Briefs 5. Fleiss JL. Statistical Methods for Rates and Proportions. NewYork, NY: John Wiley & Sons Inc; 1981:173. 6. Kleinbaum DG, Kupper LL, Muller KE. Applied Regression Analysis and Other Multivariable Models. Boston, Mass: PWS-Kent Publishing Co; 1988:41-63. 7. Fauci AS, Lane HC. Human immunodeficiency virus (HIV) disease: AIDS and related disorders. In: Isselbacher KJ, Martin JB, Braunwald E, Fauci AS, Wilson JD, Kasper DL, eds. Harrison 's Principles of Internal Medicine. New York, NY: McGraw-Hill Book Co Inc; 1994: 1567-1618. 8. Thamer M, Richard C, Casebeer AW, Ray NF. Health insurance coverage among foreign-born US residents: the impact of race, ethnicity, and
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11.
12.
Joseph R. DiFranza, MD, and John J. Librett, MPH
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13. Deren S, Shedlin M, Beardsley M. HIVrelated concerns and behaviors among Hispanic women. AIDS Educ Prev. 1996;8: 335-342. 14. Murphy J, Mueller G, Whitman S. Epidemiology of AIDS among Hispanics in Chicago. J Acquir Immune Defic Syndr Hum Retrovirol. 1996;1 1:83-87. 15. Diaz T, Klevens RM. Differences by ancestry in sociodemographics and risk behaviors among Latinos with AIDS. The Supplement to HIV and AIDS Surveillance Project Group. Ethn Dis. 1997;7:200-206. 16. Kelly JJ, Chu SY, Diaz T, Leary LS, Buehler JW. Race/ethnicity misclassification of persons reported with AIDS. Ethn Health. 1996; 1: 87-94.
State and Federal Revenues From Tobacco Consumed by Minors
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length of residence. Am JPublic Health. 1997; 87:96-102. Schur CL, Albers LA. Language, sociodemographics, and health care use of Hispanic adults. JHealth Cam Poor Underseved. 1996;7:140-158. Flaskerud JH, Uman G. Directions for AIDS education for Hispanic women based on analyses of survey findings. Public Health Rep. 1993;108:298-304. Marin BV, Tschann JM, Gomez CA, Kegeles SM. Acculturation and gender differences in sexual attitudes and behaviors: Hispanic vs non-Hispanic White unmarried adults. Am J Public Health. 1993;83:1759-1761. Marin BV, Marin G. Predictors of condom accessibility among Hispanics in San Francisco. Am JPublic Health. 1992;82:592-595.
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In 1988, American children younger than 18 years consumed cigarettes worth an estimated $1.23 billion, generating $152 million in federal revenues and $173 million in state revenues.' Developments over the past decade have included (1) an increase in the adolescent population, (2) an increase in the prevalence of smoking among youths, (3) an increase in the price ofcigarettes, (4) increases in state and federal cigarette excise taxes, (5) the availability of data on daily cigarette consumption among American adolescents, (6) the enactment of state and federal laws making the sale of tobacco to persons younger than 18 years illegal in all 50 states, and (7) the enactment of a federal law requiring all states to enforce the prohibition on the sale of tobacco to minors.2-6 Our purpose in this study was to estimate the value of cigarettes consumed in 1997 by American youths younger than 18 years.
exclusion of nondaily smokers and youths younger than 12 years from the current study, the methods were the same as those used for an earlier study of the revenues from children's smoking.' Age-specific estimates of the youth population for July 1, 1997, were obtained from US Census Bureau projections.3 Census data also indicate that 92.6% of youths aged 12 through 14 years and 92.4% of those aged 15 through 17 years attend school.7 From these numbers and proportions, we derived the number of students and school dropouts for each age stratum (Table 1). Data on the proportion of daily smokers in the 8th, 10th, and 12th grades were obtained from the 1997 Monitoring The Future Study.4 The proportion of daily smokers in the 9th grade was assumed to be the midpoint between the proportions for the 8th and 10th grades, and the proportion of daily smokers in the 1 1th grade was assumed to be the midpoint between
Methods The retail value of cigarettes consumed by youths was estimated as the product of the number ofyouths who smoke daily, the average cigarette consumption of daily smokers, and the cost per pack of cigarettes. We performed separate calculations for youths of each age from 12 through 17 years and for students and school dropouts. We calculated conservative and comprehensive estimates and then averaged the two. Except for the
Joseph R. DiFranza is with the Department of Family Medicine and Community Health, University of Massachusetts Medical Center, Worcester. John J. Librett is with the Division of Community and Family Health Services, Utah Department of Health, Salt Lake City. Requests for reprints should be sent to Joseph R. DiFranza, MD, Department of Family Medicine and Community Health, University of Massachusetts Medical Center, 55 Lake Ave, Worcester, MA 01655 (e-mail:
[email protected]).
July 1999, Vol. 89, No. 7
Briefs
TABLE 1-Number of Daily Smokers Aged 12-17 Years: United States, 1997
Age, y
US Population
Proportion in School
Student Population
12 13 14 15 16 17 Total
3834000 3756000 3852000 3885000 3819000 3906000 23052000
0.926 0.926 0.926 0.924 0.924 0.924
3550284 3478056 3566952 3589740 3528756 3609144 21322932
Proportion of Students Smoking Daily
No. of Students Smoking Daily
Dropout Population
0.0668 0.0900 0.1350 0.1800 0.2130 0.2460
237159 313025 481539 646153 751625 887849 3317350
283716 277944 285048 295260 290244 296856 1729068
Proportion of Dropouts Smoking Dailya
No. of Dropouts Smoking Daily
Total No. of Daily Smokers
0.1104 0.1487 0.2230 0.2974 0.3519 0.4064
31309 41 325 63571 87799 102130 120640 446774
268468 354350 545110 733952 853755 1008489 3764124
V~~~~~~~~~~~~~~
Source. Population estimates and proportions in school are from the US Census Bureau.3'7 Proportions of daily smokers are from the Monitoring the Future Study.4 aNumbers in this column were carried out 5 decimal places for our calculations.
proportions for the 10th and 12th grades. The proportion for the 7th grade was derived from data about the grade of initiation of daily smoking among 8th graders, corrected for those who had quit." The average 7th grader is 12 years old at the beginning of the school year, and we assumed that the student body ages 1 year with each subsequent grade. For the conservative estimate, data on the daily cigarette consumption of daily smokers were obtained from 412 smokers aged 12 through 17 years (mean = 15.15 years) attending a school smoking cessation program in Utah. The majority (56.3%) of students attending this class had been cited for possession of tobacco and had chosen this program over other options offered by the court. The remaining students attended the program on their own initiative, to quit smoking and/or to earn academic credits. On admission to the program, students were asked to complete a tobacco use survey, on which they indicated by filling in a blank the number of cigarettes they consumed in a typical day. Because the mean ages and consumption rates for those attending on their own initiative and those sent by the court were almost identical, data for the 2 groups were combined. The data from one 12-year-old student who claimed to smoke 40 cigarettes per day were thought to be spurious and were excluded. Self-reports of cigarette consumption reliably underestimate actual consumption, accounting for only 72% of the cigarettes sold in the United States.' For the comprehensive estimate, we multiplied the selfreported consumption figures used for the conservative estimate by a factor of 1.39 (1/0.72) to correct for underreporting. Pirie and colleagues reported that the rate of daily smoking among 273 high school dropouts (most of whom were aged 16 to 18 years in 1984) was quadruple the
the
July 1999, Vol. 89, No. 7
rate among students (77.7% vs
19%).9 The
1992 National Health Interview Survey found that the prevalence of smoking in the previous 30 days among youths aged 12 through 19 years was 65.2% higher for dropouts than for those attending school.'0 Although the latter study did not measure daily smoking, it is more recent than that by Pirie et al., and it includes youths as young as 12 years. To produce more conservative estimates of consumption, we assumed 65.2% higher smoking rates for school dropouts in calculating both the conservative estimate and the comprehensive estimate. The average retail price (including taxes) for all brands of cigarettes for 1997 was $1.95 per pack; the average for the fullprice brands smoked by youths was $2.05.21' The former value was used for the conservafive estimate and the latter value for the comprehensive estimate. State cigarette excise taxes averaged 31.7 cents per pack in 1997, while the federal tax was 24 cents per pack.2 A pack contains 20 cigarettes.
Results An estimated 3.76 million youths aged 12 through 17 years are daily smokers. By conservative estimate, these youths consume 773 million packs of cigarettes each year, for a retail value of $1.5 billion (Table 2); this figure includes federal revenues of $186 million and state revenues of $245 million. The comprehensive method produced an estimate of 1.1 billion packs per year, for a retail value of $2.2 billion, including federal revenues of $258 million and state revenues of $341 million. The average of the 2 estimates is 924 million packs per year, for a retail value of $1.86 billion, including annual federal revenues of $222 million and state revenues of $293 million.
Discussion Despite the federal requirement that states enforce a prohibition on the sale of cigarettes to minors, youths generate a tremendous amount of cigarette revenue for the tobacco industry and state and federal governments, and this amount appears to have increased sharply over the past decade.6 This revenue could be used to enforce laws prohibiting the sale of tobacco to minors.
The methods used for this study are comparable to those we used to estimate young smokers' consumption for 1988.' To make the present study more conservative in its estimate, we excluded youths younger than 12 years and youths who do not smoke every day. Reliable data on the daily tobacco consumption of these groups are unavailable. It has been estimated that youths who do not smoke daily consume less than 10% of the total tobacco consumed by youths younger than 18 years and that children younger than 12 years consume about 1%.1 By excluding these populations, this study underestimates the total value of tobacco consumed by youths. The vast majority of studies concerning tobacco consumption among youths cannot provide average consumption levels because respondents are asked to check off ranges such as "one half pack or more."4 Our source of consumption data is our own survey, conducted in Utah. There are obvious concerns about the generalizability of these data. Since these survey respondents were youths who needed assistance with quitting or who had been caught smoking by authorities, it is possible that they were heavier-than-average smokers. On the other hand, some may have already cut down on their consumption in anticipation of quitting. In fact, the average consumption rate (11.5 cigarettes per day) measured in this population was lower than rates obtained in 3 previous surveys of other populations (12.0, 13.7, and 16.0 cigarettes perday).12-14 American Journal of Public Health
1107
Briefs
TABLE 2-Estimated Annual Cigarette Consumption by US Youths Aged 12-17 Years
Age, y
No. of Daily Smokersa
No. of Cigarettes/db
12 13 14 15 16 17 Total
268468 354350 545110 733952 853755 1008489 3764124
7.13 7.44 9.85 11.79 10.86 14.36
Conservative Estimate Retail Value, $ No. of (at $1.95/Pack) Packsty 34972370 48159507 98097260 158070933 169263488 264549492 773113050
68196122 93911038 191289657 308238319 330063801 515871 509 1507570447
Comprehensive Estimate Retail Value, $ No. of (at $2.05/Pack) Packs/y Cigarettes/dc No. of 9.91 10.34 13.70 16.39 15.09 19.97
48611595 66941714 136355191 219718597 235276248 367723794 1074627139
99653769 137230514 279528142 450423123 482316309 753833778 2202985635
aFrom Table 1.
bNumbers in this column were carried out to 3 decimal places for our calculations.
cNumbers in this column were carried out to 5 decimal places for our calculations.
The 1989 Teenage Attitudes and Practices Survey reported a mean consumption of 8 cigarettes per day, but that figure is low because it includes youths who were not daily smokers.'5 Despite the possible limitations, we used the Utah survey data because they are original and current and provide age-specific rates for daily smokers. Using these data instead of data from other surveys'2'14 resulted in a more conservative estimate of consumption. Our findings are conservative also in that they do not take into account the November 1998 wholesale price increase of $0.45 per pack resulting from the settlement of state lawsuits against the tobacco industry.'6 Although the impact ofthis increase on overall price and consumption has yet to be determined, it will almost certainly increase the overall value of the tobacco consumed by
youths. The Monitoring the Future Study4 was used as the source for prevalence estimates because it is national in scope, involves more than 50000 students, and has been conducted annually since 1975. Census data37 were felt to be the most reliable source for population estimates. Our comprehensive estimate excluded generic brands because youths are far less likely than adults to smoke these cheaper brands." We esfimate that youths younger than 18 years consume about 3.9% of all cigarettes sold in the United States. This represents an increase over our earlier estimate of 3.3%,1 which is to be expected, given the declines in adult smoking and the increases in youth smoking that have occurred since 1988*Z4The
1108 American Journal of Public Health
Investor Responsibility Research Center calculates 1997 profits from tobacco sales for the 5 largest tobacco companies in the US market at more than $12 billion.'7 If 3.90/o ofthis sum represents the profit from cigarettes consumed by youths younger than 18 years, these 5 companies profited by $480 million from young smokers in 1997, a substantial increase over the $221 million estimated for 1988.' D
Contributors J. J. Librett designed and conducted the survey of adolescent smokers and analyzed the data from that survey. J. R. DiFranza conducted the main analysis and wrote the paper.
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