preventing Tobacco Use Among Young People

onset in this study. McCaul et al. (1982) found mo asso-
cation between boys’ smoking and participation in ex-
pracurricular activities. Among urban black fermales in
Brunswick and Messeri’s (1984) study, those who re-
ported minimal concern about their health and those
who reported a larger appetite were more likely to begin
smoking; 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 Messert 1983).
Sussman et al. (1993) found that among youth at the
highest risk of smoking, those who did not smoke re-

"ted that they valued their health. Finally, in Kelder’s
(1992) longitudinal study of secondary school students
in the north-central United States, cigarette smoking was
found to be related to poor food choices and less exercise
after the eighth grade; the correlation between these
behaviors was stronger with increasing age.

Behavioral Skills

The final set of behavioral factors comprises the
behavioral skills that are necessary to begin smoking,
those that are necessary to resist influences to smoke,
and those that are necessary to cope with other social

experimenters 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 (Salomon
et al. 1984; Lawrance and Rubinson 1986; Reardon,
Sussman, Flay 1989). Conrad, Flay, and Hilt (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 distress (Wills
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 pressures, 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
“Instilling Skills for Resisting Social Influences to Smoke”
and “Exemplary Programs for Resisting Social Influences”).

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 sociodemographic and environmental factors pass
as they influence behavior. Personal risk factors also
explain differences in behavior among individuals ex-

to the same or similar 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 (SEU) 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, Lauer 1987;
Sussman et al. 1987; Conrad, Flay, 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 negative social consequences
of smoking has been associated with a decline in smok-
ing prevalence among secondary school students
(Chassin et al. 1987). Botvin et al. (1992) found that lack
of concern about the harmful effects of smoking was
associated with intentions to smoke among young,
inner-city black adolescents. Similarly, dismissing Or
minimizing the health consequences of smoking has been
associated with both initiation of cigarette use and adult
smoking levels (Mittelmark et al. 1987; Swan, Creeser,
Murray 1990). Krohn, Naughton, and Lauer (1987) found
that smoking behavior predicted 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

beginning to smoke; beginning to smoke appears to ac-
centuate adolescents’ denial of the health consequences.

Psychosocial Risk Factors 101
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 Cleary 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 and
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. (1984), who suggest that positive attitudes toward
smoking, such as the idea that smoking is fun or pleasur-
able, 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 (11- and 12-year-olds).

Subjective Expected Utility

Bauman et al. (1984) have examined the SEU of
smoking for adolescents in a longitudinal study in N orth

102 Psychosocial Risk Factors

Surgeon General’s Report

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 (Bauman 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 Werch (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. Ahigren 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 ina 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-
age—that is, by appearing mature or “cool.” Smoking
onset was seen as a way to improve self-image among
Preventing Tobacco Use Among Young People

whites, blacks, and Hispanics in southern California
(Sussman et al. 1987). Role models who smoke are
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 toadopta 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

Anindividual'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 one-year 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 toassess whether underlying emotional or psycho-
logical problems predictadolescent 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 8th- and 11th-grade students, a
finding 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,

ple 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 diminish; as tolerance to nicotine increases, the
possible antidepressant effects of smoking (such as alert-
ness, euphoria, and calm) dissipate (Newcomb,
McCarthey, Bentler 1989). Similarly, Leventhal, Fleming,
and Glynn (1988) found that reported feelings of help-
lessness were associated with more rapid movement toa
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
cyclemay begin early inlife. 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 1984), adolescent males
were more likely to begin smoking if they were pessimis-
tic 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 (Le., a

Psychosocial Risk Factors 103
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 only three factors that predicted onset among
all ethnic groups. McNeill et al. (1988) found that future
intentions to smoke increased the odds of starting to

smoke by a factor of 2.44 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, several research-
ers have used intentions to smoke as an outcome measure
in their studies, especially in populations (such as pre-
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

104 Psychosocial Risk Factors

Surgeon General's Report

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 first tries are mostly adverse (unpleasant taste, cough-
ing, headache, nausea, dizziness) (Hahn et al. 1990), those
who persist report increasingly 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 9to
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, Flay, and Hill (1992) review of 27 prospective
studies; for the most part, this summary table is consis-
tent with Table 1. Among the sociodemographic factors,
age is the risk factor consistently linked with onset in
early adolescence; ages 11 through 15 (seventh through
ninth grades) are the peak age group for first trial and
experimentation. Cigarette smoking clearly has social
meanings that are attractive to many young and vulner-
able identity-seeking adolescents. This age factor is even
more pronounced when linked with SES, another im-
portant sociodemographic risk factor for smoking onset.
Alternative 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
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 sociodemographic 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 free-time 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 less
risk of smoking include academic achievement, involve-
ment in sports (for females), healthy 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 internaliza-
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
perceive that their peers are smokers. The shift from
social to more personal 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; Pentz et al. 1989; Santi et al.

Initiation of Smokeless Tobacco Use

Surgeon General’s Report

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 cross-sectional; a

few have also been guided by behavioral theory. None- .

theless, a number of methodologically sound studies
provide knowledge about 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 functions 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 summarized here. These data clearly indicate
that smokeless tobacco use among young people is par-
ticularly prevalent among non-Hispanic white males.

106 Psychosocial Risk Factors

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 reported 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, indicated 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 Begins” 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 [USDHHS] 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
sociodemographic factors may also be related to higher
rates of smokeless tobacco use among youth: one or no
parents in the household (Jonesand Moberg 1988; Murray
et al. 1988; see “Sociodemographic Risk Factors for
preventing Tobacco Use Among Young People

smokeless Tobacco Use” in Chapter 3); lower parental
education (Bauman, Koch, Lentz 1989; Botvin, Baker,
Tortu 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
“Sociodemographic 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 (USDHHS 1986), 90

rcent 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. (1991)
found that 50 percent of store personnel were willing to
sell to minors. In another study (Leopardi et al. 1989),
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; Colborn, 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 find 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 12-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
(Ary, 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:

e 86 percent perceived that most or some students at
their school approved of smokeless tobacco use.

Psychosocial Risk Factors 107
* 98 percent said their best male friends either approved
of, or were neutral toward, their smokeless tobacco
use.

* 93 percent said their parents knew of their smokeless
tobacco use.

* 68 percent said their fathers and 45 percent said their
mothers approved of, or were neutral toward, their
smokeless tobacco use:

* 91 percent said their brothers and 71 percent said their
sisters 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.

e 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). Williams et al. (1986) found that 55 percent of
smokeless tobacco users indicated that their parents dis-
approved of their use. Ina study by Ary et al. (1989),
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,

108 Psychosocial Risk Factors

Surgeon General's Report

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 statistical power 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 parents 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).
Preventing 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 (Ary,
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.) Ina
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

rcent of those who had never smoked—reported
smokeless tobacco onset at follow-up. Ary, Lichtenstein,
and Severson (1987) used discriminant analysis to iden-
tify predictors of the onset of smokeless tobacco use nine
months after smoking onset among 7th, 9th, and 10th
graders. The discriminant function accounted for.11
percent of the variance, and having tried smoking was
an important predictor, correlating at 0.64 with the dis-
criminant function. In 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
(Sussman 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 follow-up. Ina
separate study, Ary (1989) examined these relationships
and found that frequency of smoking was related to
continued daily smokeless tobacco use at 12-month
follow-up but not at 6-month follow-up. A 24month
follow-up study of ninth graders also found general
support for the influence of smoking on later use of
smokeless tobacco (Murray et al. 1988). Although the
findings from these thrée prospective studies are incon-
clusive, numerous studies report 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 (Lichtenstein 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
(Sussman et al. 1989) found that seventh- and eighth-
grade females showed no relationship between having
fried 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, Severson
1987). In a separate study, initial use of alcohol or mari-
juana 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 12-month 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 (Sussman 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 use of 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 Ary’s separate
study [1989]) 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 particularly high
(76 percent in Ary, Lichtenstein, and Severson’s study
[1987] and 74 percent in Ary’s separate study [1989]).
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
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, Laflin, 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

110 Psychosocial Risk Factors

Surgeon General's Report

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 wasa 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 predominantly 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 rural
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” (Le., “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 11th- 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.
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 (USDHHS 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 alterna-
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;
Colborn, Cummings, Michalek 1989; Glover, Laflin,
Edwards 1989; Marty, McDermott, Williams 1986), 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 (Polcyn et al. 1991). In another study, 8th-
through 11th-grade students’ expectancy and beliefs
about the positive attributes of smokeless tobacco use
(e.g., tastes good, is relaxing, helps concentration) were
related to current smokeless tobacco use (Colborn,
Cummings, Michalek 1989). Negative attributes of
smokeless tobacco use (i.e., gives bad breath, stains teeth)
were negatively related to current smokeless tobacco use
(Colborn, Cummings, Michalek 1989). No prospective
studies were found.

Social Image

Other research suggests that smokeless tobacco use
has a more positive social image than smoking (Chassin
et al. 1985; Chassin and Presson 1988). One study of high
school students found that students were more likely to
have used smokeless tobacco during the past month and
that nonusers were more likely to have intentions of using
if the students’ real and ideal self-concepts were similar to
their perceived image of smokeless tobacco users (Chassin
et al. 1985). This finding suggests that youth may take up
smokeless tobaccoasa method of attaining a valued social
image. Positive social attributes expected from smokeless
tobacco use (e.g., increases attractiveness, brings more
friends, makes one become more “macho”) were also
shown to be significantly related to concurrent use of
smokeless tobacco (Colborn, Cummings, Michalek 1989).
No prospective research was found.

Psychosocial Risk Factors 111
Personality Traits

Some studies have examined relationships between
smokeless tobacco use and a number of personality traits.
A positive association was found with anger (Jacobs et
al. 1988), anxiety (Jacobs et al. 1988), assertiveness (Botvin,
Baker, Tortu 1989), depression (jones and Moberg 1988;
Rouse 1989), and locus of control (Dignan et al. 1986). A
negative association was found with anxiety, curiosity
(Jacobs et al. 1988), and self-concept (Dignan et al. 1985).

Smokeless Tobacco Use as a Risk Factor for
Continued Use
Intentions to Use Smokeless Tobacco

Consistent with data on youth smoking, the re-
search indicates a strong relationship between concur

rent smokeless tobacco use and intention to use in the’

future. Brubaker and Loftin (1987) found that reported
intention to use smokeless tobacco in the week after the
survey was strongly related to current smokeless to-
bacco use in a small sample of fifth- through eighth-
grade males. Intention to use in the next two weeks was
also related to current-use status (Gerber, Newman, Mar-
tin 1988). No studies were found, however, that exam-
ined the prospective relationship between intention to
use smokeless tobacco and the initiation or continuation
of use.

Current Use of Smokeless Tobacco

Ary, Lichtenstein, and Severson (1987). prospec-
tively examined the predictors of frequency of smoke-
less tobacco use at a nine-month follow-up for their
sample of daily users of smokeless tobacco. Current
use of smokeless tobacco was the best predictor of later
use; the initial rate of use was highly correlated with the
rate of use nine months later and accounted for 33
percent of the variance. This finding suggests that the
successful reduction of smokeless tobacco use will re-
quire early intervention before the development of physi-
ological addiction.

Summary of Psychosocial Risk Factors for
Smokeless Tobacco Use

The major factors associated with the initiation
and development of smokeless tobacco use found in
this review are shown in Table 1. With the exception of
adequate knowledge of the health consequences of
smokeless tobacco use and the social acceptance af-
forded by smokeless tobacco use, these factors are nearly
identical to those found for the onset of smoking. Al-
though most youth perceive that smokeless tobacco use
can be harmful to health, most smokeless tobacco users

112 Psychosocial Risk Factors

Surgeon General's Report .

do not perceive the risk to be great, particularly to
themselves, and particularly compared with the health
risk of cigarette smoking. Peer modeling of smokeless
tobacco use seems to be strongly and consistently re-
lated to the onset and continued use of smokeless to-
bacco. Smokeless tobacco use serves social functions
within the peer group that may support experimental
and continued use. The evidence is less conclusive for
modeling by parents and siblings. Peer and, notably,
parental acceptance of smokeless tobacco use is much
higher than for cigarette smoking.

Fairly consistent evidence indicates that smokeless
tobacco use is related to concurrent use of cigarettes,
alcohol, and marijuana. Findings from prospective stud-
ies suggest that the use of smokeless tobacco may pre-
cede the use of these other substances and occurs early in
a sequence of drug use by some adolescents. Prospective
evidence shows that smoking and the use of alcohol and
marijuana are also related to the onset and continued use
of smokeless tobacco. Engaging in risk-taking behavior
and having poor academic performance also appear to
be related to smokeless tobacco use (see “Smokeless
Tobacco Use and Other Health-Related Behaviors” and
“Sociodemographic Risk Factors for Smokeless Tobacco
Use” in Chapter 3). There is mixed evidence that smoke-
less tobacco use is associated with youthful athletic par-
ticipation; nonetheless, some professional athletes have
promoted its use both indirectly (through visible per-
sonal use) and directly (through advertising).

Finally, there is evidence of concurrent relation-
ships (but no prospective evidence) between smokeless
tobacco use and health beliefs /knowledge, attitudes, ex-
pectancies, and social image. The perception that smoke-
less tobacco use may be a healthier choice than cigarette
smoking consistently emerges in the data and indicates
the need for prevention programs that stress the health
consequences of smokeless tobacco use.

Smokeless tobacco use, then, appears to be a
function of the social world of young people, who see
this “adult” behavior as an aid—a generally accessible
one—in improving their individual social image. More-
over, perhaps because even among adults the health
consequences of smokeless tobacco use are not widely
understood, adults lack consensus on whether smoke-
less tobacco use should be actively discouraged. Peer
use of smokeless tobacco thus becomes a strong motiva-
tor for initiation and continued use.

These misperceptions on the part of adolescents
and adults alike are of serious concem, given the health-
compromising, addictive aspects of smokeless tobacco
use. More strikingly, smokeless tobacco use is associated
strongly with other drug use and may serve as an entry
behavior to the use of cigarettes, alcohol, and illegal
substances.
preventing Tobacco Use Among Young People

Implications of Research for Preventing Tobacco Use: Modifying Psychosocial Risk

 

Although substantial research has examined the
onset of tobacco use for individual adolescents, there is
clearly a need to examine how change in community and
cultural factors may modify onset rates. This review of
the literature strongly suggests that the onset of to-
bacco use is socially learned and is a social behavior for
adolescents, with socially relevant meanings, images,
and functions. Therefore, rather than focusing only on
individuals and families as the primary targets of pre-
vention efforts, attention should also be directed to the
social environment of adolescents. These efforts should
consistently and persuasively promote the prevention
and cessation of tobacco use and should demonstrate
that the meanings of tobacco use are negative. Preven-
tion efforts should portray tobacco use as a behavior that
is nonnormative, unattractive, addictive, and immature.

Although the meanings of tobacco use are learned
in childhood, early to middle adolescence appears to be
the time of greatest need for direct intervention. This
idea is not only supported epidemiologically by the oc-
currence of highest onset rates during this time, but also
developmentally, in that the challenges of adolescence
can expose youth to the perceived utility of tobacco use.
The meanings of tobacco use that have been established
in our society become personally relevant during adoles-
cence. Tobacco use becomes a mechanism to establish
social relationships, display independence, and create a
new, mature identity. Moreover, because many adoles-
cents believe themselves to be all but invulnerable, have
a short perspective on their future, have limited abstract
cognitive abilities, and highly value their associations
with same-age peers, adolescents may view tobacco use
as particularly functional to them and not potentially
harmful. Adolescence is clearly a vulnerable time when
adult involvement and protection is still warranted and
required. Adults should see the prevention of adoles-
cent tobacco use as an important part of their responsi-
bility in the healthful socialization of the young.

The onset of tobacco use is strongly associated with
peer influences, peer smoking, and peer approval of
smoking. Programs that prevent tobacco use should
systematically seek peer-group involvement and enlist
peer role models who do not use tobacco. The emphasis
of this involvement should be to affect peer-related norms
and to persuade adolescents that most people their age
do not use tobacco, that tobacco use has negative social
consequences, and that tobacco use projects an image
that, instead of being “cool,” is unattractive, unpopular,
and immature. Parents should also pay attention to the

amount of time adolescents spend with peers, to peers’
behavior, and to unsupervised peer-group activities.

The increased need for social competencies during
adolescence (i.e., the ability of young people to decipher,
cope with, and deal with the social environment) should
be a critical focus of comprehensive efforts to prevent
tobacco use. Adolescents need skills to help them iden-
tify, resist, and refute environmental influences—whether
from the media, adults, or peers—to use tobacco.
Similarly, adolescents may need to be taught how to
cope better with difficult, stressful situations at home or
at school. Without such skills, many youth may con-
tinue to use tobacco as a mechanism to deal with low
self-esteem, depression, and the feelings of helpless-
ness that can result from the ordinary challenges of
growing up.

Positive social bonding with family and schools and
health-enhancing behavior, such as physical activity,
should be encouraged among youth as protective factors
against tobacco use. Students who perform poorly in
school should be offered tutoring and academic counsel-
ing; besides being personally motivating, such support
can increase students’ affiliation with school and decrease
their involvement in tobacco use. Encouraging sports
participation (and countering the negative role models of
some professional athletes by providing explicit mes-
sages about the health consequences of smokeless tobacco
use), regular physical activity, and a healthy diet may
increase adolescents’ valuation of, and attachment to,
health and a healthy body that might be compromised by
tobacco use. Parents may also need to demonstrate their
support for academic achievement, health activities, and
a greater link between home and school.

Finally, to substantially modify tobacco use and to
provide adolescents with consistent messages against
tobacco use, the community (and society on the whole)
should embrace the prevention of tobacco use. A focus
on individuals, families, or peer groups is necessary but
not sufficient to address the origins of tobacco’s appeal to
young people. Limiting the acceptability of tobacco use
through restrictive policies, such as legislation support-
ing clean indoor air and school policies banning tobacco
use, provides a clear message to adolescents that tobacco
use is not acceptable as a public behavior. Severely
limiting adolescents’ access to tobacco products makes it
clear that cigarettes and smokeless products are danger-
ous substances. Mandating tobacco-use prevention pro-
grams in schools signals the importance of this topic
through the use of explicit, earmarked resources. These

Psychosocial Risk Factors 113
community actions provide external support for par-
ents, teachers, and adolescents to assert their beliefs
about the health hazards of tobacco use and to assist
their demand for tobacco-free environments. Such clear,
normative messages emanating from the community
level reinforce those messages given at school or at

Conclusions

Surgeon General's Report

home. Above all, community action at multiple levels
of the social environment directly and consistently re-
futes the notion that tobacco use is an attractive adult
behavior. Community intervention should be a top
priority in poorer communities, where the need for
action is especially great.

 

1. Theinitiation and development of tobacco use among
children and adolescents progresses in five stages:
from forming attitudes and beliefs about tobacco, to
trying, experimenting with, and regularly using to-
bacco, to being addicted. This process generally
takes about three years.

2. Sociodemographic factors associated with the onset
of tobacco use include being an adolescent from a
family with low socioeconomic status.

3. Environmental risk factors for tobacco use include
accessibility and availability of tobacco products,
perceptions by adolescents that tobacco use is nor-
mative, peers’ and siblings’ use and approval of
tobacco use, and lack of parental support and in-
volvement as adolescents face the challenges of

growing up.

114 Psychosocial Risk Factors

4. Behavioral risk factors for tobacco use include low
levels of academic achievement and school involve-
ment, lack of skills required to resist influences to
use tobacco, and experimentation with any tobacco
product.

5. Personal risk factors for tobacco use include a lower
self-image and lower self-esteem than peers, the be-
lief that tobacco use is functional, and lack of self-
efficacy in the ability to refuse offers to use tobacco.
For smokeless tobacco use, insufficient knowledge
of the health consequences is also a factor.
Preventing Tobacco Use Among Young People

Chapter 5: Efforts to Prevent Tobacco Use Among Young People

Introduction

 

This chapter examines the range and effectiveness
of efforts to prevent tobacco use among young people.
The first section provides data on recent public opinion
of strategies to reduce tobacco use among young people.
The second set of sections focuses on educational efforts
to reduce cigarette smoking and smokeless tobacco use
among young people, including school-based, clinic,

and communitywide programs. The third set of sections
examines the impact of social conditions and public poli-
cies, including the effects of mass media programming,
legal restrictions, warning labels, and tobacco taxation.
Together, these efforts can inoculate against the
psychosocial risk factors discussed in Chapters 4 and 5, as
shown in Figure 1.

Figure 1. Efforts to prevent tobacco use among young people, by stage of initiation

Never Smoker .
Mass media programming
Counteradvertising
Communitywide programs
Trying

Social influences programs

Taxation and cost

Restricting sales to minors

—_ Nonsmoker

 

-

Experimentation

Social influences programs

Taxation and cost

— Nonsmoker

 

r

Regular Use

Restrictions on smoking at school

Cessation programs

—_ > Quit

 

i

Addiction

Source: Adapted from U.S. Department of Health and Human Services (1991).

Prevention 115
Surgeon General's Report

Public Opinion About Preventing Tobacco Use Among Young People

 

Introduction

The information in this section is derived from
several different sources, including national surveys con-
ducted by the federal government and by private organi-
zations (e.g., the Gallup Organization, Louis Harris and
Associates), statewide su‘ veys conducted by government
agencies or private organizations (e.g., the American
Cancer Society [ACS]), and community-based surveys.
Aremarkably consistent pattern emerges regarding public
opinion of tobacco-control policies. First, both smokers
and nonsmokers express much greater support for poli-
cies to prevent youth from smoking than for policies to
discourage adult smoking. A second finding is that
nonsmokers are consistently more supportive of govern-
ment efforts to regulate tobacco than are smokers.

Public Opinion About Tobacco Education

Historically, public support for efforts to keep chil-
dren from smoking has been stronger than support for
efforts to reduce smoking among adults. During the first
half of this century, most states instituted laws that prohib-
ited the sale or gift of cigarettes to minors (Hawkins 1964),
since tobacco use was viewed as an adult behavior and
children were seen as a group to be protected from poten-
tially harmful substances. However, as the health dangers
of smoking became known, the public looked to schools to
do more to educate children about the hazards of tobacco
use. For example, a 1957 national survey of adults (N =
1,541) conducted by the Gallup Organization (1957) found
that 68 percent of respondents believed that the danger
from smoking was great enough to warrant literature
being distributed to schoolchildren to warn them of these
dangers. Fifty-three percent of the respondents also felt
that the danger was sufficient to warrant an announce-
ment from the federal government (presumably, to adult
smokers) regarding the danger of smoking.

Traditionally, public and private efforts to reduce
the initiation of smoking by children have involved
schools (U.S. Department of Health and Human Services
[USDHHS] 1989). A number of states have enacted laws
that mandate education about smoking and health in
schools. In part, the emphasis on school-based education
reflects a belief that education is the most effective way to
discourage children from smoking. A 1984 national
survey of adults sponsored by the American Board of
Family Practice (Research and Forecasts, Inc. 1985) asked
respondents to indicate what approaches they believed
were effective in discouraging smoking. The highest-
rated approach, mentioned by 81 percent of those

116 Prevention

surveyed (N = 1,007), was providing smoking-related
education to children in grade school. The use of public
service campaigns, television shows, and other media to
motivate teenagers not to smoke was mentioned by 66
percent of respondents. Twenty-one percent felt that
legally banning the use of tobacco would be effective.

There is strong public support for tobacco educa-
tion efforts in the schools. The 1989 Smoking Activity
Volunteer-Executed Survey (SAVES), which was admin-
istered to adults in four states (Arizona, Michigan, Penn-
sylvania, and Texas), collected information on a wide
range of issues relevant to policies concerning smoking
(Marcus et al., in press). Trained and supervised ACS
volunteers used standardized questionnaires to conduct
telephone interviews of the sampled adults. Data col-
lected in this survey found that a high proportion of the
respondents (87 to 91 percent) agreed with the statement,
“There should be a strong tobacco education program in
the school system” (Marcus et al., in press). Only a
minority of these respondents (13 to 33 percent) agreed
with the statement, “Currently, schools are doing enough
to prevent children from starting to use tobacco.” This
finding is consistent with the results of a 1990 telephone
survey of California adults, in which 74 percent of re-
spondents felt that antitobacco education in schools
should be increased (California Department of Health
Services 1991).

Restrictions on Smoking in Schools

Traditionally, even secondary schools that prohibit
smoking by students have allowed teachers and staff to
smoke in designated areas away from students (USDHHS
1989). This double standard reflects public opinion about
restricting smoking in school settings. A 1987 telephone
survey of adults in Minnesota (Forster et al. 1991) found
strong support (93 percent) for a policy prohibiting stu-
dents from smoking in school, and a smaller percentage
(77 percent) favored a ban on smoking among teachers
and staff. School smoking policies, like those for other
workplaces, have become more restrictive in recent years.
Several states and many communities have enacted laws
that completely ban or severely restrict smoking in schools
and on school property (Coalition on Smoking OR Health
1992). These laws are discussed later in this chapter.

The 1989 Surgeon General's report on smoking and
health (USDHHS 1989) clearly documented the trend of
Americans to increasingly support restrictions on smok-
ing in a wide range of public locations, such as restau-
rants, worksites, and schools. In general, surveys that
Preventing Tobacco Use Among Young People

ask about limiting smoking in various settings have found
that support for such restrictions in schools is usually
stronger than for other locations. For example, findings
from a telephone survey for the 1989 National Cancer
Institute (NCI) Community Intervention Trial for Smok-
ing Cessation (COMMIT) (Centers for Disease Control
[CDC] 1991a) revealed that fewer than one-quarter of
adult respondents in 10 US. intervention communities
supported a complete ban on smoking in private worksites
and restaurants, whereas over half endorsed a ban on
smoking on school grounds. Support for banning smok-
ing in secondary schools possibly reflects the broad soci-
etal belief that schools have an important role to play in
discouraging tobacco use by children.

Restrictions on Tobacco Advertising
and Promotion

Numerous national, state, and local surveys have
tried to assess public opinion about restrictions on to-
bacco product advertising. Ina series of national Gallup
surveys (Gallup Organization 1978, 1987, 1988, 1991,
1993) conducted between 1977 and 1993, support for a
complete ban on cigarette advertising increased from 36
to 53 percent. The 1989 COMMIT survey (CDC 1991a)
of a representative sample of 300 to 400 adults 25 to 64
years old in each of 10 intervention communities in 9
states found that between one-half and three-quarters
agreed with the statement, “All tobacco advertising
should be eliminated.”

Some surveys have asked about limiting specific
types of tobacco advertising (e.g., billboards, newspa-
pers, magazines) and promotional practices (e.g., distri-
bution of free tobacco samples, tobacco company
sponsorship of sporting and cultural events) (Table 1). A
1987 telephone survey (Forster et al. 1991) of 821 adults
from seven Minnesota communities asked respondents
to indicate their support for restrictions on various forms
of advertising. Seventy-three percent of respondents
favored a ban on tobacco signs and billboards; 70 percent
supported a ban on tobacco advertising in newspapers
and magazines. The ACS-sponsored 1989 SAVES
survey of four states found that support for a ban on
cigarette advertising in newspapers, in magazines, and
on billboards ranged from 61 to 69 percent (Marcus et al.,
in press). Over three-quarters of respondents in this
survey agreed with the statement, “Tobacco companies
should be prohibited from distributing free tobacco
samples on public property or through the mail.” Com-
parable results were obtained in a 1990 telephone survey
of adults in California (California Department of Health
Services 1991). Fifty-four percent of respondents in this
survey supported a ban on tobacco ads on outdoor bill-
boards; 49 percent supported a ban on tobacco ads in

newspapers and magazines; 67 percent supported a ban
on the distribution of free tobacco samples or coupons
to obtain free samples by mail; and 75 percent supported
a ban on the distribution of free tobacco samples on
public property.

Three surveys (California Department of Health
Services 1991; CDC 1991a; Marcus et al., in press) have
measured public opinion about tobacco company spon-
sorship of sporting and cultural events (Table 1). In the
1989 COMMIT survey (CDC 1991a) of 10 communities,
from one-third to more than one-half of respondents
supported a ban on such sponsorship. The 1989 SAVES
survey (Marcus et al., in press) found that about one-half
of respondents agreed with the statement, “Tobacco com-
panies should be prohibited from sponsoring sports
events or advertising their products at these events.”
Fifty-two percent of respondents in the aforementioned
1990 California survey (California Department of Health
Services 1991) believed that sponsorship of sporting or
cultural events by tobacco companies should be banned.
In all three surveys, support for a ban on tobacco com-
pany sponsorship of sporting and cultural events was
about twice as strong among nonsmokers as it was
among smokers.

The function and effect of tobacco advertising have
been the subject of much controversy and debate among
scientists and within the tobacco industry. The tobacco
industry has argued that advertising targets adults only
and encourages regular smokers to switch brands or to
maintain brand loyalty (Tobacco Institute 1964; see “The
‘Maturity’ of the Cigarette Market” in Chapter 5). Many
health experts assert that tobacco advertising targets chil-
dren to encourage them to start using tobacco (Tye 1987,
DiFranza et al. 1991; Fischer et al. 1991; Pierce et al. 1991;
CDC 1992a). In fact, a major newspaper, the Seattle Times,
voluntarily discontinued tobacco advertising in June 1993,
citing “growing medical evidence on the dangers of smok-
ing, as well as tobacco advertisers’ recent targeting of
youth and racial minorities” (Nogaki and Gupta 1993,
p. El). Legislative proposals to restrict or prohibit to-
bacco advertising are often presented as a means of
protecting children (Myers and Hollar 1989). in 1986,
about half of the respondents to the Adult Use of Tobacco
Survey (AUTS) (USDHHS 1990c) agreed with the state-
ment, “If cigarettes were not advertised anywhere, fewer
young people would start smoking.” In July 1990, a
national Gallup survey (Gallup Organization 1990c) of
adults found that more respondents (49 percent) thought
that advertising and promotion paid for by the tobacco
companies represented an active attempt to get teenag-
ers and young people to start smoking than believed that
such efforts were to encourage brand switching among
people who already smoke (38 percent).

Prevention 117
Surgeon General's Report

Table 1. Public opinion about restricting or banning different types of tobacco advertising and promotions,
United States, 1987-1991

   
 
  
 
  
 
   
  
    

 

   
 
 

Source and

year of survey Description of survey Questions or statements Responses
“University of ~“5.5Telephone survey of a

Minnesota 1987 random sample of adults ©
_ Forster et al. 1991) (aged 18-74 years) in seven

communities in Minnesota

 
  

pelbey Wie saa ae Fok ate

American Cancer Telephone survey ofa Advertising of cigarettes should be Agreement across the

Society 1989 random sample of adults banned in newspapers, magazines, - four states sampled:
(Marcus et al., in (aged 2 18 years) in four and outdoor posters or billboards. 61%-69%
press) states: Arizona (N = 294),
Pennsylvania (N = 291), Tobacco companies should be 73%-81 %
Texas (N = 303), and prohibited from distributing free
Michigan (N = 98) tobacco samples on public property
or through the mail.
Tobacco companies should be 49%--59%

prohibited from sponsoring sports
events or advertising their products
at these events.

  
       
  
 
 
 
 
 
 

 
 

 

 

: National.Cancer
“Institute 1989.
- (Centers for Disease .

Control 1991b) 3
Ss va aud . we Ok

PE TACO ATR TRAN OEE RE foe PR ITE

jes should not be

 
 

   

  

ea snas ic 2 amie AE RL a

California Telephone survey of a Do you think advertising of tobacco 54% favored a ban
Department random sample of adults products on outdoor billboards (42% smokers; 62%
of Health (aged 2 18 years) in should be allowed or banned? nonsmokers)
Services 1990 California (N = 6,600)
(California Do you think advertising of tobacco 49% favored a ban
Department products through newspapers and (38% smokers; 57%
of Health magazines should be allowed or nonsmokers)
Services 1991) banned?
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 75% favored a ban
cigarettes and tobacco products on (62% smokers; 84%
public property should be allowed nonsmokers)
or banned?
Do you think that distribution of free 67% favored a ban
tobacco samples or coupons to obtain (52% smokers; 78%
free samples by mail should be nonsmokers)

allowed or banned?

 

 

*COMMIT = Community Intervention Trial for Smoking Cessation.

118 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
right to smoke coexists with a Jess 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 AUTS (U.S. Department of Health, Education, and
Welfare [USDHEW] 1969), 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) providea similar picture; 76 percent responded
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. 1991) found that 75 percent favored a policy whereby
retailers would lose their tobacco licenses if they sold
cigarettes to minors. Two-thirds of adult participants in
the 1989 COMMIT 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 1991), 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), where between 76 and 89 percent of
adults agreed with the statement, “Cigarette vending

Prevention 119
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

   
  
   
   

 

Telephone survey of a
random sample of adults
(aged 2 18 years) in four
states: Arizona (N = 294),
Pennsylvania (N = 291),
Texas (N = 303), and
Michigan (N = 98)

es

American Cancer
Society 1989
(Marcus et al., in press)

   
     

Telephone survey of a
random sample of adults
(aged 2 18 years) in
California (N = 6,600)

California

Department of Health
Services (California
Department of Health
Services 1991)

Questions or statements Responses

Do you think there should Support for a ban across

be laws to ban the sale of the four states sampled:
cigarettes through vending 60%-68%
machines?

oe : eel <

82% favored a ban (74% -

Do you think cigarette
smokers; 87% nonsmokers)

vending machines that are
accessible to minors should
be allowed or banned?

 

*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

120 Prevention

Associates and Robert Teeter 1990a, b, c: Yankelovich,
Clancy, Shulman 1990a, 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 reducing the federal budget deficit or to pay for health
care reform (Toner 1993) (Table 3).

Support for raising tobacco taxes tends to increase
when tax revenue is earmarked for specific purposes,
Preventing Tobacco Use Among Young People

especially for health and educational programs (Gallup cigarettes to pay for an expanded federal antidrug pro-
Organization 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
ciated Press/Media General 1989) found that 75 percent of al., in press) found that about two-thirds 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 National personal Taking into account 64% favored raising ciga-
1989 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?

   
   
    
 
       

meeiae AR TMT

Gallup Or nization —

  

educe the deficit,
which one of the

  

your first choice to
help reduce the

 
 

Hart Research National telephone Let us suppose the January 1990: 78% favor
Associates and survey of a random government needed to May 1990: 83% favor
Robert Teeter sample of registered raise taxes. Do you July 1990: 78% favor
1990a, b, c voters (January survey favor or oppose

N = 1,510; May survey raising alcohol and

N = 1,007; July survey tobacco taxes?

N = 1,555)

     
    
      

  
  

ancy,

    

  
     

 

National telephone oe

 

Yankelovi Do

 

   
  
   
     
     
    

 

  

ch, Cl : you favor or ~:
Shulman’ Survey of adults (aged oppose raising taxes
1990a, b 2 18 years) (May " on cigarettes to reduce
N= the federal budget ~”

deficit?

 

 
   

   

we Bee oe whe So =

Associated Press/ National telephone To pay for a bigger September 1989: 75% favor
Media General survey of adults (aged federal antidrug May 1990: 77% favor
1989, 1990 > 18 years) (September program, would you

1989 survey N = 1,071; support or oppose

May 1990 survey higher federal taxes on

N = 1,143) cigarettes?

 

Prevention 121
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 fora 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 froma survey conducted in
Canada, where tobacco taxes have increased sharply in
the past decade. A December 1990 poll conducted for the

Surgeon General's Report

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 50-cent 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 establish-
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 [PHS] 1964), smoking prevention has been recog-
nized asa 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 1960s, 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

122 Prevention

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 more 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 (USDHHS
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 1970s, 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.
Preventing Tobacco Use Among Young People

Information 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
educational methods to convey information, including
books, pamphlets, posters, films, and lectures (Thomp-
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 beginning 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 knowledge of 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
discussed 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
(McGuire 1964; Fishbein 1967). 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 (Durell and Bukoski 1984). Interventions based
on the affective 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 typically 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-
rette smoking 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 antisocial 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 (thatis,
without conclusive findings) that these programs may
have had the untoward effect of eliciting interest in the
behaviors they attempted to discourage (Kinder, Pape,
Walfish 1980; Schaps et al. 1981; Hansen et al. 1988).
Nonetheless, affective education programs marked the
beginning 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 1960s and 1970s, 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 (Leventhal 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, Presson,
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
(1984), these factors have been studied categorically as
sociodemographic, environmental, behavioral, and per-
sonal variables. Throughout the 1980s, using data from
both longitudinal (McAlister, Krosnick, Milburn 1984)
and cross-sectional (Chassin, Presson, Sherman 1984)
surveys, researchers developed a clearer understanding,
of the etiology of smoking behavior.

Prevention 123
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 (NIDA) 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 influences, 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, suchas 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

124 = Prevention

Surgeon General's Report

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). Ina recent meta-analysis (Rooney
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 discussed 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
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
nts, 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
romote overall competence and reduce motivations to
smoke (Botvin and Wills 1985).

Curriculum Format

Among the numerous approaches to teaching skills
to resist social 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.
Perry, Klepp, and Sillers (1989), for example, used same-age
peers in a smoking-prevention program that promoted
cardiovascular health. Ellickson and Bell (1990), on the
other hand, employed trained health educators to deliver
their intervention to seventh graders and contrasted this
approach by delivering the intervention through students’
regular teachers assisted by teen leaders. Similarly, Arkin et
al. (1981) organized seventh-grade student nominations of
classmates who students felt would be effective peer lead-
ers. Those selected then served as discussion leaders and
helped students rehearse and role-play appropriate re-
sponses to situations that simulated social pressure.

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.

oo

The program should be socially and culturally acceptable to each community.

 

Source: Glynn (1989).

Prevention 125