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Tobacco Use and Usual Source of Cigarettes Among High School Students -- United States, 1995

Approximately 90% of all initiation of tobacco use occurs among persons aged less than or equal to 18 years, and the prevalence of tobacco use among adolescents is increasing (1,2). Despite laws prohibiting the sale of tobacco to minors in all states and the District of Columbia, most minors are able to purchase tobacco products (1,3). To determine current prevalences of the use of cigarettes and smokeless tobacco products (i.e., chewing tobacco and snuff) by high school students, the usual source of cigarettes among those who smoked, and the percentage of students who were asked to show proof of age when buying cigarettes, CDC analyzed data from the 1995 Youth Risk Behavior Survey (YRBS). This report summarizes the results of the analysis, which indicate a higher prevalence of smoking among high school students in 1995 than in 1993 and 1991, a doubling of the prevalence of current smoking among non-Hispanic black male students during 1991-1995, and that most high school students aged less than or equal to 17 years who buy cigarettes from stores are not asked to show proof of age.

YRBS, a component of CDC's Youth Risk Behavior Surveillance System (4), biennially measures the prevalence of priority health-risk behaviors among youth through representative national, state, and local surveys. The 1995 national YRBS used a three-stage sample design to obtain a representative sample of 10,904 students in grades 9-12 in the 50 states and the District of Columbia. The school-response rate was 70%, and the student-response rate was 86%. Data were weighted to provide national estimates, and SUDAAN was used to calculate standard errors for determining 95% confidence intervals.

Students completed a self-administered questionnaire about the number of days during the 30 days preceding the survey they had smoked cigarettes or used smokeless tobacco. Current cigarette and smokeless tobacco users were defined as students who reported product use on greater than or equal to 1 of the 30 days preceding the survey. Frequent cigarette users were defined as students who reported cigarette use on greater than or equal to 20 of the 30 days preceding the survey. Students also were asked "During the past 30 days, how did you usually get your own cigarettes?" and "When you bought cigarettes in a store during the past 30 days, were you ever asked to show proof of age?" Data were presented only for blacks, whites, and Hispanics because numbers for other racial/ethnic groups were too small for meaningful analysis. Prevalence of Cigarette Use

The overall prevalences of current cigarette use and frequent cigarette use were 34.8% and 16.1%, respectively. The prevalence of current cigarette use was higher among non-Hispanic white (38.3%) and Hispanic students (34.0%) than among non-Hispanic black students (19.2%) (Table_1). Among non-Hispanic black students, males were more than twice as likely (27.8%) to be current smokers than were females (12.2%). The prevalence of current smoking was higher among students in grade 12 (38.2%) than in grade 9 (31.2%). Frequent cigarette smoking was more common among non-Hispanic white students (19.5%) than among non-Hispanic black (4.5%) or Hispanic students (10.0%); however, non-Hispanic black male students were approximately six times more likely (8.5%) than non-Hispanic black female students (1.3%) to be frequent smokers. Prevalence of Smokeless Tobacco Use

The overall prevalence of current smokeless tobacco use was 11.4% (Table_1). The prevalence of current smokeless tobacco use was higher among male students (19.7%) than among female students (2.4%) and among non-Hispanic white students (14.5%) than non-Hispanic black (2.2%) or Hispanic students (4.4%). Non-Hispanic white male students were more likely (25.1%) than any other subgroup to report smokeless tobacco use. Usual Source of Cigarettes

Among students aged less than or equal to 17 years in grades 9-12 who were current smokers, 38.7% reported that they usually bought cigarettes in a store and 2.2%, from vending machines (Table_2). One third (32.9%) reported that they usually borrowed cigarettes from someone else; 15.8%, that they usually gave "someone else money to buy them for me"; and 4.2%, that they usually stole cigarettes during the 30 days preceding the survey. Non-Hispanic white students were more likely (41.3%) than non-Hispanic black students (27.2%) to report usually obtaining cigarettes by buying them in stores. Students in grades 11 and 12 were more likely (50.8% and 50.4%, respectively) to usually buy cigarettes in stores than were students in grades 9 and 10 (22.2% and 34.6%, respectively), and students who smoked on greater than or equal to 20 of the 30 days preceding the survey were more likely (60.9%) to usually buy cigarettes in stores than were students who smoked on 1-5 days (15.9%) or 6-19 days (35.2%) of the 30 days preceding the survey.

Male students were more likely than female students to report usually buying cigarettes from a vending machine (3.4% and 0.9%, respectively). Female students were more likely (21.9%) to obtain cigarettes by giving someone else money to buy them than were male students (10.1%), non-Hispanic white students more likely (17.8%) than non-Hispanic black students (7.3%), and students who smoked on greater than or equal to 20 of the 30 days preceding the survey more likely (21.9%) than students who smoked on 1-5 of the 30 days preceding the survey (6.6%).

Students in grade 9 were more likely (43.0%) to report borrowing as their usual source of cigarettes than were students in grades 11 or 12 (27.2% and 26.9%, respectively), and students who smoked on 1-5 of the 30 days preceding the survey were more likely (63.1%) to report borrowing than were students who smoked on greater than or equal to 20 of the 30 days preceding the survey (6.6%). Male students were more likely (6.4%) to report stealing as a usual source of cigarettes than were female students (1.8%).

Among students aged less than or equal to 17 years who were current smokers, 77.5% reported never being asked for proof of age when buying cigarettes in a store during the 30 days preceding the survey.

Reported by: Office on Smoking and Health, and Div of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings in this report extend findings of a previous report (2) and indicate that current cigarette smoking among students in grades 9-12 increased from 27.5% in 1991 (1) to 30.5% in 1993 (4) to 34.8% in 1995. In addition, the prevalence of current smoking among non-Hispanic black male students nearly doubled from 1991 (14.1%) (1) to 1995 (27.8%), but among non-Hispanic black female students remained stable (11.3% in 1991 {1} and 12.2% in 1995). Although reasons for differences in the prevalence of smoking among non-Hispanic black males and females are unknown, CDC is funding research activities to help explain these differences.

Differences in the prevalence of tobacco use and sources of cigarettes among racial/ethnic groups underscore the need to assess potential contributing factors such as attitudes of minors, parents, and vendors; enforcement of laws; community norms; marketing practices; and mass media exposure. For example, the finding in this report that non-Hispanic white high school students are more likely to smoke than non-Hispanic black students may be associated with several factors: black youth are less concerned than white youth about the potential weight-controlling effects of cigarette smoking; black parents may be more likely than white parents to advise their children not to smoke; and black community leaders may have responded to the targeting of their communities by tobacco marketing efforts with counter-messages and activities (5).

These YRBS findings also are consistent with previous documentation of the sources of the cigarettes obtained by minors and the high percentage of minors who have not been asked for proof of age when purchasing cigarettes (1,3,6,7; CDC, unpublished data, 1995). The low proportion of current smokers who usually obtained cigarettes from vending machines may have reflected the generally higher price of cigarettes sold from vending machines, the ease of purchase from over-the-counter sources, and the classification categories used in the questionnaire (1,3,6). Stealing has been reported previously as an important source of cigarettes for some minors (1,6,7) and is more common in stores that use industry-promoted self-service displays than in stores that use only behind-the-counter vendor-assisted displays (6,7; R. Kropp, North Bay Health Center, unpublished data, 1995; K.M. Cummings, personal communication, 1996; M. Caldwell, personal communication, 1996).

Vendors requiring proof of age is an important method of preventing tobacco sales to minors (1,6,7; CDC, unpublished data, 1994). However, in 1995, most (77.5%) students who were current smokers reported that they had not been asked to show proof of age when buying cigarettes during the 30 days preceding the survey.

All states have enacted laws to restrict the access to tobacco products by youth, and most adults support enforcement of these laws. However, enforcement of these laws varies by jurisdiction and, in general, needs to be strengthened (8). Federal law (i.e., Synar Amendment * ) and implementing regulations require states to develop a strategy and a time frame for achieving an inspection failure rate of less than or equal to 20% (9).

In August 1995, the Food and Drug Administration (FDA) proposed regulations to reduce for minors both access to and the appeal of cigarettes and smokeless tobacco products (10). The FDA is reviewing public comments on the proposed regulations, which would 1) require retailers to verify the age of persons who want to purchase cigarettes or smokeless tobacco products; 2) eliminate "impersonal" methods of sale and distribution that do not readily allow age verifications (e.g., mail orders, self-service displays, free samples, and vending machines); 3) limit advertising in publications with substantial youth readership to a text-only format; 4) ban outdoor advertising of tobacco products within 1000 feet of schools and playgrounds and limit remaining outdoor advertising to a text-only format; 5) prohibit the sale or distribution of all brand-identifiable nontobacco items and services; 6) prohibit the sponsorship of all events using tobacco brand names; and 7) establish an industry-funded education campaign.

References

  1. US Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta: 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. Johnston L, Bachman J, O'Malley P. Cigarette smoking among American teens rises again in 1995. Ann Arbor, Michigan: University of Michigan News and Information Services, December 11, 1995.

  3. CDC. Accessibility of tobacco products to youths aged 12-17 years -- United States, 1989 and 1993. MMWR 1996;45:125-30.

  4. Kann L, Warren CW, Harris WA, et al. Youth risk behavior surveillance -- United States, 1993. MMWR 1995;44(no. SS-1).

  5. McIntosh H. Black teens not smoking in great numbers. J Natl Cancer Inst 1995;87:564.

  6. Institute of Medicine. Growing up tobacco free: preventing nicotine addiction in children and youths. Washington, DC: National Academy Press, 1994.

  7. Wildey MB, Woodruff SI, Pampalone SZ, et al. Self-service sale of tobacco: how it contributes to youth access. Tobacco Control 1995;4:355-61.

  8. US Department of Health and Human Services. State oversight of tobacco sales to minors. Washington, DC: US Department of Health and Human Services, Office of Inspector General, Office of Evaluation and Inspections, 1995; publication no. OEI-02-94-00270.

  9. Substance Abuse and Mental Health Services Administration. Final regulations to implement section 1926 of the Public Health Service Act regarding the sale and distribution of tobacco products to individuals under the age of 18. Federal Register 1996;13:1492-500.

  10. Food and Drug Administration. Regulations restricting the sale and distribution of cigarettes and smokeless tobacco products to protect children and adolescents: proposed rule analysis regarding FDA's jurisdiction over nicotine-containing cigarettes and smokeless tobacco products: proposed rule. Federal Register 1995;155:41,314-75.

    • Public Law 102-321, section 1926 (42 USC section 300x-26).


Table_1
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TABLE 1. Percentage of high school students who used cigarettes or smokeless tobacco,
by sex, race/ethnicity, and grade - United States, Youth Risk Behavior Survey, 1995 *
========================================================================================
                                Cigarette use                     Current
                      -------------------------------------      smokeless
                          Current +          Frequent &         tobacco use @
                      -----------------    ----------------   -----------------
Category                %   (95% CI **)      %    (95% CI)      %   (95% CI)
----------------------------------------------------------------------------------------
Sex
 Female               34.3    (+/-3.1%)    15.9   (+/-3.0%)    2.4   (+/-1.3%)
 Male                 35.4    (+/-2.4%)    16.3   (+/-2.8%)   19.7   (+/-2.5%)

Race/Ethnicity++
 White, non-Hispanic  38.3    (+/-2.6%)    19.5   (+/-3.5%)   14.5   (+/-1.7%)
  Female              39.8    (+/-3.2%)    20.8   (+/-3.8%)    2.5   (+/-1.1%)
  Male                37.0    (+/-3.3%)    18.4   (+/-3.7%)   25.1   (+/-3.0%)
 Black, non-Hispanic  19.2    (+/-3.0%)     4.5   (+/-1.8%)    2.2   (+/-1.0%)
  Female              12.2    (+/-3.0%)     1.3   (+/-0.7%)    1.1   (+/-1.2%)
  Male                27.8    (+/-5.6%)     8.5   (+/-3.4%)    3.5   (+/-1.4%)
 Hispanic             34.0    (+/-5.2%)    10.0   (+/-3.3%)    4.4   (+/-1.8%)
  Female              32.9    (+/-5.8%)     9.3   (+/-4.0%)    3.1   (+/-3.3%)
  Male                34.9    (+/-8.2%)    10.7   (+/-4.2%)    5.8   (+/-2.4%)

Grade
  9                   31.2    (+/-1.7%)     9.6   (+/-2.7%)   11.2   (+/-1.7%)
 10                   33.1    (+/-3.8%)    13.3   (+/-3.0%)    9.6   (+/-2.2%)
 11                   35.8    (+/-3.6%)    19.2   (+/-3.1%)   13.0   (+/-2.7%)
 12                   38.2    (+/-3.5%)    20.9   (+/-4.0%)   11.2   (+/-2.8%)
Total                 34.8    (+/-2.2%)    16.1   (+/-2.6%)   11.4   (+/-1.7%)
----------------------------------------------------------------------------------------
*  Sample sizes: 10,473 for current or frequent cigarette use and 10,772 for current
   smokeless tobacco use. Sample sizes differ because of missing data.
+  Smoked cigarettes on >=1 of the 30 days preceding the survey.
&  Smoked cigarettes on >=20 of the 30 days preceding the survey.
@  Used smokeless tobacco on >=1 of the 30 days preceding the survey.
** Confidence interval.
++ Numbers for other racial/ethnic groups were too small for meaningful analysis.
========================================================================================

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Table_2
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TABLE 2. Percentage distribution of usual source of cigarettes during the 30 days preceding the survey and percentage asked for
proof of age when buying cigarettes in a store, among high school students aged <=17 years who currently smoked cigarettes *, by
sex, race/ethnicity, grade, and frequency of cigarette smoking - United States, Youth Risk Behavior Survey, 1995
=========================================================================================================================================
                                                      Gave
                                  Bought in          someone        Borrowed                                         Not asked to show
                  Bought in       a vending        else money         from                           Obtained some     proof of age
                   a store +       machine           to buy         somebody           Stole           other way       when buying &
                --------------   -------------    --------------  ---------------   -------------    -------------   --------------------
Category         %  (95% CI @)    %  (95% CI)       %  (95% CI)     %  (95% CI)      %  (95% CI)      %  (95% CI)       %     (95% CI)
-----------------------------------------------------------------------------------------------------------------------------------------
Sex
 Female         36.5 (+/-5.3%)   0.9 (+/-0.5%)    21.9 (+/-5.3%)  31.7 ( +/-3.6%)   1.8 (+/-1.3%)    7.1 (+/-2.1%)    81.0   (+/-5.5%)
 Male           40.8 (+/-5.5%)   3.4 (+/-1.5%)    10.1 (+/-2.5%)  33.9 ( +/-5.8%)   6.4 (+/-2.1%)    5.4 (+/-1.3%)    74.7   (+/-4.1%)

Race/Ethnicity ++
 White,
  non-Hispanic  41.3 (+/-5.7%)   1.8 (+/-0.8%)    17.8 (+/-4.6%)  31.5 (+/- 5.3%)   3.7 (+/-1.6%)    3.8 (+/-1.2%)    76.5   (+/-5.1%)
 Black,
  non-Hispanic  27.2 (+/-7.6%)   6.1 (+/-4.4%)     7.3 (+/-5.7%)  41.0 (+/-10.1%)   7.9 (+/-3.9%)   10.4 (+/-3.9%)    86.0   (+/-6.6%)
 Hispanic       32.6 (+/-6.3%)   2.1 (+/-1.4%)    11.7 (+/-4.9%)  33.1 (+/- 6.5%)   5.1 (+/-2.3%)   15.4 (+/-3.8%)    79.7   (+/-8.1%)

Grade
  9             22.2 (+/-5.1%)   3.9 (+/-2.2%)    16.2 (+/-4.5%)  43.0 (+/- 7.7%)   6.5 (+/-2.5%)    8.2 (+/-2.9%)    83.2   (+/-7.3%)
 10             34.6 (+/-6.3%)   2.0 (+/-1.5%)    19.4 (+/-4.3%)  32.9 (+/- 5.7%)   3.3 (+/-2.0%)    7.8 (+/-2.6%)    75.3   (+/-5.5%)
 11             50.8 (+/-6.5%)   1.6 (+/-1.2%)    13.2 (+/-4.5%)  27.2 (+/- 4.5%)   3.1 (+/-2.1%)    4.0 (+/-2.0%)    76.1   (+/-3.4%)
 12             50.4 (+/-7.0%)   1.0 (+/-1.7%)    13.3 (+/-7.8%)  26.9 (+/- 6.7%)   4.1 (+/-3.2%)    4.4 (+/-4.2%)    77.9   (+/-9.7%)

Frequency
 of cigarette
 smoking **
 1  5           15.9 (+/-3.4%)   1.9 (+/-1.4%)     6.6 (+/-3.4%)  63.1 (+/- 5.3%)   3.1 (+/-2.3%)    9.4 (+/-3.0%)    88.2   (+/-6.7%)
 6-19           35.2 (+/-5.5%)   1.6 (+/-0.8%)    19.9 (+/-4.7%)  34.8 (+/- 4.6%)   2.3 (+/-1.7%)    6.3 (+/-2.9%)    81.9   (+/-6.9%)
 >=20           60.9 (+/-7.8%)   2.4 (+/-1.5%)    21.9 (+/-6.8%)   6.6 (+/- 2.0%)   5.1 (+/-2.0%)    3.2 (+/-2.0%)    71.1   (+/-5.6%)

Total           38.7 (+/-4.6%)   2.2 (+/-0.9%)    15.8 (+/-3.6%)  32.9 (+/- 4.0%)   4.2 (+/-1.4%)    6.2 (+/-1.6%)    17.5   (+/-4.0%)
-----------------------------------------------------------------------------------------------------------------------------------------
*  Smoked cigarettes on >=1 of the 30 days preceding the survey (n=2989).
+  Convenience store, supermarket, or gas station.
&  Among students who ever bought cigarettes in a store during the 30 days preceding the survey (n=1904).
@  Confidence interval.
++ Numbers for other racial/ethnic groups were too small for meaningful analysis.
** Number of days of the 30 days preceding the survey on which cigarettes were smoked.
=========================================================================================================================================

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