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

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).

TABLE 1. Real * cigarette price per pack, real weekly income of high school seniors, and
real price per pack as a percentage of real weekly income among high school seniors
-- United States, 1980-1989
==========================================================================================
                                                              Real price of cigarette
          Real average cigarette     Real average weekly      pack as percentage of
Year      price per pack (cents) +    income (dollars) &        real weekly income
------------------------------------------------------------------------------------------
1980               72.8                       NA @                     NA
1981               69.3                       NA                       NA
1982               72.2                      52.83                     1.4
1983               82.2                      51.26                     1.6
1984               91.1                      52.00                     1.7
1985               90.9                      51.84                     1.7
1986               95.3                      53.63                     1.8
1987               96.8                      55.15                     1.8
1988              103.3                      53.53                     1.9
1989              102.8                      53.13                     1.9
------------------------------------------------------------------------------------------
* Real prices and incomes were obtained by dividing the actual prices and incomes by
  the National Consumer Price Index, using the average of 1982-1984 as the reference.
+ Source: The Tobacco Institute.
& Sourec: CDC.
@ Not available.
==========================================================================================

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