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RESEARCH ARTICLE

Salient Environmental and Perceptual Correlates of Current and Established Smoking for 2 Representative Cohorts of Indiana Adolescents ABSTRACT

DONG-CHUL SEO, PhDa AMY E. BODDE, MPHb MOHAMMAD R. TORABI, PhDc

PURPOSE: A secondary analysis of 2000 and 2004 Indiana Youth Tobacco Survey (IYTS) data was conducted to investigate salient environmental and perceptual correlates of adolescents’ current and established smoking while controlling for demographic variables such as gender, grade, and race/ethnicity and to compare the pattern of significant correlates between the years. METHODS: The IYTS was an anonymous school-based survey regarding tobacco use; familiarity with pro- and anti-tobacco media messages; exposure to environmental tobacco smoke (ETS); minors’ access to tobacco products; and general knowledge, attitudes, and beliefs about tobacco. In 2000, a representative sample of 1416 public high school students in grades 9-12 and 1516 public middle school students in grades 6-8 (71.44% and 72.53% response rates, respectively) were surveyed. In 2004, 3433 public high school students and 1990 public middle school students (63.04% and 65.44 % response rates, respectively) were surveyed. RESULTS: Significant predictors of adolescents’ current and established smoking habits included exposure to ETS either in homes or in cars, exposure to pro-tobacco messages, perceived benefit of smoking, and perceived peer acceptance of smoking. The influence of exposure to pro-tobacco messages greatly outweighed exposure to any anti-tobacco messages. CONCLUSIONS: The findings of this study warrant that more efforts and resources be placed on preventing youth from being exposed to ETS, and to control pro-tobacco marketing and improve the tobacco counter-marketing messages. The perceived benefits of smoking found here indicate that smoking for relaxation and weight control may be major influencing factors on adolescent smoking. Keywords: tobacco use; environmental tobacco smoke; tobacco marketing; adolescent health. Citation: Seo D-C, Bodde AE, Torabi MR. Salient environmental and perceptual correlates of current and established smoking for 2 representative cohorts of Indiana adolescents. J Sch Health. 2009; 79: 98-107. Accepted on November 20, 2007

a

Assistant Professor, ([email protected]), Department of Applied Health Science, Indiana University, HPER 116, 1025 E. Seventh St, Bloomington, IN 47405.

b c

Associate Instructor, Doctoral Candidate, ([email protected]), Department of Applied Health Science, Indiana University, 1025 E. Seventh St, Bloomington, IN 47405.

Chancellor’s Professor, ([email protected]), Department of Applied Health Science, Indiana University, 1025 E. Seventh St, Bloomington, IN 47405.

Address correspondence to: Dong-Chul Seo, ([email protected]), Assistant Professor, Department of Applied Health Science, Indiana University, HPER 116, 1025 E. Seventh St, Bloomington, IN 47405. American Institutes for Research (00001-1784.009) and Indiana Tobacco Prevention and Cessation funded this research.

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s tobacco usage continues to be the leading cause of preventable death in the United States,1 the importance of preventing and intervening on youth tobacco use is critical. Most adult smokers begin their habit in adolescence,2,3 and it is important to understand the factors that influence adolescents to use tobacco in order to prevent smoking uptake before the smoking addiction occurs. While some factors that affect adolescents’ smoking are well established, others are still not. For example, there are well-established associations between youth tobacco use and race/ ethnicity,4-6 the influence of peers,5,7-11 pro-tobacco advertising,12-18 and the alluring promotional items provided by the tobacco industry.16,19-21 However, several factors, such as exposure to counter-tobacco campaigns, exposure to information about health consequences of tobacco use, exposure to environmental tobacco smoke (ETS) in homes and/or cars, and perceived benefit of smoking have not shown consistent and robust associations with youth tobacco use.22-24 Exposure to pro-tobacco messages and marketing promotions continue to steadily demonstrate a strong positive association with adolescent tobacco use12-18, 19-21,23,25 and seem to outweigh the effect of countertobacco marketing efforts.24,26 Although some studies on the impact of tobacco counter-marketing on adolescents’ smoking behavior have shown positive results,27,28 some other counter-tobacco campaigns and programs, including statewide anti-tobacco campaigns funded by cigarette excise taxes, have not consistently shown positive impacts on youth tobacco use.22,24 It is still unclear whether anti-tobacco campaigns and messages are strong enough to negate the effect of pro-tobacco advertisements. Exposure to information about health consequences of smoking is also a factor that has yet to show a consistent association with youth tobacco use. Some studies have shown that advice from a clinician regarding the danger of tobacco use is associated with a lower rate of tobacco use initiation among teens,29 while others have shown that health information as relayed by the news media is associated more with cessation rather than prevention.30 It has also been shown that health information is more effective in preventing tobacco use among adolescents when coupled with skills interventions.31 There seem to be inconclusive findings on how this information about health consequences affects teen smoking rates. There is a scarcity of research on the relationship between exposure to ETS and adolescent tobacco use, especially in private venues such as homes or cars. Exposure to ETS has been associated with increased smoking among adults,32 and while many studies can be identified that measure exposure to ETS, there are far fewer studies that indicate whether or not it is a predictive factor of adolescent smoking. Journal of School Health

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Perceived benefit of smoking may seem like an obvious factor associated with adolescent tobacco use. However, the evidence about this important concept is still unclear,33 and few studies have examined it. Some of the perceived benefits of smoking so far recorded include weight control,9 social desirability and perceived improvement in self-image and selfesteem.9,12,34 Identifying such reasons and examining the strength of association between perceived benefit of smoking and actual tobacco use may be critical in order to understand teens’ motivations for smoking and how and where to intervene with antismoking messages. Furthermore, adolescent tobacco usage showed a steady increase throughout the 1990s; however, the trends since 2000 are less clear,25,35,36 indicating a need to study trends across time. In this study, the investigators hypothesized that after controlling for demographic variables such as gender, grade, and race/ethnicity, adolescents’ current or established smoking status would be predicted by exposure to pro-tobacco or tobacco countermarketing messages, exposure to information about health consequences of tobacco use, exposure to ETS in homes and/or cars, perceived benefit of smoking, and perceived peer acceptance toward smoking. The major research questions included (1) whether antitobacco campaigns and messages were strong enough to negate the effect of pro-tobacco advertisements, which was examined through the comparison of magnitudes of their relationships with youth tobacco use in the adjusted model; (2) if the exposure to ETS would predict both current and established smoking; (3) whether there was a positive relationship between perceived benefit of smoking and actual smoking behavior; and (4) if there was any noticeable change in adolescents’ current and established smoking between 2000 and 2004. The study protocol was approved by the sponsoring Institution’s Human Subjects Committee. METHODS This particular analysis of the Indiana Youth Tobacco Survey (IYTS) data was part of a larger study regarding youth tobacco use.26 Sampling The IYTS data collection protocol was designed by the Centers for Disease Control and Prevention (CDC), in collaboration with the American Legacy Foundation. All public schools in Indiana with grades 6-12 were included in the sampling frame and participants in the survey were selected using a 2-stage cluster sampling method. For 2000, data were obtained from 2932 students at 80 schools across the state. For 2004, data were collected from 5423 students in 92 schools across the state.

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Procedures The IYTS is a statewide survey that tracks tobacco usage and related factors among adolescents, beginning in 2000. The IYTS questionnaire, also developed by the CDC, included questions about tobacco use; familiarity with pro- and anti-tobacco media messages; exposure to ETS; minors’ ability to purchase or obtain tobacco products; and general knowledge, attitudes, and beliefs about tobacco. Each IYTS was an anonymous, schoolbased, self-administered paper and pencil survey that took approximately 25 minutes to complete.

tobacco use was measured with dichotomous variables that captured exposure to the messages received from their parents, doctors, dentists, school teachers, or peers. Respondents’ exposure to ETS was measured by the number of days a student was in the same room with someone who was smoking cigarettes or was in a car with someone who was smoking during the past 7 days. In 2004, 2 additional questions were added to assess perceived peer acceptance of smoking and perceived benefit of smoking. Respondents’ perceived peer acceptance to smoking was measured by the question ‘‘Do most people of your age think it is okay to smoke?’’ Perceived benefit of smoking was measured by 5 variables: ‘‘having more friends,’’ ‘‘looking cool,’’ ‘‘helping relaxation,’’ ‘‘feeling more comfortable in social situations,’’ and ‘‘helping keep weight down.’’

Measures Key variables were established by using the operational definitions provided by the Indiana Tobacco Prevention and Cessation Agency. The primary outcome variables of interest were current smoking and established smoking. Current smokers were respondents who smoked a cigarette at least 1 day during the past 30 days, while established smokers were respondents who had smoked 20 or more of the past 30 days and who had smoked 100 or more cigarettes during their lifetime. Respondents’ exposure to pro-tobacco messages and advertisements through various media including TV, movies, Internet, convenience stores, or a racing event were measured by 6 questionnaire items. The 6 items were summated and the score was categorized into low, medium, and high exposure. Exposure to tobacco counter-marketing through various media was measured by 2 items whose scores were also categorized into low, medium, and high exposure. Respondents’ exposure to information about health consequences of

Data Analysis To account for the complex sample design of the IYTS, the statistical package SUDAAN (Research Triangle Institute, Research Triangle Park, UNC) was used in estimating sampling variances and standard errors. The sampling weights provided by the American Institutes for Research were used to adjust for unequal probabilities of selection, nonresponse, and disproportionate selection of different population groups. Bivariate relationships were examined using chi-square tests and standard logistic analyses after small frequency categories were collapsed to compute reliable estimates. For example, in IYTS 2000, the age categories ‘‘18 years old’’ and ‘‘191 years old’’ were merged into ‘‘181 years old’’ because the frequency for ‘‘191 years old’’ was too small (n = 6). Adjusted

Table 1. Perceived Benefit of Smoking, IYTS 2004* Current Smoking Status Definitely Yes

Probably Yes

Probably Not

Definitely Not

Perceived Benefit of Smoking

Yes

No

Yes

No

Yes

No

Yes

No

Have more friends Look cool Help relax Feel comfortable at parties Keep weight down

11.5 11.5 53.8 31.0 18.3

3.9 3.4 7.9 7.2 6.5

26.4 13.8 29.2 40.8 22.4

11.0 6.0 29.9 33.8 18.2

43.9 30.1 10.8 17.4 36.6

48.0 13.8 23.7 28.4 34.9

18.2 44.6 6.2 10.7 22.7

37.1 76.9 38.5 30.7 40.4

Established Smoking Status Definitely Yes

Have more friends Look cool Help relax Feel comfortable at parties Keep weight down

Probably Yes

Probably Not

Yes

No

Yes

No

Yes

No

Yes

No

13.4 10.6 63.5 38.2 20.1

3.9 3.4 7.9 7.2 6.5

27.7 11.4 24.1 36.5 26.5

11.0 6.0 29.9 33.8 18.2

41.8 26.4 8.2 15.5 34.7

48.0 13.8 23.7 28.4 34.9

17.2 51.6 4.2 9.9 18.8

37.1 76.9 38.5 30.7 40.4

*The numbers are weighted percentages. They may not add up to 100 due to rounding errors.

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Definitely Not

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odds ratios (ORs) of each of the significant predictors of current smoking and established smoking were computed, controlling for gender, grade, and race/ethnicity.

Table 2. Exposure to Tobacco Counter-Marketing and Pro-Tobacco Messages, Indiana Youth Tobacco Survey 2000 Message

RESULTS Response Rate For 2000, 38 of the 47 selected middle schools participated (80.85% school response rate) and 1516 of the 1690 middle school students completed usable questionnaires (89.7% student response rate), resulting in an overall response rate of 72.53%. Of the high schools, 42 of the 50 selected high schools participated (84.0%) and 1416 of the 1665 students completed usable questionnaires (85.05%), resulting in an overall response rate of 71.44%. In 2004, 47 of the 60 selected middle schools participated (78.33% school response rate) and 1990 of the 2382 middle school students completed usable questionnaires (83.54 % student response rate), resulting in an overall response rate of 65.44%. Of the high schools, 45 of the 57 selected high schools participated (78.95%) and 3433 of the 4299 students completed usable questionnaires (79.86%), resulting in an overall response rate of 63.04%. For both years, boys comprised about 52% of the sample and each grade accounted for 14-15% of the sample except that 11th and 12th grades comprised 13% and 12%, respectively. Descriptive Results Results of this study indicate that many favorable changes occurred between 2000 and 2004 in terms of prevalence of smoking and its correlates among adolescents in grades 6-12. The weighted percentage of current smokers changed from 21.8% in 2000 to 15.2% in 2004 (p , .0001); established smokers from 11.1% to 6.4% (p , .0001); lifetime nonsmokers from 59.9% to 69.5% (p , .0001); those who had been highly exposed to anti-tobacco messages from 6.9% to 14.8% (p , .0001); those exposed to information about health consequences of tobacco use from 83.7% to 89.0% (p , .0001); and those moderately exposed to pro-tobacco messages and advertisements from 65.2% to 58.9% (p , .0001). However, the proportion of students with high exposure to protobacco messages did not differ significantly between the 2 years. Desirable changes also occurred in the exposure to ETS. In 2000, 29.5% of students reported being in the same room every day with someone who smoked during the past 7 days, but the number dropped to 24.5% (p , .0001) in 2004. Whereas 45.1% of students in 2000 did not ride in a car with someone who smoked during the past 7 days, 53.2% did not in 2004 (p , .0001). In terms of perceived benefit of smoking, the most cited benefit was ‘‘helping relaxation’’—54% of current smokers and 64% of estabJournal of School Health

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Have seen commercials on TV or any media about dangers of smoking in the past 30 days None 1-3 times 1-3 times a week Daily or almost daily More than once a day How often did you see antismoking messages on outdoor signs in the past 30 days? None 1-3 times 1-3 times a week Daily or almost daily More than once a day When you watch TV or go to movies, how often you see actors using tobacco? I don’t watch TV or movies Most of the time Some of the time Hardly ever Never When you watch TV, how often you see athletes using tobacco? I don’t watch TV Most of the time Some of the time Hardly ever Never When using the Internet, how often do you see ads for tobacco products? I don’t use Internet Most of the time Some of the time Hardly ever Never How many ads did you see on newspapers or magazines in the past 30 days? A lot (Daily or almost daily)‡ (1-3 times per week)‡ A few (1-3 times in the past 30 days)‡ None (I don’t read newspapers or magazines)‡ Did you buy or receive anything having tobacco company name or picture in the past 12 months? Yes No How often do you see tobacco adds in convenience store? I never go to a convenience store A lot Sometimes Never

2004 N*

%†

17.9 17.9 19.0 26.8 18.4

1147 1011 937 1298 813

22.6 19.3 17.5 24.4 16.2

916 1169 458 229 108

32.1 40.7 16.0 7.7 3.5

1718 1585 863 640 388

34.7 29.0 16.4 12.5 7.4

115 991 1371 342 81

3.7 33.9 47.9 11.8 2.7

234 1786 2498 575 147

4.1 33.0 47.6 11.9 3.3

135 158 486 1283 833

4.4 5.2 17.1 44.5 28.7

359 367 861 2076 1536

6.5 7.0 17.0 39.3 30.2

561 214 455 816 829

19.4 7.2 15.3 29.0 29.1

655 550 1160 1661 1170

12.6 10.4 21.9 31.7 23.4

876

30.7

1277 711

44.9 24.5

697 689 1482 1073 1311

13.7 13.3 26.7 20.0 26.4

623 2192

22.3 77.7

1024 3969

20.2 79.8

163 1527 957 211

5.4 53.8 33.5 7.3

308 3247 1359 297

6.0 62.5 25.5 6.0

N*

%

530 508 543 764 551

†

*Unweighted frequencies. They may not add up to the total due to missing values. † Weighted percentages. Percentages may not add up to 100% due to rounding errors. ‡ Response options in parentheses represent those in 2004.

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lished smokers, respectively, said ‘‘definitely yes’’ as a benefit of smoking. An alarming finding was that about 41-47% of smokers and 25% of nonsmoking students, respectively, reported keeping weight down as a benefit of smoking (Tables 1 and 2).

Bivariate and Multivariate Analyses for Current Smoking Gender was not significant but grade and race/ethnicity were significant in predicting students’ current smoking status in IYTS 2000 and 2004. Unsurpris-

ingly, sixth and seventh graders were less likely, and 12th graders were more likely than ninth graders to be current smokers for both years. Also, AfricanAmerican students were less likely than whites to be current smokers. As shown in Tables 3 and 4, students who started cigarette smoking when they were 13-14 years old were less likely to be current smokers than those who started at ages 9-10 years by a factor of 0.52 (95% CI: 0.31-0.88) in IYTS 2000 and 0.57 (95% CI: 0.40-0.82) in IYTS 2004 when adjusted for gender, grade, and race/ethnicity.

Table 3. Bivariate Association for Current Smoking, Indiana Youth Tobacco Survey 2000

Gender Female Male First cigarette smoking age for ever-smokers 8 years old or younger 9 or 10 years old 11 or 12 years old 13 or 14 years old 15 or 16 years old 17 years old or older Exposure to pro-tobacco message Low Moderate High Exposure to anti-tobacco message Low Moderate High Exposure to information about health consequences of tobacco use No exposure Exposed Exposure to environmental tobacco smoke in homes 0 days 1 or 2 days 3 or 4 days 5 or 6 days 7 days Exposure to environmental tobacco smoke in cars 0 days 1 or 2 days 3 or 4 days 5 or 6 days 7 days Perceived benefit of smoking‡ High perceived benefit Moderate perceived benefit Low perceive benefit Perceived peer acceptance to smoking‡ Definitely yes Probably yes Probably not Definitely not

N*

Current Smokers, n (%)†

1438 1488

284 (47.6) 295 (52.4)

2004 v2 (p value)

N*

Current Smokers, n (%)†

2712 2682

410 (48.9) 425 (51.1)

0.21 (.6489)

0.06 (.8001)

204.67 (,.0001) 143 146 329 324 133 18

69 79 180 146 74 10

(12.0) (13.2) (31.9) (25.9) (13.9) (2.1)

129.73 (,.0001) 234 220 389 521 287 54

96 120 186 234 119 26

94 (18.0) 387 (73.0) 45 (9.0)

720 1879 203

111 (20.2) 383 (72.7) 42 (7.1)

459 2421

75 (13.3) 498 (86.7)

38.14 (,.0001) 1740 2772 226

171 (24.4) 484 (66.6) 66 (9.0)

1754 2603 755

250 (31.9) 413 (51.1) 131 (17.0)

597 4592

76 (8.9) 730 (91.1)

1863 1166 543 330 1256

87 114 114 77 418

(11.7) (14.5) (13.7) (9.8) (50.4)

2728 873 524 300 731

132 153 124 96 298

(17.0) (19.8) (14.9) (12.2) (36.1)

599 1878 2886

245 (31.3) 427 (50.6) 152 (18.1)

1118 2113 1427 616

283 359 141 29

9.01 (.0151)

4.04 (.1390)

2.96 (.0905)

3.91 (.0513)

124.84 (,.0001) 943 642 301 169 820

49 85 89 48 294

(8.1) (14.7) (15.5) (8.3) (53.4)

1327 542 320 150 535

80 96 105 53 235

(13.3) (16.3) (18.8) (9.0) (42.5)

94.98 (,.0001)

116.23 (,.0001)

88.29 (,.0001)

95.91 (,.0001)

69.14 (,.0001)

*Unweighted frequencies. They may not add up to the total due to missing values. † Unweighted frequencies of current smokers and weighted percentages. Percentages may not add up to 100 % due to rounding errors. ‡ These variables were measured only for 2004.

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(12.0) (16.2) (22.9) (28.1) (15.8) (4.2)

48.46 (,.0001) 819 1780 133

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(34.9) (43.2) (18.5) (3.4)

Exposure to pro-tobacco messages was a significant predictor for current smoking, whereas exposure to anti-tobacco messages and exposure to information about health consequences of tobacco use were not significant predictors for current smoking in IYTS 2000 and 2004 in the adjusted logistic models. Students who experienced a high level (adjusted OR = 5.25 for 2000 and 3.81 for 2004) and a moderate level (adjusted OR = 1.98 for 2000 and 1.86 for 2004) of exposure to pro-tobacco messages were more likely to be current smokers than those with a low level of exposure. For both years, students’ exposure to ETS was significantly associated with current smoking. Interestingly, there was a dose-response relationship between

number of exposed days either in home or in cars and the ORs (both unadjusted and adjusted) of current smoking in both years. The more days in the past 7 days students were in the same room or in the same car with someone who smoked the more likely students were current smokers regardless of the year of survey or statistical adjustment of other variables in logistic models. Perceived benefit of smoking, measured by summating 5 relevant items in IYTS 2004, was also significantly associated with current smoking. Students with high and moderate perceived benefit of smoking were more likely to be current smokers than those with low perceived benefit by a factor of 15.9 (95% CI: 11.9-21.2) and 5.21 (95% CI: 4.04-6.73), respectively, in the adjusted model.

Table 4. Logistic Regression of Current Smoking, Indiana Youth Tobacco Survey 2000

First cigarette smoking age for ever-smokers 8 years old or younger 9 or 10 years old 11 or 12 years old 13 or 14 years old 15 or 16 years old 17 years old or older Exposure to pro-tobacco message Low Moderate High Exposure to anti-tobacco message Low Moderate High Exposure to information about health consequences of tobacco use No exposure Exposed Exposure to environmental tobacco smoke in homes 0 days 1 or 2 days 3 or 4 days 5 or 6 days 7 days Exposure to environmental tobacco smoke in cars 0 days 1 or 2 days 3 or 4 days 5 or 6 days 7 days Perceived benefit of smoking† High perceived benefit Moderate perceived benefit Low perceived benefit Perceived peer acceptance to smoking† Definitely yes Probably yes Probably not Definitely not

2004

OR

95% CI

AOR*

95% CI

OR

95% CI

AOR*

95% CI

1.19 1.0 1.07 0.68 1.05 1.31

0.70–2.02 Reference 0.70-1.65 0.43-1.06 0.63-1.74 0.48-3.56

1.23 1.0 0.95 0.52 0.67 0.81

0.70-2.17 Reference 0.60-1.50 0.31-0.88 0.38-1.17 0.31-2.12

0.49 1.0 0.66 0.57 0.50 0.57

0.30-0.82 Reference 0.44-0.98 0.41-0.81 0.32-0.77 0.32-0.99

0.52 1.0 0.66 0.57 0.47 0.54

0.31-0.88 Reference 0.43-1.00 0.40-0.82 0.30-0.73 0.29-1.00

1.0 2.16 4.66

Reference 1.71-2.73 2.66-8.16

1.0 1.98 5.25

Reference 1.60,2.46 2.90 9.56

1.0 1.84 3.79

Reference 1.45-2.35 2.59-5.55

1.0 1.86 3.81

Reference 1.47-2.36 2.59-5.60

0.71 1.05 1.0

0.44-1.17 0.73-1.52 Reference

0.68 1.03 1.0

0.41-1.11 0.71-1.51 Reference

0.78 0.85 1.0

0.62-0.99 0.66-1.10 Reference

0.71 0.75 1.0

0.56-0.90 0.59-0.96 Reference

0.73 1.0

0.52-1.04 Reference

1.63 1.0

0.44,0.90 Reference

0.76 1.0

0.58,1.00 Reference

0.59 1.0

0.44,0.78 Reference

1.0 2.82 7.77 7.88 10.9

Reference 1.91-4.15 5.39-11.2 5.07-12.2 7.47-16.0

1.0 2.46 6.26 6.54 9.70

Reference 1.69-3.58 4.29-9.13 4.23-10.1 6.97-13.5

1.0 2.02 5.25 5.89 9.06

Reference 1.44-2.82 3.62-7.62 4.00-8.68 6.84-12.0

1.0 1.88 4.40 5.59 9.50

Reference 1.31-2.71 2.95-6.56 3.76-8.29 7.05-12.8

1.0 3.36 8.25 8.91 13.8

Reference 2.64-4.27 6.06-11.3 6.06-13.1 10.2-18.6

1.0 3.10 7.69 8.74 14.7

Reference 2.46-3.90 5.69-10.4 5.67-13.5 10.8-20.1

1.0 4.41 5.84 9.56 13.2

Reference 3.17-6.14 4.13-8.26 7.18-12.7 9.52-18.2

1.0 4.23 6.10 10.6 15.1

Reference 3.02-5.92 4.30-8.65 7.72-14.4 10.9-21.1

15.8 5.85 1.0

11.9-20.9 4.48-7.62 Reference

15.9 5.21 1.0

11.9-21.2 4.04-6.73 Reference

8.97 4.99 2.48 1.0

5.23-15.3 2.92-8.53 1.42-4.33 Reference

7.22 3.64 2.08 1.0

4.34-12.0 2.22-5.96 1.19-3.64 Reference

CI, confidence interval; AOR, adjusted odds ratio. *Adjusted for gender, grade, and race/ethnicity. † These variables were measured only for 2004.


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Bivariate and Multivariate Analyses for Established Smoking Many similarities were observed between current smoking and established smoking in their significant correlates. As was observed in the current smoking, gender was not significant but grade and race/ethnicity were significant in predicting students’ established smoking status in IYTS 2000 and 2004 (Tables 5 and 6). Also, middle school students (grades sixth to eighth) were less likely and 11th and 12th graders were more likely than ninth graders to be established smokers for

both years. Also, African-American students were less likely than whites to be established smokers. As was observed in current smoking, exposure to pro-tobacco messages was a significant predictor for established smoking, whereas exposure to anti-tobacco messages and information about health consequences were not significant predictors in IYTS 2000 and 2004 adjusted logistic models. For both years, students’ exposure to ETS was significantly associated with established smoking, showing an overall dose-response relationship. However, 1 or 2 days of exposure in home

Table 5. Bivariate Association for Established Smoking, Indiana Youth Tobacco Survey 2000

Gender Female Male First cigarette smoking age for ever-smokers 8 years old or younger 9 or 10 years old 11 or 12 years old 13 or 14 years old 15 or 16 years old 17 years old or older Exposure to pro-tobacco message Low Moderate High Exposure to anti-tobacco message Low Moderate High Exposure to information about health consequences of tobacco use No exposure Exposed Exposure to environmental tobacco smoke in homes 0 days 1 or 2 days 3 or 4 days 5 or 6 days 7 days Exposure to environmental tobacco smoke in cars 0 days 1 or 2 days 3 or 4 days 5 or 6 days 7 days Perceived benefit of smoking‡ High perceived benefit Moderate perceived benefit Low perceived benefit Perceived peer acceptance to smoking‡ Definitely yes Probably yes Probably not Definitely not

N*

Established Smokers, n (%)†

1438 1488

115 (45.9) 133 (54.1)

2004 v2 (p value)

N*

Established Smokers, n (%)†

2712 2682

152 (44.9) 178 (55.1)

0.62 (.4343)

1.27 (.2639)

75.97 (,.0001) 143 146 329 324 133 18

40 34 82 63 22 5

(16.6) (13.3) (34.8) (24.1) (9.4) (1.9)

73.64 (,.0001) 234 220 389 521 287 54

41 (19.2) 166 (71.7) 20 (9.2)

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(14.7) (21.5) (24.5) (26.7) (10.6) (2.0)

720 1879 203

42 (17.3) 163 (73.9) 21 (8.7)

459 2421

27 (10.7) 218 (89.4)

42.70 (,.0001) 1740 2772 226

65 (21.5) 199 (67.1) 28 (11.5)

1754 2603 755

98 (30.6) 167 (51.7) 51 (17.7)

597 4592

31 (9.1) 290 (91.0)

1863 1166 543 330 1256

24 20 28 30 219

(7.4) (6.5) (9.4) (9.7) (67.0)

2728 873 524 300 731

32 37 41 35 172

(10.6) (13.2) (12.3) (11.3) (52.7)

599 1878 2886

110 (34.9) 160 (48.4) 55 (16.8)

1118 2113 1427 616

113 152 49 7

12.46 (.0035)

3.05 (.2242)

6.07 (.0166)

1.53 (.2202)

81.36 (,.0001) 943 642 301 169 820

10 22 29 20 162

(3.5) (8.3) (12.1) (7.8) (68.4)

1327 542 320 150 535

12 20 37 24 151

(4.6) (7.3) (14.7) (9.8) (63.7)

62.46 (,.0001)

63.32 (,.0001)

55.60 (,.0001)

64.53 (,.0001)

53.74 (,.0001)

*Unweighted frequencies. They may not add up to the total due to missing values. † Unweighted frequencies of established smokers and weighted percentages. Percentages may not add up to 100% due to rounding errors. ‡ These variables were measured only for 2004.

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51 68 79 86 32 5

21.20 (.0001) 819 1780 133

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(35.3) (47.9) (14.8) (2.1)

for 2004 failed to reach significance probably due to the small cell size of this category. DISCUSSION The findings of this study that used a representative sample of Indiana adolescents, grades 6-12, indicate that many positive improvements were made between 2000 and 2004 in terms of their tobacco use and exposure to risk or protective factors. As perceived benefit of smoking was significantly correlated with smoking status, it is important to investigate the factors that shape these favorable perceptions. Results of this study are in line with the literature that recognizes weight control9 and social

acceptance9,12,34 as perceived benefits of smoking. It is noteworthy, however, that relaxation was the highest ranking perceived benefit, and should be further explored as this concept has received little attention in the literature. It is important to understand why teens depend on tobacco for relaxation as well as which types of stressors are more likely to be correlated with smoking as stress relief. Because perceived benefit in general has been studied very little, it should become a vital area of research that could potentially inform intervention design.33 An important finding of this study is the strong association between exposure to ETS either in homes or cars and youth smoking. While no causal inference can be made from these results, it is important to

Table 6. Logistic Regression of Established Smoking, Indiana Youth Tobacco Survey 2000

First cigarette smoking age for ever-smokers 8 years old or younger 9 or 10 years old 11 or 12 years old 13 or 14 years old 15 or 16 years old 17 years old or older Exposure to pro-tobacco message Low Moderate High Exposure to anti-tobacco message Low Moderate High Exposure to information about health consequences of tobacco use No exposure Exposed Exposure to environmental tobacco smoke in homes 0 days 1 or 2 days 3 or 4 days 5 or 6 days 7 days Exposure to environmental tobacco smoke in cars 0 days 1 or 2 days 3 or 4 days 5 or 6 days 7 days Perceived benefit of smoking† High perceived benefit Moderate perceived benefit Low perceived benefit Perceived peer acceptance to smoking† Definitely yes Probably yes Probably not Definitely not

2004

OR

95% CI

AOR*

95% CI

OR

95% CI

AOR*

95% CI

1.63 1.0 1.16 0.63 0.70 1.19

0.93-2.86 Reference 0.67-2.01 0.34-1.15 0.35-1.43 0.34-4.14

2.25 1.0 0.89 0.33 0.20 0.36

1.05-4.84 Reference 0.46-1.75 0.16-0.68 0.10-0.39 0.10-1.24

0.46 1.0 0.53 0.41 0.26 0.20

0.26-0.79 Reference 0.34-0.84 0.27-0.62 0.15-0.45 0.07-0.60

0.51 1.0 0.42 0.30 0.12 0.10

0.28-0.93 Reference 0.23-0.77 0.18-0.49 0.06-0.25 0.03-0.31

1.0 1.99 4.43

Reference 1.38-2.86 2.17-9.04

1.0 1.76 4.66

Reference 1.24-2.50 2.25. 9.63

1.0 2.10 5.44

Reference 1.58-2.80 3.17-9.33

1.0 2.04 5.09

Reference 1.56-2.68 2.88-9.00

0.50 0.87 1.0

0.30-0.81 0.54-1.39 Reference

0.43 0.79 1.0

0.24-1.16 0.46-1.34 Reference

0.72 0.82 1.0

0.50-1.03 0.58-1.17 Reference

0.62 0.70 1.0

0.41-1.05 0.49-1.39 Reference

0.57 1.0

0.37-0.88 Reference

0.42 1.0

0.27-1.26 Reference

0.78 1.0

0.52-1.17 Reference

0.54 1.0

0.34-1.25 Reference

1.0 3.66 14.0 17.0 32.3

Reference 1.38-9.73 5.47-35.8 8.41-34.6 14.8-70.6

1.0 2.68 9.30 11.8 25.8

Reference 1.02-7.03 3.57-24.2 5.50-25.2 12.5-53.1

1.0 1.44 5.75 9.23 19.1

Reference 0.72-2.87 3.04-10.9 4.74-18.0 11.7-31.2

1.0 1.30 4.49 8.43 20.5

Reference 0.59-2.83 2.32-8.71 4.27-16.7 12.5-33.5

1.0 4.33 18.6 28.0 59.9

Reference 1.83-10.3 9.53-36.3 13.6-57.4 32.7-110

1.0 3.66 16.2 27.9 70.1

Reference 1.50-8.94 7.94-33.2 12.5-62.4 36.1-136

1.0 4.69 7.70 14.2 30.8

Reference 2.61-8.44 4.13-14.4 8.96-22.4 19.6-48.5

1.0 4.80 9.30 18.0 44.1

Reference 2.63-8.77 4.81-18.0 10.6-30.5 27.3-71.2

18.9 6.01 1.0

12.9-27.6 4.19-8.62 Reference

19.9 5.18 1.0

13.3-29.7 3.53-7.58 Reference

14.6 8.90 3.18 1.0

6.02-35.4 3.81-20.8 1.31-7.72 Reference

9.65 5.03 2.26 1.0

3.97-23.5 2.17-11.7 0.93-5.49 Reference

CI, confidence interval; AOR, adjusted odds ratio. *Adjusted for gender, grade, and race/ethnicity. † These variables were measured only for 2004.


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consider the implications of ETS on adolescents’ smoking. It is a reasonable assumption that at least several factors, such as biological or psychosocial processes, mediate the association between exposure to ETS and teen smoking behavior. Repeated physical exposure to ETS might make the exposed more susceptible to addiction to nicotine via chemical reactions37 or development of a favorable sense of tobacco smell. Having more exposure to ETS might also mean that the individual has more smokers near him/her. Thus, the extent of exposure to ETS could be a proxy measure of number of friends or family members who smoke. Future research with prospective design is warranted to reveal the mechanism by which the link between exposure to ETS and youth smoking is decomposed and intermediate factors, if any, are identified. As suggested by the literature12-18 exposure to protobacco messages was a significant predictor for both current and established smoking in this study, whereas exposure to anti-tobacco messages and exposure to information about health consequences of tobacco use were not significant predictors for either current or established smoking in both years in the adjusted models.22,24 Although many policy-level efforts have been made to reduce adolescent exposure to protobacco marketing, such marketing is still pervasive and seems to be connected to regular tobacco usage among youth. It may be that because the funding that backs pro-tobacco advertising is so much higher than the funding that backs anti-tobacco campaigns. Also, it might be that the messages and advertisements from the tobacco industry are more prevalent, attractive, flashy, and appealing than those of the lower budget public health messages. More efforts should be made to control this pro-tobacco marketing and further research should explore the factors that influence teen’s exposure to pro-tobacco messages and the mechanism by which this may lead to higher rates of tobacco usage. Because exposure to anti-tobacco messages showed no significant relationship to decreased tobacco usage, further study needs to be conducted to enhance the effectiveness of such messages, and to battle adolescents’ exposure to pro-tobacco messages. It seems that the anti-tobacco messages, although pervasive, are not sufficient to battle the pro-tobacco messages being received. It has been recommended by others that antidrug media campaigns be tested thoroughly before disseminated to the public.38 Furthermore, such messages should be pilot tested to an audience of teenagers to explore which tobacco counter-marketing strategies are most effective for reducing youth tobacco use. As mentioned previously, some anti-tobacco campaigns have shown more efficacy than others22-24 and it appears anti-tobacco messages should be very specifically tailored to teens 106

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based on factors such as age, smoking status, and even certain psychological profiles.12 Not surprisingly, perceived peer acceptance demonstrated a significant association with current and established smoking, as peers are often the most influential power during youth.7,8 It is important to note that the literature suggests that there is not only a high rate of perceived peer acceptance among smokers but that overestimation of peer tobacco use and acceptance is also high,39,40 creating what is referred to as a ‘‘false consensus effect’’39 as teens accept and do what they assume is a social norm. Therefore, reducing teens’ perceptions of peer tobacco use and acceptance may be an important area to target in research, campaigns, and interventions. These findings are subject to some limitations. One limitation is due to the fact that the findings were based on self-report by the students, as opposed to direct measurement of the variables. However, given the complexity of directly measuring factors such as exposure to ETS or pro-tobacco messages for a large sample of adolescents, self-report is an adequate way to explore youth tobacco usage. Second, although causal relationships should not be inferred from these findings, the consistent patterns observed across 2000 and 2004 do lend to the evidence of a link between the significant variables and current and established smoking patterns. Third, the findings should be only generalized to public middle and high school students. Despite these limitations, this study contributes to the literature by providing an insight into salient factors of youth tobacco smoking.

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