Trends in Cigarette Smoking Among High School Students ---United States, 1991--2001

Cigarette smoking among adolescents is one of the 10 Leading Health Indicators that reflect the major health concerns in the United States (1). To examine changes in cigarette smoking among U.S. high school students during 1991--2001, CDC analyzed data from the national Youth Risk Behavior Survey (YRBS). This report summarizes the results of the analysis, which found that although cigarette smoking rates increased during most of the 1990s, they have declined significantly since 1997. If this pattern continues, the United States could achieve the national health objective for 2010 of reducing current smoking rates among high school students to <16% (objective no. 27-2b) (1) .

YRBS, a component of CDC's Youth Risk Behavior Surveillance System, measures the prevalence of health risk behaviors among high school students through representative biennial national, state, and local surveys. The 1991, 1993, 1995, 1997, 1999, and 2001 national surveys used independent three-stage cluster samples to obtain cross-sectional data representative of students in grades 9--12 in all 50 states and the District of Columbia. During 1991--2001, sample sizes ranged from 10,904 to 16,296, school response rates ranged from 70% to 79%, student response rates ranged from 83% to 90%, and overall response rates ranged from 60% to 70%.

For each cross-sectional survey, students completed an anonymous, self-administered questionnaire that included identically worded questions about cigarette smoking. For this report, three behaviors were assessed: lifetime smoking (defined as having ever smoked cigarettes, even one or two puffs), current smoking (defined as smoking on >1 of the 30 days preceding the survey), and current frequent smoking (defined as smoking on >20 of the 30 days preceding the survey). Data are presented only for non-Hispanic black, non-Hispanic white, and Hispanic students because the numbers of students from other racial/ethnic populations were too small for meaningful analysis. Current smoking was analyzed among sex, racial/ethnic, and grade subgroups.

Data were weighted to provide national estimates, and SUDAAN was used for all data analysis. Temporal changes were analyzed using logistic regression analyses that assessed linear and quadratic time effects simultaneously and that controlled for sex, race/ethnicity, and grade. Quadratic trends indicated a significant but nonlinear trend in the data over time. When a significant quadratic trend accompanied a significant linear trend, the data demonstrated some nonlinear variation (e.g., leveling off or change in direction) in addition to a linear trend.

Significant linear and quadratic trends were detected for lifetime, current, and current frequent smoking. The prevalence of lifetime smoking, although stable through the 1990s, declined significantly from 70.4% in 1999 to 63.9% in 2001 (Table 1). The prevalence of current smoking increased from 27.5% in 1991 to 36.4% in 1997 and then declined significantly to 28.5% in 2001. Current frequent smoking increased from 12.7% in 1991 to 16.7% in 1997 and 16.8% in 1999 and then declined significantly to 13.8% in 2001.

Among female students, a significant quadratic trend was detected, indicating that the prevalence of current smoking peaked during 1997--1999 and then declined significantly by 2001 (Table 2). Similarly, among white female, black male, Hispanic, Hispanic female, Hispanic male, and 9th- and 11th-grade students, current smoking prevalence peaked by 1999 and then declined significantly by 2001. A positive linear trend was detected among black female students, indicating that the prevalence of current smoking among this subgroup increased significantly throughout the decade.

Among male students, significant linear and quadratic trends were detected, indicating that the prevalence of current smoking increased significantly during 1991--1997 and then declined significantly by 2001. A similar pattern was detected among white, white male, black, and 10th- and 12th-grade students; however, among 12th-grade students, the increase lasted until 1999.

During 2001, white and Hispanic students were significantly more likely than black students to report current smoking. Current smoking was significantly more likely to be reported by white and Hispanic female students than by black female students, by white and Hispanic male students than by black male students, and by 12th-grade students than by 9th- and 10th-grade students.

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

Editorial Note:

This report indicates that substantial progress is being made toward achieving the national health objective for 2010 of reducing cigarette smoking rates among high school students. The data are consistent with other national surveys suggesting that smoking levels among high school students have peaked and are now declining (2,3). Factors that might have contributed to the decline in cigarette use include a 70% increase in the retail price of cigarettes during December 1997--May 2001 (4), increased school-based efforts to prevent tobacco use (5), and increased exposure of youth to both state and national mass media smoking prevention campaigns (6). Factors that might have promoted cigarette use include tobacco industry expenditures on advertising and promotion, which increased substantially during 1998--1999 (7), and the frequency with which smoking was depicted in films (8).

Despite the declines in cigarette smoking rates among high school students, 28.5% of high school students are current smokers, and 13.8% are current frequent smokers. Many high school students already are nicotine dependent. Because schools reach most youth and could provide students with the motivation and skills to quit smoking, effective school-based or school-linked cessation programs are needed.

Additional research might examine how current smoking rates and temporal changes in these rates vary among racial/ethnic populations. For example, throughout the 1990s, YRBS and other national surveys reported that black high school students smoked at lower rates than white and Hispanic high school students (2).

The findings in this report are subject to at least two limitations. First, these data reflect only adolescents who attend high school. In 1998, 5% of persons aged 16--17 years were not enrolled in a high school program and had not completed high school (9). Second, the extent of underreporting or overreporting in YRBS cannot be determined, although the survey questions demonstrate good test-retest reliability (10).

Reducing youth smoking further will require that states and communities implement comprehensive, effective, and sustainable tobacco-control programs to reduce the appeal of tobacco products, including at least the following six interventions: youth-oriented mass media campaigns, increased tobacco excise taxes, smoke-free policies for schools and other community venues, greater regulation of tobacco products, reductions in youth access to tobacco products, and school-based health programs to reduce tobacco use and addiction.

References

1. U.S. Department of Health and Human Services. Healthy People 2010 (conference ed., 2 vols). Washington, DC: U.S. Department of Health and Human Services, 2000.
2. Johnston LD, O'Malley PM, Bachman JG. Monitoring the Future national results on adolescent drug use: overview of key findings, 2001. Bethesda, Maryland: National Institute on Drug Abuse, 2002 (NIH Publication no. 02-5105).
3. Substance Abuse and Mental Health Services Administration. Summary of findings from the 2000 National Household Survey on Drug Abuse. Rockville, Maryland: U.S. Department of Health and Human Services, 2001 (DHHS publication no. [SMA] 01-3549).
4. U.S. Department of Labor, Bureau of Labor Statistics. Consumer Price Index-All Urban Consumers (Current Series). Washington, DC: U.S. Department of Labor, 2002.
5. Kolbe LJ, Kann L, Brener ND. Overview and summary findings: school health policies and programs study 2000. J Sch Health 2001;71:253--9.
6. Farrelly MC, Healton CG, Davis KC, Messeri P, Hersey JC, Haviland ML. Getting to the truth: evaluating national tobacco countermarketing campaigns. Am J Public Health, 2002 (in press).
7. Federal Trade Commission. Cigarette report for 1999. Washington, DC: Federal Trade Commission, 2001.
8. Sargent JD, Beach ML, Dalton MA, et al. Effect of seeing tobacco use in films on trying smoking among adolescents: cross sectional study. BMJ 2001;323:1--6.
9. Kaufman P, Kwon JY, Klein S, Chapman CD. Dropout rates in the United States: 1998. Washington, DC: U.S. Department of Education, National Center for Educational Statistics, 1999.
10. 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 (in press).

Table 1


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Table 2


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