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Cigarette Use Among High School Students --- United States, 1991--2007

Cigarette use is the leading preventable cause of death in the United States (1). A national health objective for 2010 is to reduce the prevalence of current cigarette use among high school students to 16% or less (27-2b) (1). To examine changes in cigarette use among high school students in the United States during 1991--2007, CDC analyzed data from the national Youth Risk Behavior Survey (YRBS). This report summarizes the results of that analysis, which indicated that the prevalence of lifetime cigarette use was stable during 1991--1999 and then declined from 70.4% in 1999 to 50.3% in 2007. The prevalence of current cigarette use increased from 27.5% in 1991 to 36.4% in 1997, declined to 21.9% in 2003, and remained stable from 2003 to 2007. The prevalence of current frequent cigarette use increased from 12.7% in 1991 to 16.8% in 1999 and then declined to 8.1% in 2007. To resume the declines observed in current cigarette use during 1997--2003 and achieve the 2010 objective, communitywide comprehensive tobacco-control programs that use coordinated evidence-based strategies should be implemented and revitalized.

The biennial national YRBS, a component of CDC's Youth Risk Behavior Surveillance System, used independent, three-stage cluster samples for the 1991--2007 surveys to obtain cross-sectional data representative of public and private school students in grades 9--12 in all 50 states and the District of Columbia (2). Sample sizes ranged from 10,904 to 16,296. For each cross-sectional national survey, students completed anonymous, self-administered questionnaires that included identically worded questions about cigarette use. School response rates ranged from 70% to 81%, and student response rates ranged from 83% to 90%; therefore, overall response rates for the surveys ranged from 60% to 70%.

For this analysis, temporal changes for three behaviors were assessed: lifetime cigarette use (i.e., ever tried cigarette smoking, even one or two puffs), current cigarette use (i.e., smoked cigarettes on at least 1 day during the 30 days before the survey), and current frequent cigarette use (i.e., smoked cigarettes on 20 or more days during the 30 days before the survey). Race/ethnicity data are presented only for non-Hispanic black, non-Hispanic white, and Hispanic students (who might be of any race); the numbers of students from other racial/ethnic groups were too small for meaningful analysis.

Data were weighted to provide national estimates, and statistical software used for all data analyses accounted for the complex sample design. Temporal changes were analyzed using logistic regression analyses, which controlled for sex, race/ethnicity, and grade and simultaneously assessed linear, quadratic, and cubic time effects (p<0.05).*

Significant linear and quadratic trends were detected for lifetime and current frequent cigarette use (Table 1). The prevalence of lifetime cigarette use was stable during 1991--1999 and then declined from 70.4% in 1999 to 50.3% in 2007. The prevalence of current frequent cigarette use increased from 12.7% in 1991 to 16.8% in 1999 and then declined to 8.1% in 2007.

Significant linear, quadratic, and cubic trends were detected for current cigarette use. The prevalence of current cigarette use increased from 27.5% in 1991 to 36.4% in 1997, declined to 21.9% in 2003, and remained stable from 2003 to 2007. For current cigarette use, similar patterns were detected among the sex subgroups overall, all grade subgroups, and white and Hispanic students (Table 2).

Among black students overall and black male students, significant quadratic and cubic trends were detected. The prevalence of current cigarette use among black students overall increased from 12.6% in 1991 to 22.7% in 1997, declined to 14.7% in 2001, and then declined more gradually to 11.6% in 2007. Among black male students, the prevalence of current cigarette use increased from 14.1% in 1991 to 28.2% in 1997, declined to 16.3% in 2001, and then remained stable from 2001 to 2007. Among black female students, a significant linear and quadratic trend was detected. The prevalence of current cigarette use increased from 11.3% in 1991 to 17.7% in 1999 and then declined to 8.4% in 2007.

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

Editorial Note:

The findings in this report show that current cigarette use among high school students declined from 1997 to 2003, but rates remained stable from 2003 to 2007. This trend is consistent with 30-day cigarette use trends reported from the Monitoring the Future survey (an ongoing national study of the behaviors, attitudes, and values of 8th, 10th, and 12th grade students), which also show declines starting in the late 1990s and stable rates more recently (3).

The sharp increase in cigarette use during the early to mid-1990s observed in this and other surveys might have resulted from expanded tobacco company promotional efforts, including discounted prices on cigarette brands most often smoked by adolescents, product placement in movies, development of nontobacco product lines with company symbols (e.g., hats and t-shirts), and sponsorship of music concerts and other youth-focused events (4). Evidence suggests that exposure to pro-tobacco marketing and depictions of tobacco use in films and videos and on television more than doubles the odds of adolescents initiating tobacco use (5). Communitywide programs to counteract pro-tobacco marketing and resume the declines in youth tobacco use observed during 1997--2003 should include combinations of counter-advertising mass media campaigns; comprehensive school-based tobacco-use prevention policies and programs; community interventions that reduce tobacco advertising, promotions, and commercial availability of tobacco products; and higher prices for tobacco products through increases in unit prices and excise taxes (5--7).

The differences in current cigarette use among racial/ethnic subgroups suggest that lower rates of current cigarette use among high school students are achievable. The data in this analysis show that current cigarette use remained stable among white and Hispanic students overall from 2003 to 2007, but among black students overall, current cigarette use continued to decline. This decline can be attributed largely to declines among black female students. Whereas rates among black male students remained stable from 2001 to 2007, black female students showed a continued decline in current cigarette use from 1999 to 2007. In 2007, black female students had the lowest rate of current cigarette use among all sex and racial/ethnic subgroups.

The findings in this report are subject to at least two limitations. First, these data apply only to youths who attend school and, therefore, are not representative of all persons in this age group. Nationwide, in 2005, of persons aged 16--17 years, approximately 3% were not enrolled in a high school program and had not completed high school (8). Second, the extent of underreporting or overreporting of cigarette use cannot be determined, although the survey questions demonstrate good test-retest reliability (9), and high school students do not tend to underreport cigarette use (10).

The national health objective for 2010 of reducing current cigarette use among high school students to less than 16% can be achieved if the declines in current cigarette observed during 1997--2003 resume. Communitywide, comprehensive tobacco-control programs that use coordinated evidence-based strategies should be implemented and revitalized to further limit cigarette use by high school students. A better understanding of the factors responsible for the continued decline and low rate of current cigarette use among black female students can help guide and strengthen comprehensive tobacco-control efforts in the future for all use.

References

  1. US Department of Health and Human Services. Tobacco use; 27-2: reduce tobacco use by adolescents. In: Healthy people 2010: understanding and improving health. 2nd ed. Washington, DC: US Department of Health and Human Services; 2000. Available at http://www.healthypeople.gov/document/pdf/volume2/27tobacco.pdf.
  2. CDC. Methodology of the Youth Risk Behavior Surveillance System. MMWR 2004;53(No. RR-12).
  3. Johnston LD, O'Malley PM, Bachman JG, Schulenberg JE. Trends on cigarette smoking and smokeless tobacco, table 1. Ann Arbor, MI: University of Michigan; 2007. Available at http://monitoringthefuture.org/data/07data/pr07cig1.pdf.
  4. Nelson DE, Mowery P, Asman K, et al. Long-term trends in adolescent and young adult smoking in the United States: metapatterns and implications. Am J Public Health 2008;98:905--15.
  5. Wellman RJ, Sugarman DB, DiFranza JR, Winickoff JP. The extent to which tobacco marketing and tobacco use in films contribute to children's use of tobacco. Arch Pediatr Adolesc Med 2006;160:1285--96.
  6. Zaza S, Briss PA, Harris KW, eds. Tobacco. In: The guide to community preventive services: what works to promote health? New York, NY: Oxford University Press; 2005. Available at http://www.thecommunityguide.org/tobacco/default.htm.
  7. CDC. Best practices for comprehensive tobacco control programs---2007. Atlanta, GA: US Department of Health and Human Services, CDC; 2007. Available at http://www.cdc.gov/tobacco/tobacco_control_programs/stateandcommunity/best_practices.
  8. Laird J, Kienzl G, DeBell M, Chapman C. Dropout rates in the United States: 2005. Washington, DC: US Department of Education, National Center for Education Statistics, 2007. NCES publication no. 2007--059.
  9. Brener ND, Kann L, McManus T, Kinchen SA, Sundberg EC, Ross JG. Reliability of the 1999 Youth Risk Behavior Survey questionnaire. J Adolesc Health 2002;31:336--42.
  10. Messeri PA, Allen JA, Mowery PD, et al. Do tobacco countermarketing campaigns increase adolescent under-reporting of smoking? Addict Beh 2007;32:1532--6.

* Quadratic and cubic trends indicate a significant but nonlinear trend in the data over time (e.g., whereas a linear trend is depicted with a straight line, a quadratic trend is depicted with a curve with one bend and a cubic trend with a curve with two bends). Trends that include significant cubic or quadratic and linear components demonstrate nonlinear variation in addition to an overall increase or decrease over time.

Table 1

TABLE 1. Percentage of high school students who reported lifetime cigarette use,* current cigarette use,† and current frequent
cigarette use§ — Youth Risk Behavior Survey, United States, 1991–2007Ά
Cigarette 1991 1993 1995 1997 1999 2001 2003 2005 2007
use % (95% CI**) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI)
Lifetime†† 70.1 69.5 71.3 70.2 70.4 63.9 58.4 54.3 50.3
(67.8–72.3) (68.1–70.8) (69.5–73.0) (68.2–72.1) (67.3–73.3) (61.6–66.0) (55.1–61.6) (51.2–57.3) (47.2–53.5)
Current§§ 27.5 30.5 34.8 36.4 34.8 28.5 21.9 23.0 20.0
(24.8–30.3) (28.6–32.4) (32.5–37.2) (34.1–38.7) (32.3–37.4) (26.4–30.6) (19.8–24.2) (20.7–25.5) (17.6–22.6)
Current 12.7 13.8 16.1 16.7 16.8 13.8 9.7 9.4 8.1
frequent†† (10.6–15.3) (12.1–15.5) (13.6–19.1) (14.8–18.7) (14.3–19.6) (12.3–15.5) (8.3–11.3) (7.9–11.0) (6.7–9.8)
* Ever tried cigarette smoking, even one or two puffs.
† Smoked cigarettes on at least 1 day during the 30 days before the survey.
§ Smoked cigarettes on 20 or more days during the 30 days before the survey.
Ά Linear, quadratic, and cubic trend analyses were conducted using a logistic regression model controlling for sex, race/ethnicity, and grade. These prevalence estimates are not
standardized by demographic variables.
** Confidence interval.
†† Significant linear and quadratic effects only (p<0.05).
§§ Significant linear, quadratic, and cubic effects (p<0.05).
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Table 2

TABLE 2. Percentage of high school students who reported current cigarette use,* by sex, race/ethnicity, and grade — Youth Risk
Behavior Survey, United States, 1991–2007†
1991 1993 1995 1997 1999 2001 2003 2005 2007
Characteristic % (95% CI§) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI)
Sex
FemaleΆ 27.3 31.2 34.3 34.7 34.9 27.7 21.9 23.0 18.7
(23.9–31.0) (29.1–33.4) (31.0–37.7) (31.8–37.6) (32.3–37.7) (25.6–30.0) (19.2–24.9) (20.4–25.8) (16.5–21.1)
MaleΆ 27.6 29.8 35.4 37.7 34.7 29.2 21.8 22.9 21.3
(24.6–30.9) (27.4–32.3) (32.9–37.9) (35.0–40.6) (31.8–37.7) (26.7–32.0) (19.8–24.1) (20.7–25.3) (18.3–24.6)
Race/Ethnicity**
White, non- 30.9 33.7 38.3 39.7 38.6 31.9 24.9 25.9 23.2
HispanicΆ (27.6–34.5) (31.4–36.0) (35.6–41.1) (37.3–42.2) (35.5–41.9) (29.6–34.4) (22.4–27.5) (22.9–29.2) (20.4–26.2)
FemaleΆ 31.7 35.3 39.8 39.9 39.1 31.2 26.6 27.0 22.5
(27.1–36.7) (32.6–38.0) (36.3–43.5) (36.6–43.2) (35.4–42.9) (28.7–33.7) (22.9–30.5) (23.4–31.0) (19.6–25.7)
MaleΆ 30.2 32.2 37.0 39.6 38.2 32.7 23.3 24.9 23.8
(26.5–34.3) (29.4–35.0) (33.7–40.5) (35.8–43.5) (34.6–41.8) (29.7–35.9) (20.7–26.0) (22.2–27.7) (20.2–27.8)
Black, non- 12.6 15.4 19.1 22.7 19.7 14.7 15.1 12.9 11.6
Hispanic†† (10.2–15.5) (12.9–18.2) (16.1–22.6) (19.0–26.8) (15.8–24.3) (12.0–17.9) (12.4–18.2) (11.1–14.8) (9.5–14.1)
Female§§ 11.3 14.4 12.2 17.4 17.7 13.3 10.8 11.9 8.4
(9.2–13.9) (11.9–17.4) (9.3–15.7) (13.8–21.7) (14.4–21.7) (10.1–17.2) (8.2–14.2) (10.2–13.8) (6.6–10.6)
Male†† 14.1 16.3 27.8 28.2 21.8 16.3 19.3 14.0 14.9
(10.1–19.4) (12.4–21.1) (22.5–33.9) (23.0–34.1) (15.4–29.9) (13.2–19.8) (15.8–23.5) (11.5–16.9) (11.7–18.8)
HispanicΆ 25.3 28.7 34.0 34.0 32.7 26.6 18.4 22.0 16.7
(22.5–28.2) (25.8–31.8) (28.7–39.6) (31.3–36.9) (29.0–36.6) (22.4–31.2) (16.1–20.9) (18.7–25.8) (13.5–20.4)
FemaleΆ 22.9 27.3 32.9 32.3 31.5 26.0 17.7 19.2 14.6
(19.2–27.1) (23.5–31.5) (27.4–39.0) (28.6–36.2) (26.8–36.5) (22.3–30.0) (15.6–19.9) (16.4–22.5) (11.3–18.8)
MaleΆ 27.8 30.2 34.9 35.5 34.0 27.2 19.1 24.8 18.7
(24.3–31.8) (26.7–33.8) (26.6–44.3) (31.9–39.2) (29.7–38.7) (20.6–35.0) (15.8–23.0) (20.0–30.4) (15.0–23.2)
School grade
9thΆ 23.2 27.8 31.2 33.4 27.6 23.9 17.4 19.7 14.3
(19.5–27.4) (25.4–30.3) (29.5–32.9) (28.4–38.9) (24.0–31.6) (21.1–27.0) (15.0–20.1) (17.5–22.1) (11.9–17.1)
10thΆ 25.2 28.0 33.1 35.3 34.7 26.9 21.8 21.4 19.6
(22.5–28.1) (24.7–31.6) (29.3–37.1) (31.2–39.7) (32.2–37.2) (23.8–30.3) (19.0–24.9) (18.4–24.8) (16.7–22.8)
11thΆ 31.6 31.1 35.9 36.6 36.0 29.8 23.6 24.3 21.6
(27.8–35.7) (27.9–34.4) (32.0–39.9) (32.9–40.4) (33.1–39.1) (26.1–33.7) (20.5–27.0) (21.2–27.7) (18.4–25.2)
12thΆ 30.1 34.5 38.2 39.6 42.8 35.2 26.2 27.6 26.5
(25.7–34.8) (30.7–38.5) (34.6–41.9) (34.7–44.6) (37.2–48.5) (31.1–39.5) (23.4–29.3) (24.0–31.5) (22.5–30.8)
* Smoked cigarettes on at least 1 day during the 30 days before the survey.
† Linear, quadratic, and cubic trend analyses were conducted using a logistic regression model controlling for sex, race/ethnicity, and grade in school. These prevalence
estimates are not standardized by demographic variables.
§ Confidence interval.
Ά Significant linear, quadratic, and cubic effects (p<0.05).
** Numbers for other racial/ethnic groups were too small for meaningful analysis.
†† Significant quadratic and cubic effects only (p<0.05).
§§ Significant linear and quadratic effects only (p<0.05).
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Date last reviewed: 6/26/2008

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