Morbidity and Mortality Weekly Report July 20, 1995
July 20, 1995
The July 21, 1995, issue of the Centers for Disease Control and Prevention's (CDC) Morbidity and Mortality Weekly Report (MMWR) contains the article, "Trends in Smoking Initiation Among Adolescents and Young Adults--United States, 1980-1989." The study found that adolescent smoking initiation rates decreased slightly from 1980 through 1984, and then increased through 1989. Cigarette marketing practices appeared to be the factor most likely to account for this increase in teen smoking initiation rates. The study also found:
* This lack of progress in decreasing smoking among youth resulted in more than 600,000 additional teenagers starting to smoke. * During the 1980s, cigarette promotional expenditures (in 1993 dollars) more than quadrupled, from $771 million in 1980 to $3.2 billion in 1989. The largest increase in adolescent smoking initiation was in 1988, the year that the Joe Camel cartoon character was introduced nationally. * The most recent national survey data show that adolescent smoking rates continue to rise. To reverse this trend, intensified youth prevention efforts are needed, such as restricting the features of cigarette advertising and promotion that appeal to youths, conducting mass media campaigns, strictly enforcing laws that prohibit tobacco sales to minors, and increasing cigarette excise taxes.Another significant study released today, the Monitoring the Future Study, from the Institute for Social Research, University of Michigan, contains 1994 smoking prevalence data for eighth and tenth graders, and high school seniors. This research shows a continued increase from 1991 to 1994 in smoking prevalence among teenagers of all ages.
MMWR articles can be retrieved using the CDC WONDER electronic communication system and on INTERNET at ftp://ftp.cdc.gov or http://www.cdc.gov.
For additional information on the article, please contact Tim Hensley or Llelwyn Grant, Health Communications Branch, Office on Smoking and Health, Centers Disease Control and Prevention, (404)488-5493.
Jeffrey W. McKenna, M.S.
Chief, Health Communications Branch
Office on Smoking and Health
National Center for Chronic Disease
Prevention and Health Promotion
Below is the press release for the University of Michigan Survey Research Center study that found cigarette smoking is rising among young Americans.
July 17, 1995
Contact: Diane Swanbrow
Phone: (313) 747-4416
Smoking rates climb among American teen-agers, who find smoking increasingly acceptable and seriously underestimate the risks.
FOR RELEASE AT 6:00 A.M. EDT, THURSDAY, JULY 20, 1995.
EDITORS: For more information about the study, contact Lloyd D. Johnston, Ph.D., the principal investigator, at (313) 763-5043.
ANN ARBOR---Reporting on their 20th national survey of American high school seniors, and their fourth national survey of eighth- and tenth-grade students, scientists at the University of Michigan Survey Research Center conclude that cigarette smoking is rising among young Americans.
For more than a decade we have been reporting that the smoking rate among American high school seniors was holding constant despite the accumulating evidence of smoking's lethal effects, despite the many new restrictions on cigarette smoking, and despite the fact that smoking has fallen considerably among adults, states Lloyd D. Johnston, the principal investigator of the study.
Johnston and colleagues Jerald G. Bachman and Patrick M. O'Malley have directed the Monitoring the Future Study of licit and illicit drug use for over 20 years, under a series of research grants from the National Institute on Drug Abuse.
We are now in a period of clear and continuing increase in cigarette smoking among teens. Twelfth-graders showed an increase in smoking which began in 1992, while the eighth- and tenth-graders have shown a steady increase since first surveyed in 1991, states Johnston. (See Figure 1)
This is extremely bad news for the health and longevity of the next generation.
The proportional increase in smoking is greatest among the eighth-graders, who are 13- to 14-years-old. Their rate of current smoking---that is, smoking any cigarettes in the past 30 days---rose by 30 percent between 1991 and 1994, from 14.3 percent to 18.6 percent.
Tenth-graders current smoking rate increased by more than two-tenths, from 20.8 percent to 25.4 percent over the same interval. Among high school seniors, the current smoking rate has been increasing since 1992, and has risen by one-eighth, from 27.8 percent to 31.2 percent in 1994. (See Figure 1 and Table 1.)
While the daily smoking rates are at lower levels, the increases in them are of the same order of magnitude, states Johnston, and, of course, a great many of the lighter smokers at these young ages are on their way to becoming heavy smokers. The daily smoking rates for eighth-, 10th- and 12th-grade students in 1994 are 9 percent, 15 percent, and 19 percent, respectively.
The investigators conclude that teen-agers greatly underestimate the dangers of smoking, with only about half of all eighth-graders believing that smokers run a great risk of harming themselves by smoking a pack or more daily. (See Figure 4.) At 13 to 14 years old, eighth-graders are at an age by which a great many of those who will eventually become smokers have already begun to smoke.
From some of our earlier work we also know that teen-agers greatly overestimate their ability to stop smoking once they have begun, Johnston observes, so they are making decisions about whether or not to smoke at a very early age, with little or no appreciation of the likely consequences of those decisions.
In fact, even before they finish high school, a majority (56 percent) of the half-pack-a-day smokers say they tried to quit smoking and found they could not. Many of them have tried to quit on multiple occasions.
We know that once a birth cohort establishes a particularly high or low rate of smoking in adolescence, relative to other birth cohorts, it continues to maintain a relatively high or low rate throughout the life cycle, adds O'Malley, who has written on this subject using follow-up surveys of previous high school graduating classes. Thus the higher rates that we are observing now are likely to remain high later in life for these children.
The increases in smoking are very broad. They are found among boys and girls, those planning to go to college and those not (the latter tend to have much higher smoking rates), in all regions of the country, and in large cities as well as rural areas. (See Table 2.) The investigators also note that the increases are found at all socioeconomic levels and in all three of the largest racial/ethnic groups (whites, African-Americans and Hispanics).
No segment of the population is being spared these increases, so all parents should be concerned, caution the investigators.
As to the likely causes of this recent upturn in smoking among American youth, the investigators point to several factors. In addition to their unrealistically low perception of the dangers of smoking, there has been a clear weakening of peer norms against smoking, Johnston points out. (See Figure 3 and Table 3.) While the majority still say they disapprove of regular smoking, that proportion has been declining steadily since the early 1990s.
In the larger context, of course, we still must explain why these smoking-related attitudes are changing, or in the case of perceived risk, why they are not changing, Johnston says. The dangers teens associate with regular pack-a-day smoking have held fairly steady in recent years and even may have begun to decline in 1994. (See Figure 4 and Table 3.)
For one thing, children are bombarded with images of the benefits of smoking by an industry advertising and promotion effort which approaches five billion dollars per year. Cigarette smoking is continually associated with social success, sexual attractiveness, a healthy demeanor, exciting sporting activities, a cool and tough image for the boys, a slender body and liberated spirit for the girls, autonomy and independence for both sexes, and so on, says Johnston. What else could an American adolescent want?
And, in case the younger children don't get the point, they now have a cartoon character with which to identify. Past research has shown that he is widely known to them.
Further, many movies and television programs portray smoking as more common and socially acceptable than it in fact is among the general population, Johnston adds, and it is my impression that smoking by the characters in movies and television dramas has become even more frequent.
But, even if it just held steady, it would present an unrealistic portrayal, because among adults both the use of cigarettes and the acceptability of smoking have been declining substantially.
Price is still another factor which may have contributed to the increase in smoking by young people, according to the investigators. The tobacco companies cut prices on major brands beginning in early 1993. In addition, the many new promotional prizes in effect reduce the price of the product and serve to reward use.
The investigators find that cigarettes are almost universally available to teen-agers. Three-quarters of eighth-graders and 90 percent of 10th-graders say that cigarettes are fairly easy or very easy for them to get. The investigators do not even bother to ask 12th-graders the question, believing that virtually all of them would report easy access to cigarettes. (See Table 3.) There is no evidence that availability has changed much, however. We have never made a serious effort to control children's access to cigarettes, which itself sends a message that adults don't care much if they smoke, observes Johnston.
The recent increase in cigarette smoking coincides with a sharp increase in marijuana use among American teens, as reported by the same study, and the investigators observe that the increase in smoking may in fact be contributing to the rise in marijuana use. Cigarette smoking and marijuana smoking are very highly correlated, with cigarette smoking usually coming first, notes Johnston. When you think about it, in order to smoke marijuana, youngsters must learn to take smoke into their lungs, which is not a normal behavior for any species. Cigarette smoking provides excellent training for just that.
The implication of this increase in adolescent smoking for the country's future rates of disease, early death, disrupted families, worker productivity, and health care costs cannot be overestimated, say the investigators. As we and many others have observed previously, cigarettes will kill far more of today s children than all other drugs combined, including alcohol. But because these consequences do not emerge for a few decades, we seem to be much less concerned about them. If cigarette smoking killed quickly, like drunk driving does, the country would be treating the current rates of adolescent smoking as an extreme emergency.
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The study, titled Monitoring the Future, was also widely known as the National High School Senior Survey. It has been conducted under a series of research grants from the National Institute on Drug Abuse. Surveys have been carried out each year since 1975 by the University of Michigan Survey Research Center. In 1994, the seniors comprised about 16,000 seniors in 139 public and private high schools nationwide, selected to be representative of all seniors in the continental United States. They completed self-administered questionnaires given to them in their classrooms by U-M personnel. Beginning in 1991, similar surveys of nationally representative samples of eighth- and 10th-graders have been conducted annually. The 1994 eighth-grade sample contained about 18,000 students in 150 schools, and the 10th-grade sample contained 16,000 students in 130 schools. In all, approximately 50,000 students in about 420 public and private secondary schools are now surveyed annually.
# # # # #
Morbidity and Mortality Weekly Report
July 21, 1995/Vol. 44/No. 28
Trends in Smoking Initiation Among Adolescents and Young Adults -- United States, 1980-1989
The evaluation of efforts to prevent tobacco use among adolescents requires accurate surveillance of both smoking prevalence and smoking initiation rates. Although several surveillance systems provide timely data about adolescent smoking prevalence (1), data characterizing rates of smoking initiation among adolescents have been limited. To improve characterization of trends in smoking initiation among young persons, data from the Tobacco Use Supplement of the 1992 and 1993 Current Population Surveys (CPS) (2) were used to estimate smoking initiation rates for persons who were adolescents (aged 14-17 years) or young adults (aged 18-21 years) during 1980-1989. This report summarizes the results of that analysis.
The CPS are monthly surveys of the U.S. civilian, noninstitutionalized population aged greater than or equal to 15 years (2). Approximately 56,000 households are surveyed each month; one household respondent provides information about all household members aged greater than or equal to 15 years. Questions about tobacco use were added to the September 1992, January 1993, and May 1993 monthly surveys. The response rates for the three surveys were 84.7%, 84.9%, and 82.0%, respectively (N=293,543 household members). To minimize biases that could result from discrepancies between self reports and proxy reports of smoking behavior (3), this analysis used data from self-respondents only (82% of total sample). Ever smokers were defined as respondents who answered "yes" to the question, "Have you smoked at least 100 cigarettes in your entire life?" Ever smokers were asked, "How old were you when you started smoking cigarettes fairly regularly?" To restrict the analysis to persons who were adolescents or young adults for some period during 1980-1989, only respondents aged 17-34 years at interview were included. The final sample consisted of 71,321 persons, of whom 27,768 (38.9%) were ever smokers.
Using the age of respondents at the time of the interview and the age they reported starting smoking, the age of respondents and their smoking status were calculated for each year during the 1980s. The denominator for the initiation rate for a given year was the number of respondents at risk for initiating smoking during that year (persons already smoking were eliminated from the denominator for that year). The numerator was the number of respondents who reported initiating smoking during that year. Data were weighted by age, sex, and race/ethnicity to provide national estimates.
Among adolescents, the smoking initiation rate decreased slightly from 1980 (5.4%) through 1984 (4.7%) and then increased through 1989 (5.5%); the largest annual increase occurred in 1988 (Figure 1). In comparison, among young adults, initiation rates decreased throughout the 1980s (Figure 1). For both age groups, initiation rates and trends were similar for males and females. Reported by: KM Cummings, PhD, D Shah, MS, Roswell Park Cancer Institute, Buffalo, New York. DR Shopland, National Cancer Institute, National Institutes of Health. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.
Editorial Note: The findings in this report indicate an increase in the rate of initiation of cigarette smoking among adolescents from 1985 through 1989, a period during which the rate among young adults declined and overall prevalence of smoking among adults decreased steadily (4). One important consequence of the increased rate of initiation among adolescents will be the increased future burden of tobacco- related disease. In particular, because of the increase in initiation since 1984, an additional 600,000 adolescents began to smoke during 1985-1989.* Of those adolescents who continue to smoke regularly, approximately 50% will die from smoking-attributable disease (5).
Potential reasons for an increase in smoking initiation rates among adolescents include a decreased real price of cigarettes, increased levels of disposable income, increased acceptability of smoking, and intensified cigarette marketing (1). However, because the real price of cigarettes increased steadily during 1985-1989 and the real average weekly income among high school seniors remained stable during this period, cigarettes were less affordable to young persons (1,6) (Table 1). In addition, the acceptability of smoking among high school seniors did not increase: during this period there were increases in the percentages of high school seniors who believed cigarettes are harmful, smoking is a "dirty habit," and becoming a smoker reflects poor judgment, and who reported they "mind being around people who are smoking" and would prefer to date nonsmokers (1).
The increase in rates of smoking initiation among adolescents during 1985-1989 may reflect increased real expenditures for cigarette advertising and promotion. The increase in rates occurred during a period when real expenditures for total cigarette advertising and promotion** doubled, and expenditures for cigarette promotion more than quadrupled (7) (Figure 2): from 1980 to 1989, total annual advertising and promotional expenditures (in 1993 dollars) increased from $2.1 billion to $4.2 billion, while promotional expenditures alone increased from $771 million (37% of total expenditures) to $3.2 billion (76%) (Figure 2). Promotional efforts have been highly effective among adolescents. For example, among persons aged 12-17 years in 1992, approximately 50% of smokers and 25% of nonsmokers reported having received promotional items from tobacco companies (1).
An association between overall cigarette marketing expenditures and initiation rates for smoking among adolescents is plausible for at least four reasons. First, brand loyalty is usually established with the first cigarette smoked (8); therefore, cigarette companies have an economic incentive to encourage first-time smokers to smoke their brands. Second, adolescents are exposed to cigarette advertising and promotions that employ themes and images that appeal to young persons (1). Third, advertising directly influences brand awareness and attitudes toward smoking among adolescents (1). Specifically, adolescents smoke the most heavily advertised brands, and changes in brand preferences among young persons are associated with changes in brand-specific advertising expenditures (9). For example, the Joe Camel campaign introduced nationally in 1988 was associated with an increase in the market share of that specific brand among adolescents (1,9). Finally, consumer research suggests that younger persons (i.e., aged 14-17 years) aspire to be young adults (10); therefore, advertising and promotional efforts targeted toward young adults may have greater appeal to adolescents because of their age aspirations.
Although current estimates of smoking initiation rates among adolescents are not available, from 1991 through 1993, the national prevalence of smoking increased among eighth- and 10th-grade students (6). To reverse the trend of increasing smoking initiation rates among adolescents and to achieve the national health objective for the year 2000 of reducing the initiation of cigarette smoking by youth (no more than 15% should become regular smokers by age 20) (objective 3.5) (4), prevention efforts that focus on young persons should be intensified. Such efforts could include making cigarettes less affordable by either increasing their real price (1) or by limiting sales to cartons rather than individual packs, enforcing laws prohibiting the sale and distribution of cigarettes to young persons (4), conducting mass media campaigns to discourage tobacco use (1), and eliminating or severely restricting all forms of tobacco product advertising and promotion to which young persons are likely to be exposed (4).
References
1. US Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994.
2. Hansen RH. The Current Population Survey: design and methodology (Technical paper no. 40). Washington, DC: US Department of Commerce, Bureau of the Census, 1985.
3. Gilpin EA, Pierce JP, Cavin SW, et al. Estimates of population smoking prevalence: self versus proxy reports of smoking status. Am J Public Health 1994;84:1576-9.
4. NCHS. Health, United States, 1992, and Healthy People 2000 review. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1993; DHHS publication no. (PHS)93-1232.
5. Peto R, Lopez AD, Boreham J, Thun M, Heath C. Mortality from smoking in developing countries, 1950-2000. Indirect estimates from national vital statistics. Oxford, England: Oxford University Press, 1994.
6. Johnston LD, O'Malley PM, Bachman JG. National survey results on drug use from the Monitoring the Future study, 1975-1993. Volume I: secondary school students. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Drug Abuse, 1994.
7. Federal Trade Commission. Report to Congress for 1990: pursuant to the Federal Cigarette Labeling and Advertising Act. Washington, DC: U.S. Federal Trade Commission, 1992.
8. DiFranza JR, Eddy JJ, Brown LF, Ryan JL, Bogojavlensky A. Tobacco acquisition and cigarette brand selection among youth. Tobacco Control 1994;3:334-8.
9. CDC. Changes in the cigarette brand preferences of adolescent smokers--United States, 1989-1993. MMWR 1994;43:577-81.
10. Teenage Research Unlimited, Inc. TRU Teenage Marketing and Lifestyle Study: wave 18, Fall 1991. Northbrook, Illinois: Teenage Research Unlimited, Inc, 1991.
* Based on the assumption that the initiation rate during 1985-1989 remained stable at the 1984 rate, and by multiplying the Bureau of the Census population estimates for persons aged 14-17 years for each year from 1985 through 1989 by the difference between the adolescent smoking initiation rate in 1984 and the rate for each year. ** Based on data from the Federal Trade Commission (7), advertising expenditures include costs to advertise outdoors (e.g., billboards), in newspapers or magazines, and on transportation (e.g., buses); promotional expenditures include costs of promotional allowances, distribution of samples or specialty items (e.g., key chains, lighters, T-shirts, caps, and calendars), public entertainment, direct mail, coupons, retail value-added promotions (e.g., specialty items distributed at the point of sale), and point-of-sale promotions (e.g., store displays).***********************
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