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Tobacco Use Among Middle and High School Students -- Florida, 1998 and 1999

Tobacco use is the single leading preventable cause of death in the United States (1), and an estimated $2 billion is spent annually in Florida to treat disease caused by smoking (2). Florida appropriated $23 million in fiscal year 1997 and $70 million in fiscal year 1998 to fund the Florida Pilot Program on Tobacco Control to prevent and reduce tobacco use among Florida youth. To determine the prevalence of cigarette, cigar, and smokeless tobacco (i.e., chewing tobacco and snuff) use among Florida middle and high school students in public schools, the Florida Department of Health conducted the Florida Youth Tobacco Survey (FYTS) in February 1998 and February 1999. The purpose of these surveys was to establish baseline parameters and monitor the progress of the pilot program, which began in April 1998. This report summarizes advance data from the surveys, which indicate that, from 1998 to 1999, the percentage of Florida public middle and high school students who smoked cigarettes decreased significantly and that the percentage of middle school students who smoked cigars and used smokeless tobacco products decreased significantly.

The 1998 FYTS used a two-stage cluster sample design within each of seven geographic regions (i.e., selecting schools within a region and classrooms within schools) for public middle schools (grades 6-8) and for public high schools (grades 9-12) to obtain a representative sample of 11,865 middle and 10,675 high school students. The 1999 survey was conducted in 242 of the 255 schools that participated in the 1998 survey sample, among a representative sample of 11,724 middle and 9254 high school students. The middle school response rates for 1998 and 1999 were 97% and 93%, respectively; the student response rates were 82% and 88%, respectively; and the overall response rates were 80% and 82%, respectively. For the high school surveys, school response rates for 1998 and 1999 were 95% and 89%, respectively; the student response rates were 76% and 79%, respectively; and the overall response rates were 72% and 70%, respectively. Data were weighted to provide estimates that can be generalized to all public school students in grades 6-12 in the seven regions and in the state. Survey data were analyzed and point estimates were generated using SAS software, and variance estimates and 95% confidence intervals were calculated using SUDAAN.

Students completed a self-administered questionnaire that included questions about tobacco use (cigarette, cigar, and smokeless tobacco), exposure to environmental tobacco smoke, minors' ability to purchase or otherwise obtain tobacco products, knowledge and attitudes about tobacco, familiarity with pro- and antitobacco media messages, and tobacco-use curriculum in schools. Current tobacco use prevalence data are presented in this report; data on other findings and survey methodology are available from the Florida Department of Health (3). Current cigarette, cigar, and smokeless tobacco users were students who reported product use on greater than or equal to 1 of the 30 days preceding the survey.

From 1998 to 1999, the prevalence of current cigarette use among middle school students declined from 18.5% to 15.0% (pless than 0.01) (Table_1); among high school students, use declined from 27.4% to 25.2% (p=0.02) (Table_2). Among middle school students, declines in current cigarette use were significant for both males and females; among high school students, the decline was statistically significant among females. Among both middle and high school students, the declines were most pronounced among non-Hispanic white students: from 22.0% to 16.1% (pless than 0.01) among middle school students and from 34.8% to 31.3% (p=0.02) among high school students. The change in prevalence of current cigarette use among non-Hispanic black or Hispanic students at the middle or high school level was not statistically significant. Prevalence of current cigarette use in these groups was lower than that among non-Hispanic whites in both 1998 and 1999.

Current cigar use declined significantly only among middle school students, from 14.1% in 1998 to 11.9% in 1999 (pless than 0.01). This overall decline was almost entirely accounted for by the decline among males, from 17.6% to 14.2%. Among racial/ethnic groups at the middle school level, the decline in current use of cigars was statistically significant only among non-Hispanic white students.

Current smokeless tobacco use declined among middle school students from 6.9% in 1998 to 4.9% in 1999. The decline occurred among male and female middle school students and among non-Hispanic white and Hispanic middle school students. Students at every grade in middle school were significantly less likely to use smokeless tobacco in 1999 than in 1998. Current use of smokeless tobacco products remained unchanged among high school students from 1998 to 1999.

Reported by: U Bauer, PhD, T Johnson, J Pallentino, JD, R Hopkins, MD, State Epidemiologist, W McDaniel, RG Brooks, MD, Secretary, Florida Dept of Health. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Nationwide, the prevalence of cigarette smoking among adolescents has increased during the 1990s (4,5); however, smoking prevalence rates among adolescents may have peaked and could be starting to decline (6). National data for comparison with the Florida data for 1998 and 1999 are unavailable, but the significant decline from 1998 to 1999 in Florida is larger than any annual decline observed nationally among youth since 1980 (5,6). In California and Massachusetts, which have initiated comprehensive tobacco prevention and education efforts, annual smoking rate increases among youth appear to have slowed, but no decline similar to that reported in Florida has been observed (7,8).

The Florida Pilot Program on Tobacco Control implements activities to combat tobacco use among youth aged less than 18 years and tobacco's attractiveness to youths. The program's major component is a youth-oriented, counter-marketing media campaign developed to reduce the allure of smoking. Community partnerships in all 67 Florida counties, an education and training initiative, and enhanced enforcement of youth tobacco access laws are the other program components. The FYTS is a key instrument to assess the program's effectiveness; however, more direct assessments are needed to determine how much of the decline in tobacco use can be attributed to the various pilot program activities and how much may be a result of cigarette price increases that occurred during the study period. Additional evaluation of program activities can be used to strengthen the program's effectiveness for diverse populations such as non-Hispanic black and Hispanic students, among whom no statistically significant declines in cigarette use were observed.

The findings described in this report are subject to at least four limitations. First, these data apply only to youth who attend public middle or high school and, therefore, are not representative of all persons in this age group. During the 1997-98 school year in Florida, 5.9% of persons aged greater than or equal to 16 years had left a high school program and had not completed high school (M.J. Butler, Florida Department of Education, personal communication, 1999). In addition, approximately 11% of middle and high school students are enrolled in private schools. Second, in both survey years, tobacco use is based on self-report. Third, trend analysis is limited to 2 years and will be enhanced by additional data collection. Finally, data are not available to fully assess the impact of recent cigarette price increases and program activities on the decline in tobacco use in Florida.

Comparisons between the significant decline in tobacco use among middle and high school students in Florida and trends in the United States overall will enable the findings in this report to be assessed more fully. However, if the observed declines in youth tobacco use are sustained over time, programs similar to the Florida Pilot Program on Tobacco Control or program components should be considered by other states to reverse the nationwide increase in youth smoking observed during the 1990s (4,5).

References

  1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207-12.

  2. CDC. State tobacco control highlights -- 1996. Atlanta, Georgia: US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1996; CDC publication no. 099-4895.

  3. Florida Department of Health. Online tobacco education resources. Available at , click on "Research." Accessed March 29, 1999.

  4. CDC. Tobacco use among high school students -- United States, 1997. MMWR 1998;47:229-33.

  5. Johnston LD, O'Malley PM, Bachman JG. National survey results on drug use from the Monitoring the Future study, 1975-1997. Vol 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, 1998; NIH publication no. 98-4345.

  6. Johnston L, Bachman J, O'Malley P. Smoking among American teens declines some. Ann Arbor, Michigan: University of Michigan News and Information Services, December 18, 1998.

  7. Independent Evaluation Consortium. Final report of the independent evaluation of the California Tobacco Prevention and Education Program: wave I data, 1996-1997. Rockville, Maryland: Gallup Organization, 1998.

  8. Connolly G, Robbins H. Designing an effective statewide tobacco control program -- Massachusetts. Cancer 1998;83:2722-7.



    Table_1
    Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.
    
    TABLE 1. Percentage of public middle school students who used cigarettes, cigars, or smokeless tobacco, by sex,
    race/ethnicity, and grade -- Florida Youth Tobacco Survey, 1998 and 1999
    ====================================================================================================================================================================================
                                        Current cigarette use*                                      Current cigar use+                             Current smokeless tobacco use&
                            -------------------------------------------------     --------------------------------------------------    -----------------------------------------------
                                   1998                 1999                             1998                  1999                          1998               1999
                               (n=11,031)             (n=10,268)                      (n=11,535)            (n=10,890)                     (n=11,633)         (n=10,919)
                            ----------------      ----------------                -----------------      ----------------               ---------------    ----------------
    Characteristic            %    (95% CI@)        %     (95% CI)    p value        %     (95% CI)        %     (95% CI)    p value     %     (95% CI)      %     (95% CI)    p value
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    Sex
     Female                 18.1    (+/-1.5)      14.9    (+/-1.8)     <0.01       10.3    (+/-1.0)       9.4    (+/-1.4)      0.26     4.4    (+/-0.6)     2.8    (+/-0.6)     <0.01
     Male                   18.9    (+/-1.7)      15.0    (+/-1.4)     <0.01       17.6    (+/-1.3)      14.2    (+/-1.3)     <0.01     9.3    (+/-1.1)     6.8    (+/-0.9)     <0.01
    Race/Ethnicity**
     Non-Hispanic white     22.0    (+/-1.8)      16.1    (+/-1.7)     <0.01       14.5    (+/-1.2)      11.1    (+/-1.4)     <0.01     7.6    (+/-1.1)     4.8    (+/-0.8)     <0.01
     Non-Hispanic black      9.5    (+/-1.4)       8.5    (+/-1.5)      0.34       13.0    (+/-1.6)      12.3    (+/-1.9)      0.55     5.3    (+/-1.1)     4.4    (+/-1.4)      0.27
     Hispanic               16.8    (+/-2.1)      16.1    (+/-2.6)      0.51       13.6    (+/-1.7)      12.9    (+/-2.3)      0.53     5.5    (+/-1.3)     3.6    (+/-1.1)      0.02
    Grade
     6                      10.5    (+/-1.4)       8.0    (+/-1.3)      0.01        7.8    (+/-0.9)       6.7    (+/-1.2)      0.16     6.0    (+/-1.0)     3.9    (+/-0.9)     <0.01
     7                      19.3    (+/-2.1)      16.6    (+/-2.5)      0.07       14.2    (+/-1.7)      11.4    (+/-1.8)      0.02     7.0    (+/-1.2)     5.2    (+/-1.0)      0.01
     8                      25.0    (+/-2.3)      19.5    (+/-2.5)     <0.01       19.5    (+/-1.7)      16.8    (+/-2.2)      0.06     7.1    (+/-1.1)     4.8    (+/-1.0)     <0.01
    Total                   18.5    (+/-1.4)      15.0    (+/-1.3)     <0.01       14.1    (+/-1.0)      11.9    (+/-1.1)     <0.01     6.9    (+/-0.7)     4.9    (+/-0.6)     <0.01
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    *  Smoked cigarettes on >=1 of the 30 days preceding the survey.
    +  Smoked cigars on >=1 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
    Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.
    
    TABLE 2. Percentage of public high school students who used cigarettes, cigars, or smokeless tobacco, by sex, race/ethnicity,
    and grade -- Florida Youth Tobacco Survey, 1998 and 1999
    ============================================================================================================================================================================
                                        Current cigarette use*                               Current cigar use+                          Current smokeless tobacco use&
                          --------------------------------------------------    ----------------------------------------------   ----------------------------------------------
                                   1998               1999                             1998              1999                          1998              1999
                                (n=9,991)           (n=9,991)                       (n=10,473)         (n=9,099)                     (n=10,202)        (n=9,041)
                           ------------------    ----------------               ----------------    ----------------             ----------------   ---------------
    Characteristic           %      (95% CI@)     %      (95% CI)    p value      %     (95% CI)     %      (95% CI)   p value     %    (95% CI)      %   (95% CI)    p value
    ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    Sex
     Female                 28.3    (+/-1.9)     25.9    (+/-2.0)      0.04     14.1    (+/-1.2)    14.1    (+/-1.6)     0.96     2.1    (+/-0.5)    2.4   (+/-0.7)      0.59
     Male                   26.5    (+/-1.9)     24.6    (+/-2.4)      0.16     27.0    (+/-1.8)    24.7    (+/-1.9)     0.08    11.2    (+/-1.6)   10.3   (+/-1.6)      0.26
    Race/Ethnicity**
     Non-Hispanic white     34.8    (+/-1.8)     31.3    (+/-2.0)      0.02     22.7    (+/-1.6)    21.4    (+/-2.2)     0.24     8.7    (+/-1.5)    8.0   (+/-1.7)      0.32
     Non-Hispanic black      9.8    (+/-1.5)      9.4    (+/-1.9)      0.61     17.1    (+/-2.1)    14.8    (+/-1.9)     0.09     3.5    (+/-1.1)    2.8   (+/-0.7)      0.24
     Hispanic               24.8    (+/-2.6)     24.2    (+/-2.8)      0.70     17.9    (+/-2.0)    18.5    (+/-2.4)     0.82     2.9    (+/-0.8)    4.4   (+/-1.2)      0.07
    Grade
     9                      25.9    (+/-2.6)     23.3    (+/-2.8)      0.17     19.3    (+/-2.3)    18.8    (+/-2.7)     0.78     6.5    (+/-1.4)    6.8   (+/-1.7)      0.74
     10                     25.5    (+/-2.8)     24.4    (+/-2.8)      0.50     19.5    (+/-2.2)    19.1    (+/-2.2)     0.76     7.0    (+/-1.7)    5.9   (+/-1.5)      0.38
     11                     29.8    (+/-2.5)     27.0    (+/-2.4)      0.08     23.2    (+/-2.5)    19.2    (+/-2.2)     0.01     7.3    (+/-1.4)    5.3   (+/-1.1)      0.02
     12                     29.8    (+/-2.9)     27.8    (+/-4.0)      0.32     21.5    (+/-2.7)    21.2    (+/-2.8)     0.86     6.4    (+/-1.3)    7.1   (+/-1.7)      0.47
    Total                   27.4    (+/-1.6)     25.2    (+/-1.8)      0.02     20.7    (+/-1.2)    19.5    (+/-1.5)     0.14     6.7    (+/-1.0)    6.4   (+/-0.9)      0.22
    ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    *  Smoked cigarettes on >=1 of the 30 days preceding the survey.
    +  Smoked cigars on >=1 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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