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, 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) were used to estimate smoking initiation rates for persons who were adolescents (age 14 to 17 years) or young adults (age 18 to 21 years) during 1980 to 1989. This report summarizes the results of that analysis.
The CPS are monthly surveys of the US civilian, noninstitutionalized population age equal to or more than 15 years. Approximately 56,000 households are surveyed each month; one household respondent provides information about all household members age equal to or more than 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, 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.
Editorial Note From the CDC
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. 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, it is estimated that an additional 600,000 adolescents began to smoke during 1985 to 1989. Of those adolescents who continue to smoke regularly, approximately 50% will die from smoking-attributable disease.
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. However, because the real price of cigarettes increased steadily during 1985 to 1989 and the real average weekly income among high school seniors remained stable during this period, cigarettes were less affordable to young persons. 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 that cigarettes are harmful, smoking is a "dirty habit," and becoming a smoker reflects poor judgment, and who reported that they "mind being around people who are smoking" and would prefer to date nonsmokers.
Is Advertising the Cause?
The increase in rates of smoking initiation among adolescents during 1985 to 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 (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 exam ple, among persons age 12 to 17 years in 1992, approximately 50% of smokers and 25% of nonsmokers reported having received promotional items from tobacco companies.
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; 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.
- Third, advertising directly influences brand awareness and attitudes toward smoking among adolescents. 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. 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.
- Finally, consumer research suggests that younger persons (ie, age 14 to 17 years) aspire to be young adults; 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 tenth-grade students. 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), prevention efforts that focus on young persons should be intensified. Such efforts could include making cigarettes less affordable by either increasing their real price or by limiting sales to cartons rather than individual packs, enforcing laws prohibiting the sale and distribution of cigarettes to young persons, conducting mass media campaigns to discourage tobacco use, and eliminating or severely restricting all forms of tobacco product advertising and promotion to which young persons are likely to be exposed.
Reported by: K.M. Cummings, PhD, D Shah, MS, Roswell Park Cancer Institute, Buffalo, New York; D.R. Shopland, National Cancer Institutes of Health, Office on Smoking and Health, National Center for Cronic Disease Prevention and Health Promotion, CDC.
Adapted from Morbidity and Mortality Weekly Report,vol 44, no.28,1995