless tobacco. Three studies reported that having tried smokeless tobacco was related to lack of health knowledge and beliefs (Cohen et al. 1987; Riley, Barenie, Myers 1989; Riley et al. 1991); only one study that exam- ined this possible link failed to find such a relationship, and that study involved very young subjects (first through seventh graders) (Lisnerski et al. 1991). Mul- tiple studies have reported that health knowledge and beliefs were significantly related to various categories of smokeless tobacco use (Boyle 1989; Polcyn et al. 1991), current smokeless tobacco use (Chassin et al. 1985; Colbom, Cummings, Michalek 1989; Glover, Laflin, Edwards 1989; Marty, McDermott, Williams 19861, level or amount of smokeless tobacco use (Riley, Barenie, Myers 1989; Riley et al. 1991), or daily smokeless tobacco use (Ary, Lichtenstein, Severson 1987). In only two studies was no relationship found between health knowledge and beliefs and smokeless tobacco use (Brownson et al. 1990; Lisnerski et al. 1991). Functional Meanings In a study of seventh- and eighth-grade students, favorable personal attitudes toward smokeless tobacco use were significantly related to concurrent use of smoke less tobacco 18 years) in four states: Arizona (N = 294), Pennsylvania (N = 2911, Texas (N = 3031, and Michigan (N = 98) Advertising of cigarettes should be banned in newspapers, magazines, and outdoor posters or billboards. Tobacco companies should be prohibited from distributing free tobacco samples on public property or through the mail. Agreement across the four states sampled: 61%-69% 73%-81% Tobacco companies should be prohibited from sponsoring sports events or advertising their products at these events. 49%59% California Department of Health Services 1990 (California Department of Health Services 1991) Telephone survey of a random sample of adults (aged Z 18 years) in California (N = 6,600) Do you think advertising of tobacco products on outdoor billboards should be allowed or banned? Do you think advertising of tobacco products through newspapers and magazines should be allowed or banned? 54% favored a ban (42% smokers; 62% nonsmokers) 49% favored a ban (38% smokers; 57% nonsmokers) Do you think sponsorship of sporting 52% favored a ban or cultural events by tobacco companies (39% smokers; 61% should be allowed or banned? nonsmokers) Do you think that distribution of free cigarettes and tobacco products on public property should be allowed or banned? 75% favored a ban (62% smokers; 84% nonsmokers1 Do you think that distribution of free tobacco samples or coupons to obtain free samples by mail should be allowed or banned? 67% favored a ban (52% smokers; 78% nonsmokers) *COMMIT = Community Intervention Trial for Smoking Cessation. 128 Prevention preventing Tobacco Use Among Young People Data collected in a 1992 national telephone poll (N = 1,200) of adults (Louis Harris and Associates 1992) suggest that a predominant belief in the individual's fight to smoke coexists with a less predominant concern about the persuasive power of tobacco advertising. An overwhelming majority (87 percent) of respondents agreed with the proposition that "to smoke or not to smoke is a personal decision that adults should be free to make for themselves." On the other hand, 68 percent favored a ban on tobacco ads in newspapers, in maga- zines, and on billboards; 73 percent said they would support an initiative to require stronger warning labels on cigarette packages; and 83 percent would favor legis- lation banning tobacco ads targeted at teenagers. Three quarters of smokers themselves supported a ban on tobacco ads targeted at teenagers. The survey report concludes that "even smokers see smoking as something to be discouraged, especially where teenagers are concerned" (p. 39). Restrictions on the Sale of Tobacco Products to Minors Public opinion strongly favors measures to discour- age tobacco sales to minors (persons under the age of 18). A 1962 national Gallup personal interview survey (Gallup Organization 1962) found that 79 percent of adults sup ported the idea that there should be a law against selling cigarettes to people under 16 years old. According to the 1964 AU'IS (U.S. Department of Health, Education, and Welfare JLJSDHEWJ 1%9), only 9 percent of adults thought that sales of cigarettes to young people under a certain age should not be against the law. Today, all states have laws prohibiting the sale of cigarettes to persons under 18 years old (CDC, OSH, unpublished data). On July 10, 1992, Congress passed Public Law 102-321, the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) Reorganization Act, which contained Section 1926, providing for the enforcement of minors' access legislation in all states receiving funding for the prevention and treatment of substance abuse. These provisions required funded states to enforce legis- lation prohibiting the sale or distribution of tobacco prod- ucts to individuals under the age of 18. Enforcement included yearly random, unannounced inspections as well as annual reports to the Secretary of Health and Human Services describing the state's enforcement ac- tivities for that year, the extent of success in reducing the availability of tobacco to children under 18, and enforce ment strategies to be used in the next year for which funding was being sought. By June 1993,49 states and the District of Columbia had passed legislation in com- pliance with Section 1926, prohibiting the sales and distribution of tobacco products to children under the age of 18. (Virginia restrictions applied only to sales of tobacco products.) Most people do not believe that laws prohibiting the sale of tobacco to minors are adequately enforced, and the overwhelming majority of both smokers and nonsmokers support stronger measures to limit minors' access to tobacco. The 1989 SAVES (Marcus et al., in press) found that 8 out of 10 adults felt it was "very easy" or "somewhat easy' for teenagers to buy cigarettes near where they live (see `Factors That Influence Tobacco Acceptability and Availability' in Chapter 4). The over- whelming majority of respondents to this survey (86 to 92 percent) felt that there should be better enforcement of existing laws banning the sale of tobacco to minors, and most (83 to 88 percent) endorsed the idea that the laws should be strengthened. Results of a 1990 survey of California adults (California Department of Health Ser- vices 1991)provideasimilarpicture;76percentresponded negatively when asked, `Do you think the laws banning the sale of tobacco products to minors have been ad- equately enforced?" Several different surveys have tried to assess public opinion regarding specific types of legislative actions (e.g., licensing retailers and banning cigarette vending machines) to prevent minors' access to tobacco (Table 2). A 1987 survey of adults in Minnesota (Forster etal.l991)foundthat75percentfavoredapolicywhereby retailers would lose their tobacco licenses if they sold cigarettes to minors. Two-thirds of adult participants in the 1989 COMMlT survey (CDC 1991a) agreed with the statement, `Tobacco products should be as strictly con- trolled as alcohol products." The majority of respon- dents in this survey (from 77 to 93 percent) also agreed with the statement, `Merchants who sell tobacco to mi- nors should be fined." The 1989 SAVES (Marcus et al., in press) asked respondents in four states if they thought the sale of cigarettes through vending machines should be banned. Overall, between 60 and 68 percent of respondents fa- vored a ban on cigarette vending machines; smokers were much less likely than nonsmokers to support a ban (42 to 58 percent vs. 66 to 72 percent). The 1987 Minne sota survey (Forster et al. 1991) found that 57 percent of adults supported a policy eliminating all cigarette vend- ing machines; 80 percent favored a policy banning vend- ing machines in locations where teenagers gather. In the 1990 California survey (California Department of Health Services 19911, a majority of both smokers (74 percent) and nonsmokers (87 percent) favored the idea of ban- ning cigarette vending machines that are accessible to minors. A similar result was found in the 1989 COMMIT survey (CDC 1991a), wherebetween 76 and 89 percent of adults agreed with the statement, "Cigarette vending Prevention 129 Surgeon General's Report Table 2. Public opinion about different legislative actions to prevent minors' access to tobacco, United States, 1987- 1991 Source and year of survey Description of survey Questions or statements Responses American Cancer Society 1989 (Marcus et al., in press) Telephone survey of a random sample of adults (aged 2 18 years) in four states: Arizona (N = 294L Pennsylvania fN = 2911, Texas (N = 3031, and Michigan (N = 98) Do you think there should be laws to ban the sale of cigarettes through vending machines? Support for a ban across the four states sampled: 60%-68% California Department of Health Services (California Department of Health SeNiCes 1991) Telephone survey of a random sample of adults (aged 2 18 years) in California (N = 6,600) Do you think cigarette vending machines that are accessible to minors should be allowed or banned? 82% favored a ban (74%. smokers; 87% nonsmokers) `COMMIT = Community Intervention Trial for Smoking Cessation. machines should be eliminated in places where teens gather." Taxes on Tobacco Products Public opinion surveys consistently show that most people would support an increase in tobacco taxes over other taxes (such as income tax, sales tax, or gasoline tax) (Gallup Organization 1989,1990a, 1993; Hart Research Associates and Robert Teeter 199Oa, b, c; Yankelovich, Clancy, Shulman WOa, b; ACS 1992; Kleine 1993). Sur- veys conducted between 1989 and 1993 show strong support for raising taxes on tobacco and alcohol as a way of nzducing the federal budget deficit or to pay for health care reform (`Toner 19931 (Table 3). Support for raising tobacco taxes tends to increase when tax revenue is earmarked for specific purposes, 120 Prevention Preventing Tobacco Use Among Young Peopie especially for health and educational programs (Gallup cigarettes to pay for an expanded federal antidrug pro- &ganization 1993), such as those aimed at preventing gram. The same questions asked in 1990 found that 77 children from smoking or from using drugs. A 1989 percent supported raising cigarette taxes (Associated national survey sponsored by the Associated Press (Asso- Press/Media General 1990). The 1989 SAVES (Marcus et &ted Press/Media General 1989) found that 75 percent of al., in press) found that about twc&irds of adults favored adults supported increasing the federal excise tax on using an extra tax on tobacco to cover the cost of Table 3. Public opinion about increasing tobacco taxes, United States, 1989-1990 - Source and year of survey Description of survey Questions Responses Gallup Organization 1989 National personal Taking into account 64% favored raising ciga- interview survey with the amount each (tax) rette taxes by 16 cents per 2,048 adults (aged 2 18 would raise, and your pack; the only other tax years) opinion about these measure mentioned more taxes, which, if any, frequently was raising the would you favor as a tax on alcohol (69%) means of reducing the federal budget deficit? Hart Research Associates and Robert Teeter 1990a, b, c National telephone survey of a random sample of registered voters (January survey N = 1,510; May survey N = 1,007; July survey N = 1,555) * `,. ,.`.*;z,`:- ^ _ .- Let us suppose the January 1990: 78% favor government needed to May 1990: 83% favor raise taxes. Do you July 1990: 78% favor favor or oppose raising alcohol and tobacco taxes? Associated Press/ Media General 1989,199O National telephone survey of adults (aged 2 18 years) (September 1989 survey N = 1,071; May 1990 survey N = 1,143) ..,i. .;I ":-22i :b& To pay for a bigger September 1989: 75% favor federal antidrug May 1990: 77% favor program, would you support or oppose higher federal taxes on cigarettes? Preuen tion 121 Surgeon General `3 Report campaigns to reduce smoking. A 1987 national survey sponsored by the American Medical Association (Harvey and Shubat 1987) found that 79 percent of adults favored an increase in the tax on tobacco products if the money from the increase went to Medicare. A 1992 survey of Michigan adults (ACS 1992) found that 72 percent would support raising the state's cigarette excise tax if the addi- tional revenue would be targeted for health care and education. Interestingly, 58 percent of respondents to this survey claimed that they would vote for a candidate who supported the tobacco tax increase, whereas 27 percent would vote for a candidate who opposed the tax increase. Some relevant information on public opinion re garding tobacco taxes comes from a survey conducted in Canada, where tobacco taxes have increased sharply in the past decade. A December 1990 poll conducted for the Council for Tobacco-Free Ontario (Council for a Tobacco Free Ontario/Non-Smokers' Rights Association 1992) questioned Ontarians about their support for a substan- tial increase in the tobacco tax. Overall, 58 percent of Ontarians supported a Went per pack increase in the cigarette tax; this support did not change when respon- dents were informed that taxes currently accounted for 60 percent of the retail price of cigarettes. However, when respondents were told that higher tobacco prices could prevent children from starting to smoke, support for the tax increase climbed to 67 percent. Support was even higher when respondents were told of different ways to use revenues raised by the new tax, such as reducing the budget deficit (70 percent support), helping people quit smoking (78 percent support), and estabhsh- ing a fund to help prevent smoking among young people (84 percent support; 77 percent among smokers). Educational Efforts to Prevent Tobacco Use Among Young People School-Based Smoking-Prevention Programs Introduction Since the 1964 publication of the first Surgeon General's report on smoking and health (public Health Service [R-IS] 1964), smoking prevention has been recog- nized as a primary strategy for controlling smoking in the general population. The first report identified the diffi- culty that long-term adult smokers typically experience in their attempts to quit. The report thus advocated programs directed at educating high school and college students about the health hazards of smoking; in theory, school-based programs would interfere with the devel- opment of smoking behavior before smoking became firmly established. When the term "prevention" was applied to health- related issues in the 196Os, however, the concept referred not exclusively to school curricula but also to efforts to disseminate warnings about products and practices that public health professionals considered potential health hazards (Schwartz 1969). The approach to prevention research at that .time consisted of biomedical research to establish physiological mechanisms of smoking-related diseases, coupled with epidemiologic research to iden- tify etiologic characteristics of smokers. This research led, when appropriate, to the dissemination of findings and recommendations to the public. A proclamation and direct warning from the U.S. Surgeon General about the life-threatening characteristics of cigarette smoking was expected to convince smokers to quit and nonsmokers to avoid taking up the practice. Had this effect been the case, the concept of smoking prevention might never have amounted to mom than "spreading the word" to those segments of the population who had not yet re- ceived it. Unfortunately, nearly three decades later and despite monumental efforts to disseminate warnings, cigarette smoking remains the single most preventable cause of death and disease in our society WSDHHS 1989). This section reviews the evolution of the concept of smoking prevention since the 1960s and identifies av- enues for future progress in this area. Early Approaches to Smoking Education and Prevention In the 1960s and early 197Os, strategies to prevent the onset of cigarette smoking were often based on the premise that adolescents who engaged in smoking be- havior had failed to comprehend the Surgeon General's warnings on the health hazards of smoking (Thompson 1978). The assumption was that these young people had a deficit of information that could be addressed by pre senting them with health messages in a manner that caught their attention and provided them with sufficient justification not to smoke. Improvements in knowledge levels, or cognitive factors, would thus lead directly to changes in behavior. 122 Prevention Preventing Tobucco Use Among Young People fnformation Deficit Model Early prevention programs based on this informa- tion deficit model tried to heighten young people's aware ness and comprehension of the negative consequences of smoking. Programs based on this model used various educationaI methods to convey information, including books, pamphlets, posters, films, and lectures Chomp son 1978). Through images and messages often intended to arouse fear, these programs were designed to con- vince the adolescent audience that persons who smoke risk a variety of serious physical consequences through- out their lives, including an increased likelihood of pre- mature death in adulthood from cardiovascular disease or cancer. The underlying assumption of these information- focused programs proved to have limited grounding. Although expanded educational efforts in schools throughout the 1970s provided adolescents with various kinds of smoking-related information, this information alone did not deter them from beghming to smoke. Com- prehensive reviews published at that time concluded that smoking-prevention programs based on the infor- mation deficit approach were not effective (Thompson 1978;Goodstadt 1978). providing knowledgeof the health consequences of smoking is still an important task for public health, but this single strategy is not sufficient to change most young people's behavior. Affective Education Model The information deficit model did not take into account the complex relationship between knowledge acquisition and subsequent behavior (nor, as will be discus& later, did it consider the addictive nature of tobacco use). For example, cognitive factors are medi- ated by different personal variables, including changes in attitudes, beliefs, intentions, and perceived norms (M&rim 1%4; Fishbem 1%7J. To rectify the shortcom- ings of information-focused interventions, alternative smoking-prevention approaches that evolved during the 1970s tried various forms of motivational or affective education. These approaches, which came to be referred to collectively as the affective education model, were based on the assumption that adolescents smoke ciga- rettes because their self-perceptions are somehow com- patible with a health-compromising behavior like smoking Khrell and Btioski 1984). Interventions based on the affectke model sought to increase adolescents' Perceptions of self-worth and to establish or clarify a health-related value system that would support a young Person's decision not to smoke. Another assumption typicalIy made by prevention Programs based on the affective education approach was that information specific to tobacco was neither necessary nor sufficient for reducing the onset of ciga- mttesmoking among adolescents (Goodstadt 1978). These affective approaches evolved out of the direct experi- ences of educators and counselors who had begun to associate cigarette smoking among adolescents with vari- ous problem behaviors, including school absenteeism, low achievement motivation, and antiso&l behavior. The intervention programs suggested that adolescents who experienced such problems could rectify them through changes in their attitudes toward school, family, or community, if sufficiently motivated to do so. Reviews based on more than a decade of research have concluded that interventions based on the affective education model were no more,, effective in reducing adolescent smoking than those based on the information deficit model. Some studies have even suggested (that is, without conclusive findings) that these programs may have had the untoward effect of eliciting interest in the behaviors they attempted to discourage (Kinder, rape, Walfish 1980; Schaps et al. 1981; Hansen et al. 1988). Nonetheless, affective education programs marked the begiming of an era during which enormous effort was expended to design smoking-prevention interventions that were more directly related to the factors believed to cause smoking among adolescents. Correlates of Adolescent Smoking Behavior Evaluations of interventions before the mid-1970s suggested that these approaches were insufficient for several reasons. For example, although high school and college students were the intended targets of smoking- prevention programs in the 1940s and 197Os, the devel- opment of smoking behavior follows a series of stages that typically begin earlier in life, when students are in the sixth or seventh grade (Lever&al and Cleary 1980). Such findings suggest that smoking-prevention inter- ventions need to be initiated earlier than high school and that attention should be given to the various stages that adolescent smokers moved through as they developed from nonsmokers into regular smokers (Chassin, I'resson, Sherman 1985). As opposed to the narrow focus of prevention mod- els based solely on information or affective factors, a broader focus and a more diverse set of correlates or antecedents began to emerge as important determinants of adolescent cigarette smoking. As reviewed by Evans (19841, these factors have been studied categorically as so&demographic, environmental, behavioral, and per- sonal variables. Throughout the 198Os, using data from both longitudinal (McAlister, Krosnick, Milbum 1984) and cmss+e&onal (Chassin, presson, Sherman 1984) surveys, researchers developed a clearer understanding of the etiology of smoking behavior. Prezwntion 123 Surgeon General's Report This research showed that prevention strategies in the 1960s and 1970s had greatly underestimated the ex- tent to which adolescent smoking was determined by social environmental variables. An exception was the early work of the proactive physicians group Doctors Ought to Care (DOC), which argued that tobacco adver- tising and promotional activities strongly influence the social environment of adolescents (Blum 1980). A de- tailed overview of the relationships of social environ- mental variables to .the acquisition of smoking behavior is found in Chapter 4 of this report (see "Environmental Factors in the Initiation of Smoking"). As the major risk factors associated with smoking onset were identified, they were translated into new intervention methods, and the programs that resulted were substantially different from the approaches that had preceded them. Instilling Skills for Resisting Social Influences to Smoke Prevention research grants from the National Insti- tute on Drug Abuse @JIDA) and the National Institutes of Health (Bell and Levy 1984; USDHHS 1984; Stone 1985; Glynn 1989) were largely responsible for creating a wave of prevention program development from the late 1970s throughout the 1980s. These efforts fundamen- tally redefined the concept of primary prevention in several ways. First, programs began to make better use of social, psychological, and behavioral theories as a basis for un- derstanding what approaches might work to modify patterns of smoking onset among adolescents. Program design became far more data driven, as researchers be- gan to design intervention components based directly on findings from theory-based etiologic research on adoles- cent smoking. This orientation led to an improved un- derstanding and targeting of the determinants and correlates of smoking behavior among adolescents. Much information was published about the characteristics and components of successful smoking-prevention programs. Much of what has been learned focuses particularly on social infhrences, norms, and skills training and has the objective of attaining behavioral abilities, methods, skills, and techniques (rather than knowledge, beliefs, or moti- vation) that make it easier to adopt and maintain health- enhancing behavior patterns, such as not smoking. Lastly, the research methodology used to evaluate the efficacy of preventive interventions became far more sophisti- cated and considerably more rigorous. Intervention Objectives This prevention intervention approach recog- nizes the social environment as the most important determinant of smoking onset and focuses on the devel- opment of norms and skills to identify and resist social influences to smoke. Underlying this approach is the assumption that adolescents who smoke may lack spe- cific skills to deal successfully with various social influ- ences that support smoking. Such influences include the misperception that most people smoke, the perceived desirable social image of smoking, the appeal of cigarette advertising and promotional activities, and the persua- sive effects of sibling and peer smoking. Although con- siderable variation can be found across curricula, programs that instill the skills needed to resist such social influences have included a fairly consistent group of components that include training in resisting social pres- sures (e.g., marketing) and peer pressures to smoke and training that fosters general assertiveness, decision mak- ing, and communication skills (Botvin and Wills 1985). These programs also promote healthful normative ex- pectations and particularly correct the misperception that most adolescents smoke. Earlier programs for adolescents designed their messages to generate fear and anxiety about long-term disease risk. Approaches that teach skills to guard against social influences have assumed that scare tactics based on long-term health risk are not pertinent to the short- term perspective of many adolescents. The principal messages of skills-based intervention have thus focused on the negative, short-term social consequences of smok- ing, on the techniques of tobacco advertising that may be falsely appealing to adolescents, and on the socially sa- lient advantages of being a nonsmoker. Overall Program Structure In 1987, the NCI convened a panel of experts to establish consensus regarding the essential structural elements of effective smoking-prevention programs (USDHHS 1991). The panel agreed that eight features could be considered both necessary and sufficient for effective school-based smoking-prevention programs (Glynn 1989) (Table 4). In a recent meta-analysis (Mooney 1992) of outcomes of research studies conducted from 1974 through 1989 on school-based smoking prevention, the essential elements of the NCI expert panel were examined and mostly supported. This meta-analysis will be discuss& later in this chapter. Most of the successful programs that provide skills for resisting social influences share several major cur- riculum components. One of these is to convey the short- term negative consequences of cigarette smoking, including social undesirability and physiological impair- ment. Another component is to have students explore inaccurate normative expectations; students thus learn that cigarette smoking is not a normative behavior for 124 Prevention preventing Tobacco Use Among Young People adolescents their age and that the majority of persons in any age group are nonsmokers. Students examine the reasons that adolescents say they smoke, including to be accepted by peers, to appear mature, or to help cope with difficult situations. The factors that affect adolescent smoking can also be explored, including the influence of parents, peers, and mass media; for example, students can learn how role modeling and advertising can falsely establish positive cultural meanings for smoking (see "Research on the Effects of Cigarette Advertising and Promotional Activities on Young People" in Chapter 5). A related component is to engage students in training, modeling, rehearsing, and reinforcing methods that counter these influences and to coach students to com- municate these techniques to others. Some approaches also include generic personal and social skills training to promote overall competence and reduce motivations to smoke (Botvin and Wills 1985). Curriculm Format Among the numerous approaches to teaching skills to resist sociai influences to smoke, the format variations are in most cases minor (Best et al. 1988). For example, a number of these approaches rely on classroom teachers to deliver the smoking-prevention program. The six- session program designed by Colquhoun and Cullen (1981) focused on refusal skills training provided by classroom teachers with the help of local physicians. Biglan, Glasgow, et al. (1987), on the other hand, trained health and science teachers to deliver intervention ses- sions on four consecutive days, followed by a booster session two weeks later. Other intervention variations have used a combina- tion of trained staff or teachers plus student peer leaders. Pa~y,IQepp,andSillas(1989),forscample,usedsame-age pees in a smoking-prevention program that promoted cardiovasda.r health. Ellickson and Bell (19901, on the other hand, employed trained health educators to deliver their intervention to seventh gradexs and contrasted this approach by delivering the intervention through students' mgulartea&rsa&tedbyteenleademSiily,Arkinet al. (1981) organ&d seventh-grade student nominations of classmates who students felt would be effective peer lead- ers Those selected then served as discussion leadem and helped students rehearse and n&play appropriate re- sponsestosituatiomthatsimuIatedsociaI~. In Project SHOUT (Students Helping Others Un- derstand Tobacco), college undergraduate students in psychology, health sciences, and other majors worked for college credit toward their degrees by serving as peer leaders to young adolescents. The college students were mature and reliable enough to deliver interventions (both in the classroom and over the telephone, in booster calls) yet sufficiently youthful to be acceptable to an adult- wary audience (Young et al. 1988; Young et al. 1990; Elder et al. 1993). Table 4. Essential elements of school-based smoking-prevention programs 1. Classroom sessions should be delivered at least five times per year in each of two years in the sixth through eighth grades. 2. The program should emphasize the social factors that influence smoking onset, short-term consequences, and refusal skills. 3. The program should be incorporated into the existing school curricula. 4. The program should be introduced during the transition from elementary school to junior high or middle school (sixth or seventh grades). 5. Students should be involved in the presentation and delivery of the program. 6. Parental involvement should be encouraged. 7. Teachers should be adequately trained. 8. The program should be socially and culturally acceptable to each community. Source: Glynn (1989). Praention 125