Why do some people never smoke cigarettes or use other tobacco products while others just experiment with tobacco products and still others become regular users? This important question has been the focus of many studies and dozens of theories. According to the dominant theories of substance use, there is a long list of causes (Petraitis, Flay, & Miller, 1995; Petraitis, Flay, Miller, Torpy, & Greiner, 1998). Prevention research on substance use has focused mainly on adolescents between the ages of 12 and 17 because those years are the highest risk years for initiating substance use.
The NHSDA emphasizes collection of substance use information on adolescents by oversampling 12 to 17 year olds and by using questionnaire modules designed specifically for youths (Lane, Gerstein, Huang, & Wright, 2001; Office of Applied Studies [OAS], 1999). A new module for 12 to 17 year olds was added to the NHSDA in 1997 to examine risk and protective factors shown in the literature to be related to substance use. The 1999 NHSDA included a risk and protective factor youth module enhanced from that used in the 1997 survey. Risk factors involve individual characteristics or social environments associated with an increased likelihood of substance use, while protective factors are attitudes and behaviors related to a decreased likelihood of substance use. The main domains included in the 1999 youth module were community, family, peer/individual, school, and general.
It is well known that perceptions of risk of harmfulness are among the most important predictors of actual substance use (Bachman, Johnston, & O'Malley, 1998; Duitsman & Colbry, 1995; Kelly et al., 1996; Resnicow et al., 1999). The NHSDA has included questions about attitudes related to cigarette and other substance use for many years. To provide a basis for analyzing trends given the major changes in the 1999 survey, a supplemental sample was interviewed using the paper-and-pencil interviewing (PAPI) technique employed in previous NHSDAs. Because of problems fielding this part of the sample, the results were thoroughly studied (OAS, 2000b). Based on that analysis, an adjustment procedure was developed and applied to a few key indicators (such as perception of risk) in an effort to document trends. Because the estimates based on 1999 PAPI data rely on a different sample and a different method of data collection, they should not be compared with 1999 computer-assisted interviewing (CAI) estimates.
Table 5.1 in Appendix E presents trend data from 1994 through 1999 for the percentages of people reporting the perception of great risk of harm from smoking one or more packs of cigarettes per day. Data are displayed by gender, age group and smoking status. Figure 5.1 shows this information for just the 1999 data by age group and race/ethnicity. The question in the 1999 survey reads as follows: "How much do people risk harming themselves physically and in other ways when they smoke one or more packs of cigarettes per day?" Response options for this question were "no risk," "slight risk," "moderate risk," and "great risk."
Former smokers and those who had never smoked, in all age and gender groups, were significantly more likely than their smoking peers to perceive great risk for heavy smoking. Also, females tended to have higher perceptions of great risk for smoking a pack or more of cigarettes per day, for all smoking groups, as compared with their male counterparts.
Even with all the information on the dangers of smoking in literature, on television, and in the media, perceptions of physical harm from cigarettes have not changed much between 1994 and 1999 for current smokers, former smokers, and those who never smoked. Only for daily smoking did more male and female daily smokers perceive great risk of harm from smoking one or more packs of cigarette per day in 1999 as compared with 1994. Among males aged 12 or older, the percentage perceiving great harm increased from 34.7 percent in 1994 to 42.3 percent in 1999. Among females, only 43.0 percent perceived great risk of harm from heavy smoking in 1994 compared with 48.7 percent in 1999. This improvement in attitudes was also seen for males and females in the 18- to 25-year-old age group and for those in the 35 years of age or older grouping. Among adolescents who reported daily smoking, there were no improvements in perceived attitudes toward heavy smoking over time for either gender. However, there were significant decreases in the prevalence of daily smoking among youths in the late 1990s, and the numbers of daily smokers for 1999 were statistically unreliable for this age group. There were no improvements observed for perceived harm from smoking for males and females in the 26- to 34-year-old age group. Among current, but not daily smokers, the trend among male adolescents was toward a greater perceived harm from smoking. Among adolescent females who reported that they were current smokers, there was no change in the proportion perceiving great risk from heavy smoking between 1994 and 1999.
Figure 5.1 Percentages of Persons Aged 12 or Older Reporting Perceptions of Great Risk from Smoking One or More Packs of Cigarettes Per Day, by Age Group and Race/Ethnicity: 1999
Note: This graph includes data from all respondents aged 12 or older.
Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1999.
Perceived harmfulness is an important explanatory variable for substance use in general, but its relationship with cigarette use is not consistent across all age groups. For example, among 12 to 17 year olds, males were significantly less likely than females to perceive great risk from smoking one or more packs of cigarettes per day. For adolescents, as noted in Chapter 2, the prevalence of current cigarette use was essentially equal for males and females (14.8 and 15.0 percent, respectively). Only 56.5 percent of adolescent males perceived great risk for heavy smoking compared with 65.0 percent of their female peers. For 18 to 25 year olds and those 26 or older, males were significantly less likely than females to associate great risk of physical harm from smoking one or more packs of cigarettes per day than their female counterparts. For both of these adult age groups, the prevalence of current cigarette use was lower among females than males (see Chapter 2).
The relationship of the perceived harm variable with the prevalence of current cigarette use by race/ethnicity again reveals inconsistencies. One would expect Asians and non-Hispanic blacks, who had low rates of current smoking for all three age groups, to have high proportions reporting great risk of harm for heavy smoking. As seen in Table 5.2, the numbers of Asians and blacks reporting great risk were generally comparable with non-Hispanic whites for all three age groups (whites had high rates of current smoking).
Perceptions of great risk for smoking by county type indicated, for the two younger age groups (12 to 17 and 18 to 25), significantly lower perceived great risk of physical harm from smoking one or more packs of cigarettes per day for people living in nonmetropolitan areas as compared with both large and small metropolitan areas. Large metropolitan areas have a population of 1 million or more, small metropolitan areas have a population of fewer than 1 million, and nonmetropolitan areas are those outside metropolitan statistical areas (MSAs). For persons 26 or older, significantly fewer people living in nonmetropolitan areas, as compared with those living in large metropolitan areas, perceived great risk of physical harm from this smoking behavior (64.7 vs. 70.3 percent). The relationship between the perception of great harm for heavy smoking, county type, and prevalence rates is consistent. In general, persons living in more urban settings were less likely to smoke than those living in more rural areas. This was particularly true for 12 to 17 year olds in that 13.3 percent of adolescents living in large metropolitan areas were current cigarette smokers compared with 16.0 percent in small metropolitan areas and 19.2 percent in completely rural areas (see Chapter 2).
As stated earlier, risk factors are attitudes and behaviors related to an increased likelihood of tobacco use, while protective factors are associated with not using tobacco products. Table 5.3 inAppendix E includes odds ratios, by 2-year age intervals, for current cigarette use by a list of risk and protective factors shown in the literature as being related to cigarette use (Chopak, Vicary, & Crockett, 1998; Griesler & Kandel, 1998; Petraitis et al., 1998; Tyas & Pederson, 1998). Because the risk and protective questions were in a module specifically developed for youths, Table 5.3 only includes data on 12- to 17-year-old respondents. In probability theory, "odds" refer to the ratio of the probability of one outcome to the probability of its opposite outcome. For cigarette use, odd ratios are a convenient way of comparing, by particular social and attitudinal characteristics, individuals who currently smoke cigarettes with individuals who are not current smokers. Each of the risk and protective factors in the 1999 NHSDA was classified into multiple levels using a Likert scale. The Likert scale format is ordinal, which means that the choices ranged from low to high or from seldom to often. To calculate an odds ratio, there must be a comparison group (reference category). The reference category is identifiable on the table because it always gets a value of 1. The reference category for each factor was the response choice where respondents were least likely to smoke.
The first factor in Table 5.3 in Appendix E corresponds to the following question: "During the past 12 months, how often did your parents tell you they were proud of you for something you had done?" The response choices were "always," "sometimes," "seldom," and "never." Without exception, adolescents who felt that their parents never said positively reinforcing things to them were more likely to smoke as compared with adolescents who always got positive reinforcement from their parents. This was particularly true for 12 and 13 year olds: Those who never got positive reinforcement from their parents were 6½ times as likely to be past month cigarette smokers when compared with 12 and 13 year olds whose parents always indicated being proud of them. The odds of smoking quadrupled for 12 and 13 year olds with parents who seldom told them that they were proud of them. Lack of positive parental reinforcement tripled the risk of smoking for 14 and 15 years olds and doubled the risk of current cigarette use for 16 and 17 year olds.
Parental attitudes toward cigarettes was a protective factor for smoking among youths. The question that youths were asked was worded as follows: "How do you think your parents would feel about you smoking one or more packs of cigarettes per day?" The response choices ranged from "neither approve nor disapprove" to "strongly disapprove." For all 12 to 17 year olds, adolescents with parents who neither approved nor disapproved of cigarette use were 5 times as likely, when compared with youths with parents who strongly disapproved of smoking, to be current cigarette smokers.
As compared with adolescents who perceived great risk of harm from smoking one or more packs of cigarettes per day, youths who saw no risk for this behavior were significantly more likely to report current cigarette use. The odds of being a current smoker approximately quadrupled for 12 and13 year olds and about tripled for older adolescents (i.e., those 14 to 17 years old) if they saw no associated risk from this behavior as compared with those youths who saw great risk of harm from engaging in this behavior.
With regard to participation in youth activities, youth counseling, and youth-oriented prevention programs, lack of participation or very limited participation (one or two activities) increased the likelihood of current smoking. The youngest adolescents (12 and 13 year olds) were 3½ times as likely to be current smokers if they participated in none of these activities as compared with 12 and 13 year olds who did three or more of the activities. Those in the older two adolescent groups (i.e., 14 to 17 year olds) were more than twice as likely to be current cigarette users if they participated in none of the activities mentioned.
Even knowing adults who smoke was a risk factor for smoking among youths. The question in the 1999 NHSDA was worded as follows: "How many of the adults that you know personally would you say smoke cigarettes?" The response choices again ranged from "none of them" to "all of them." The odds of being a current cigarette smoker increased fivefold to sevenfold for youths if most or all of the adults they knew smoked.
An additional risk and protective factor in Table 5.3 looked at the relationship between a youth's propensity to take risks and current cigarette use. The personality factors of novelty seeking or sensation seeking have been shown in the literature to be related to substance use, including cigarettes (Donohew et al., 1999). This NHSDA risk-taking question is a simplistic approach to assessing this personality factor. The specific question analyzed was worded as follows: "How often do you get a real kick out of doing things that are a little dangerous?" The response choices were "never," "seldom," "sometimes," and "always." As compared with youths who reported never getting a kick out of doing something a little dangerous, the likelihood of smoking increased twofold for seldom liking to do dangerous things, fourfold for sometimes enjoying slightly dangerous activities, and up to ninefold for always getting a kick out of doing something a little dangerous.
Multiple questions on deviant behavior risk factors were included in the 1999 NHSDA youth prevention module. The delinquent behavior questions asked adolescents how many times they did particular behaviors during the 12 months prior to being interviewed. The behaviors shown in Table 5.3 are as follows: the number of times a youth carried a handgun in the past year, the number of times a youth stole or tried to steal anything worth more than $50 in the past year, and the number of times a youth reported getting into a serious fight at school or work in the past year. The response choices were 0, 1-2, 3-5, 6-9, and 10 or more times. Even reporting any of these delinquent behaviors once ortwice increased the risk of being a current cigarette smoker (as compared with youths who never did the particular behavior).
The strongest risk factor studied was the response to the following question: "How many of your friends would you say smoke cigarettes?" The response choices ranged from "none of them" to "all of them." The odds calculated indicated that, for youths of all ages, if all or most of an adolescent's friends smoked, he or she also was a cigarette smoker. Even having a few friends who smoked cigarettes was a strong risk factor for current smoking. For 12 to 15 year olds with a few friends who smoked, the risk of cigarette use increased 7 to 8 times. Among the older youths (16 and 17 year olds), those with only a few smoking friends were 4½ times as likely to be smokers themselves.
