6: No. 3, July 2009
Co-use of Alcohol and Tobacco Among
Ninth-Graders in Louisiana
Carolyn C. Johnson, PhD; Larry S. Webber, PhD; Leann Myers, PhD; Neil W. Boris, MD; Gerald S. Berenson, MD
Suggested citation for this article: Johnson CC, Webber LS, Myers L, Boris NW, Berenson GS.
Co-use of alcohol and tobacco among ninth-graders in Louisiana. Prev Chronic Dis 2009;6(3):A85. http://www.cdc.gov/pcd/issues/2009/
jul/08_0157.htm. Accessed [date].
The co-use of alcohol and tobacco by adolescents is a public health problem that continues well into adulthood and results in negative behavioral, social, and health consequences. The purpose of this study was to examine the
co-use of alcohol and tobacco among ninth-graders in south-central Louisiana.
We created a health habits survey to collect data from 4,750 ninth-grade students, mean age 15.4 years. Cross-sectional analysis used
χ2, 1-way analysis of variance, and logistic regression methods.
Almost 20% of students were co-users. Students who were white, performed poorly in school,
did not expect to graduate high school, and had more discretionary money to spend
were more likely to be co-users. Co-users had friends who got drunk weekly and
were more likely to approve of
alcohol use among friends than among adults. Significant differences in attitudes toward drinking and smoking were observed between
co-users and nonusers. For adolescent drinkers, including girls, hard liquor
was the preferred beverage.
These data for high school students are applicable for prevention strategies at a critical age when
harmful health behaviors can mark the start of lifelong habits. Intervention efforts will be successful only
if they account for multiple levels of influence.
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Adolescent alcohol and tobacco use are public health problems. Federal legislation in 1984 mandated 21 years as the legal age for purchasing and drinking alcohol, and the legal age for purchasing tobacco is 18 years in most states (1-3). Numerous studies have shown, however, that adolescents
who are younger than 18 have easy access to both alcohol and tobacco, and availability is so widespread among youth that targeting availability may be a failed intervention strategy (4-6).
Longitudinal data show that the prevalence of alcohol and tobacco use among
into adulthood and does not begin to decrease until older ages (7).
In 2004, the US Surgeon General stressed that tobacco use causes diseases in nearly every organ of the body (8), and alcohol use in adolescence
can lead to violence (including homicides and suicides),
drowning, sexually transmitted diseases, school failure, and motor vehicle crashes. Driving while under the influence of alcohol is the leading cause of death in the United States for people aged 16 to 24 years (9,10). Extensive research has examined adolescent drinking and smoking separately, but data regarding the co-use of alcohol and tobacco are sparse (7).
Researchers have addressed psychosocial risk factors, patterns of initiation and maintenance, and even physiological and genetic contributions (11-15) for the use of tobacco and alcohol separately. Characteristics of adolescents who
use alcohol and tobacco concomitantly need to be identified because these
unhealthy behaviors often occur together.
We conducted a tobacco use prevention program, Acadiana Coalition of Teens Against Tobacco (ACTT), for high school students in south-central Louisiana. Participation by youth in national surveys has traditionally been low in this area (16,17). In this study we examined the concomitant use of alcohol and tobacco among adolescents in Acadiana during their first year of high school.
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We defined the ACTT cohort as all students enrolled in ninth grade in 24 public schools in 6 school districts and conducted baseline measurement on 4,763 students, average age 15 years. Twenty-two of the 24 schools contacted agreed to participate. We used 2 schools to develop and test instruments and intervention activities. After baseline measurement, we randomized participating schools to
intervention or control conditions; therefore, these data are not reported by condition but
in the aggregate.
Health Habits Survey
The Health Habits Survey was developed by a committee consisting of the
principal investigator, co-investigators, and program staff. Items were
extracted from Monitoring the Future (17), the Youth Risk Behavior Surveillance
System (18), and the Bogalusa Heart Study (19). The final document (5) contained
a total of 54 items in 5 sections: demographics, tobacco and alcohol use,
attitudes/beliefs about smoking and drinking, and social relationships involving
alcohol and tobacco (Appendix). Demographic items were age, sex, race, academic
performance (students were asked if their grades were mostly A’s, B’s, C’s, D’s,
or F’s), immediate goals (Looking ahead, what are your most immediate goals?), discretionary money (How much money do you usually spend per week any way you want?), and physical activity (the question was
On how many of the past 7 days did you exercise or
participate in physical activities for at least 20 minutes that made you sweat and breathe hard?). The following questions assessed 30-day prevalence for alcohol and tobacco use: During the past 30 days, how often have you had at least 1 beer, 1 glass of wine, or 1 shot of liquor? and During the past 30 days, have you smoked at least 1 cigarette? For questions regarding attitudes and beliefs about alcohol and tobacco use, Likert scale responses were obtained (Appendix).
With approval from the Tulane University institutional review board, students participated in the Health Habits Survey with “passive” consent; that is, parents signed and returned the form only if they objected to participation. Students also completed an assent form at time of administration. Staff trained in standardized protocols administered surveys in classrooms or assemblies, and a second administration was scheduled if participation was initially low. Using school enrollment lists, we randomly
assigned each student a unique 5-digit identification number before survey administration.
We used χ2 analysis to evaluate prevalence, race, sex differences, and categorical outcomes, and 1-way analysis of variance for continuous outcomes. When the distributional assumptions of analysis of variance were not met, the Kruskal-Wallis test was used. We used logistic regression methods to model alcohol prevalence as a function of relationship variables. All analyses were performed
with SAS version 9.1 (SAS Institute, Inc, Cary, North Carolina). We included all students in the
calculation of demographic frequencies, but those who self-reported as Latino, Asian American, American Indian, or “other” were excluded from additional analyses because of small sample sizes.
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Of 5,156 available ninth-graders, 4,808 responded to the survey, for a participation rate of 93.3%. Nonresponse was due to parental or student refusals
(or both) and student absences during the survey administration. Another 58 students’ data were deleted because of missing sex, race, or alcohol or tobacco use
data, resulting in 4,750 students for analysis.
Students’ mean age was 15.4 years (range, 11.8-19.3 years), and 51% were female. The sample was mainly white (61.1%) and African American (32.8%), a distribution consistent with many populations throughout the southeastern United States (20). Slightly more than 1% each was Latino, Asian, and Native American, and 1.9% reported “other.” The sex distribution was similar in all ethnic groups except for Native Americans. The prevalence of ever having used alcohol was 37.5% among
nonsmokers but was 79.5% among smokers (P < .001), indicating that the 2 behaviors clustered much higher than would be expected by chance. Approximately 34% of the total sample of adolescents who reported alcohol use preferred liquor, followed by wine (25.1%), then beer (18.2%). The number of alcoholic drinks consumed was related to the frequency of alcohol consumption (not shown). More than half of the cohort (52%) reported they
did not disapprove of their friends taking 1 or 2 drinks
every day, but 57% disapproved of adults having 1 or 2 drinks every day (not shown).
Co-use of alcohol and tobacco
Of the African American and white students combined (n = 4,431), 879 (19.8%) reported being
co-users. We examined sociodemographic characteristics for 4 tobacco and alcohol use categories:
co-users (n = 879), nonusers (n = 2,079), smokers/nondrinkers (n = 227), and drinkers/nonsmokers (n = 1,246). Alcohol use was defined as
drinking any alcoholic beverage in the last 30 days, and tobacco use was defined as
having smoked at least 1 cigarette in the
last 30 days. Comparisons of nonusers and
co-users (Table 1) showed no sex difference in any of the 4 categories, but whites (26%)
were more likely than African Americans (8.4%) to be co-users (P < .001).
Co-users were more likely to report earning mostly D’s and F’s for school grades (P < .001), and they were less likely to report expecting to graduate from high school.
Co-users also had more discretionary money to spend (P
< .001). Students who smoked but did not drink reported the fewest physically active days in the past week (P < .002); however, no significant differences in physically active days were observed for
co-users compared with the other groups.
We analyzed social relationships for all of the smoking/drinking categories, but only the comparisons between nonusers and
co-users are shown
(Table 2). (For the actual questions that contribute to the derived values, see Table 2 footnotes and
the Appendix.) Approximately 81% of
co-users indicated that most or all of their friends were likely to drink alcohol, compared with 27.9% of nonusers.
Co-users reported having more friends who drink alcohol (P < .001) and even having more friends
who drink weekly and who smoke or chew tobacco (P < .001). Two-thirds of
co-users reported that most or all of their friends smoked.
Almost all co-users (91.3%) were either often or a few times
with people who “drink for kicks,” and about half of nonusers (52.3%)
reported the same. Two-thirds of co-users had parents who smoked. Siblings
of co-users were more likely to smoke and chew tobacco compared to siblings
of nonusers and the other 2 groups. Comparisons between all of the
smoking/drinking groups (including nondrinkers/smokers and
nonsmokers/drinkers) showed similar patterns; percentages of
nondrinkers/smokers were higher than drinkers/nonsmokers and nonusers, but
lower than co-users (not shown). The only frequency comparisons that were
not significantly different among the nondrinker/smoker and
nonsmoker/drinker groups were those for chewing tobacco by parents,
siblings, or friends.
We compared attitudes and beliefs about alcohol and tobacco use of co-users
with those of the other 3 categories of use/nonuse
(Table 3 compares nonusers
with co-users). We found significant differences between co-users and nonusers.
For alcohol and tobacco disapproval, risk of harm, and what friends think,
higher scores reflected stronger disapproval. For these attitudes, scores were
consistently highest for nonusers and consistently lowest for co-users.
Nonusers had the highest level of disagreement with the statements that smoking will hurt you only if you inhale and smoking will not hurt you if you do not smoke too much.
Co-users had the lowest levels of disagreement with these statements. Comparisons with the other 2 groups (drinker/nonsmoker and smoker/nondrinker) reflected the same general pattern at the P = .001
level; means for drinkers/nonsmokers were closest to those for the nonuser category and means for nondrinkers/smokers were closest to
those for the co-user category (not shown). The only comparison not significant was that between
co-users and nondrinkers/smokers, where means were similar.
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Demographic, social, and attitudinal profiles developed in this study identify adolescents who are at high risk for alcohol and tobacco use. This information can help improve intervention strategies
for adolescents (21). Alcohol and tobacco may act as gateway agents, individually
or together, to further drug use (21).
The adolescent preference for hard liquor over beer or wine is a matter of
concern. In the 1990s, beer was the adolescent drink of choice (19,22).
Brewers such as Anheuser-Busch
now view the recent shift toward hard liquor as a business challenge (23).
Drinking hard liquor is a problem for adolescents because a 1- to 2-ounce shot,
even with 6 ounces of a mixer, can deliver more ethanol to the system than a
12-ounce beer or 6-ounce glass of wine (19). The trend toward hard liquor is
perplexing because hard liquor cannot be advertised on network television. Some
cable channels, however, such as Spike TV, do advertise hard liquor. Drink
preferences have changed and differences between male and female drinking have
narrowed, raising the question of associations between the 2 trends. For
example, a study in England found that preference for “spirits” increased with
age and was higher among girls than boys (24).
Ninth-grade students were less likely to disapprove of their friends drinking 1 or 2 drinks every day
than they were to disapprove of adults doing the same. This finding is intriguing and could imply that adolescents are more concerned about parental drinking than they are about their own or their friends’ drinking.
In the Cajun culture in the Acadiana area of Louisiana, smoking and drinking alcohol are common among adults as well as young
people. Therefore, the cultural anomaly is that these behaviors can be considered normal rather than risky (25). The
role of sociocultural factors in adolescent smoking and drinking is widely recognized (13), and it is not surprising that as many as one-fifth of the high school students in this region of Louisiana reported
co-use of alcohol and
Both girls and boys are co-users. These data are startling because for many years, more boys
than girls drank and smoked. Smoking data have been more variable (17,24); smoking rates for girls have been increasing at high school age. No difference between male and female smoking in the junior and senior high school years has been observed in some regional and local studies (26), but others report higher smoking rates in
girls (24). Amos and Bostock (2007) compared reasons boys and girls smoke to
determine why girls’ smoking rates are increasing; they found that girls smoke to alleviate stress and to maintain or lose weight, and girls consider smoking an integral part of socializing and “social sharing” (27).
More white than African American adolescents were co-users. This finding is not surprising and is consistent with national and local data (5,16,17,27).
Co-users were more likely to earn D’s and F’s in school and less likely to intend to graduate from high school. They also had the most discretionary money to spend.
Not surprising are the data showing that more co-users have friends who drink and who drink “for
kicks.” What is disturbing is the frequency with which those friends reportedly get drunk (ie,
weekly). Co-users also have more friends who smoke cigarettes, chew tobacco, or both. Consistent with the smoking literature
(19), family members of co-users, parents as well as siblings, were reported to be more likely to smoke cigarettes or chew tobacco. Several studies have shown that the
most consistent risk factors for initiating drinking and smoking in adolescence are parental approval and models for drinking and drug use (28). Some studies, though, show that these social
models are more influential early in life or at time of initiation rather than over the long term (29,30). It has recently been argued that genetic factors, which account for parental influence and drive selection of risk-taking friends, may be more important than social modeling for influencing adolescent
smoking and drinking (31). Once use of nicotine and alcohol has started, shared behavioral and neurobiological factors may enhance cross-dependence (12).
Obviously, the co-user is less likely to disapprove of
smoking and drinking or of anyone else who smokes and drinks. The co-user is
also more likely to agree that smoking is harmful only if you smoke too much
or inhale but less likely to agree that buying cigarettes is a waste of
money or disgusting. The means for reported variables of interest were
similar for smokers across the 2 categories in which smoking was involved.
Our data present a picture of the adolescent co-user as having social relationships and family members that reinforce and support smoking and drinking behaviors and attitudes. Any intervention effort that targets the
co-user will have difficulty achieving positive results unless the intervention occurs at multiple levels, such as personal, family, friends, and cultural environment. Neither
the Youth Risk Behavior Surveillance System nor Monitoring the Future report data on
co-use of alcohol and tobacco; therefore, the value of this study is to
provide information for use by schools and health educators in developing education and prevention programs and for challenging the cultural norms that place students at high behavioral risk.
Because limited data are available in this area of Louisiana, the study of adolescents in Acadiana provides valuable insights for
curbing smoking and drinking as a serious health and behavioral risk for future cardiovascular disease, malignancies, and self-defeating behaviors.
The reported data are cross-sectional; therefore, data are discussed as
associative, not causative. Traditionally, the Acadians in south-central
Louisiana have been a difficult-to-reach population, and for this reason, these data are
especially valuable. On the other hand, the culture is somewhat unusual, especially in the early ages at which adolescents engage in adult risk behaviors; therefore, the study results may not be generalizable to adolescent populations in
other areas of the United States.
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This research was supported by the Louisiana State Board of Regents with Master Settlement Agreement funds,
contract no. HEF-(2000-05)-09. We thank the administration, faculty, and students of the 22 schools in south-central Louisiana that participated in the ACTT study
for their cooperation and support.
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Corresponding Author: Carolyn C. Johnson, PhD, Tulane School of Public Health
and Tropical Medicine, Community Health Sciences, 1440 Canal St, Rm 2309, New Orleans, LA 70112. Telephone: 504-988-4068. E-mail:
Author Affiliations: Larry S. Webber, Leann Myers, Neil W. Boris, Gerald S. Berenson, Tulane University School of Public Health
and Tropical Medicine, New Orleans, Louisiana.
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