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JANUARY/FEBRUARY 2011 :: 72(1)
Behavioral Health Needs of Military Personnel and Their Families

The policy forum of this issue addresses the behavioral health needs of North Carolina service members, veterans, and their families. Also in this issue, a leading pharmaceutical company reviews how its efforts complement health reform, and original articles investigate secondhand-smoke exposure, smoking among adolescents, and characteristics of cancer survivors.


Variables Associated With Use and Susceptibility to Use of Cigarettes Among North Carolina Adolescents: Results From the 2007 Statewide Survey of High School Students

Kelly L. Kandra, Adam O. Goldstein, Scott Proescholdbell

N C Med J. 2011;72(1):13-19.PDF | TABLE OF CONTENTS

Background As North Carolina works to sustain recent reductions in smoking among adolescents, more knowledge is needed to design effective prevention programs. This study examined the variables associated with use and susceptibility to use of cigarettes use among North Carolina students in high school (ie, grades 9-12).

Methods Data were collected from the 2007 North Carolina Youth Tobacco Survey (NCYTS). The NCYTS is a biannual public school– and charter school–based survey of North Carolina students in grades 6-12. Seventy-four of 115 school districts from 3 distinct geographic regions of the state were selected for participation in the 2007 NCYTS. Logistic regression models examined factors associated with current use of cigarettes, ever having used cigarettes (also referred to as “ever use”), and susceptibility to use of cigarettes. The 2007 NCYTS was completed by 3,364 students (81.6%) at participating high schools, for an overall completion rate of 78.3% among all North Carolina high school students. All analyses included sampling weights, which enabled results to be generalized to all high school students in North Carolina.

Results A total of 48.9% of students reported ever use, 19.0% were classified as current users, and 33.5% were classified as susceptible to use. Females, nonminorities, and older students had higher odds than males, minorities, and younger students, respectively, of being a current smoker. Minorities, however, had higher odds than nonminorities of ever smoking. Use of other forms of tobacco increased the odds of current use and ever use of cigarettes. Agreement with the statement that smoking makes one look cool or fit in increased the odds of being susceptible to smoking. Having a willingness to wear an item promoting a tobacco company and having close friends who smoked individually increased the odds of each of the 3 outcomes.

Limitations Data are from a cross-sectional survey conducted every other year, in which students self-report use of, attitudes about, and perceptions about tobacco products.

Conclusions Many variables should be taken into account to optimize efforts to prevent tobacco use, countermarket campaigns, and policy initiatives in North Carolina.

Every day in the United States, 3,900 young people try cigarette smoking, and 1,500 become daily smokers [1]. According to a 2005 nationwide survey, 28% of students had tried smoking before entering high school; by the last year of high school, 53% had tried smoking [2]. Smoking rates among students in grade 8 peaked in 1996, at approximately 22%, and smoking rates among students in grade 12 peaked the following year, at approximately 37% [2]. Nationally, while smoking rates among high school students began to decline in the mid-1990s, the rate of decline began to slow around 1999 [3]. The current rate for cigarette smoking among US high school students is estimated to be 19.7% [3]. North Carolina, however, has seen a different trend. From 2003 through 2007, high school students in the state had higher rates of decline in cigarette use, compared with rates for 1999-2003 [4]. In 2007, the rate of cigarette smoking among North Carolina high school students was 19.0% [5].

This study examines variables associated with cigarette use and susceptibility to cigarette use among North Carolina students, using 2007 data from a statewide tobacco survey. This research comes at an important time, as public health efforts in the state aim to sustain reductions in cigarette consumption among youths. By identifying the variables associated with smoking and susceptibility to smoking among adolescents, state public health workers have more information about the current smoking status among North Carolina high school students. This information can be used to test for trends in the future, with the ultimate goal of designing more-effective programs to prevent tobacco use. As patterns of tobacco use change over time (eg, the smoking prevalence among females is increasing), it is useful to know how public health practices must change in order to continue to sustain reductions in tobacco consumption.

Questionnaire. The North Carolina Youth Tobacco Survey (NCYTS) includes data on the prevalence of the use of cigarettes and other tobacco products, as well as information on tobacco use, environmental tobacco smoke, cessation, pro-health media, tobacco advertising, school-based education to prevent tobacco use, community participation, and access to and availability of tobacco products.

Sampling. The NCYTS involves a biannual public school– and charter school–based survey of students in grades 6-12. The NCYTS has been conducted 5 times since 1999, with the most recent administration occurring in 2009. A multistage cluster-sample design, with corresponding sampling weights, is used to produce representative data on students in middle school (grades 6-8) and high school (grades 9-12) in North Carolina. For purposes of the current research, however, only 2007 data on high school students were used, as 2009 data were not yet available. Schools were selected on the basis of a probability proportionate to student enrollment size. Classes were randomly selected, and most students in selected classes were eligible to participate (students who had special needs and/or were enrolled in English-as-a-second-language programs were not eligible).The sampling frame for the drawn high school sample consisted of all public and charter high schools in North Carolina. In the first stage of sampling, 74 of 115 school districts were selected in 3 distinct geographic regions of the state (ie, west, central, and east). All 74 school districts agreed to participate, for a response rate of 100%. Student participation was voluntary and anonymous, and school procedures for obtaining parental permission were followed. Students recorded their responses on computer-scannable sheets.

A total of 197 high schools were selected from the 74 school districts. Of these, 191 (97.0%) participated in the study. The 2007 NCYTS was completed by 3,364 students (81.6%) at participating schools, for an overall completion rate of 78.3% among all North Carolina high school students.

Analysis. Logistic regression modeling was performed using a backward stepwise-regression approach. Separate models included the outcome variables of ever having used cigarettes (also referred to as “ever use”), current use of cigarettes, and susceptibility to use of cigarettes. In accordance with the Centers for Disease Control and Prevention (CDC) guidelines for youth smoking [6], students who smoked cigarettes on at least 1 day in the past 30 days of taking the NCYTS were considered current smokers. Susceptibility to smoking cigarettes was determined by nonsmoking students’ responses to the following questions: Do you think you will smoke a cigarette at anytime in the next year? Do you think you will be smoking cigarettes 5 years from now? If one of your best friends offered you a cigarette, would you smoke it? Students must answer “definitely not” to each question to be considered not susceptible to smoking.

Potential variables used in models included demographic characteristics, current use of specific tobacco products (eg, cigars and smokeless tobacco), counseling from parents about tobacco, attitudes about the health effects of tobacco use, attitudes about the social acceptability of tobacco, awareness of state countermarketing campaigns, influence of tobacco advertising, and exposure to cigarettes from family and friends. Final models included odds ratios (ORs) and 95% confidence intervals (CIs) for variables that were defined as statistically significant on the basis of an α level of .05. All analyses used SAS survey procedures (SAS Institute) to account for both the survey design (eg, clusters) and sampling weights. Sampling weights enable results to be generalized to all North Carolina high school students.

Approximately 19.0% of North Carolina high school students met the CDC criteria for classification as a current smoker, 48.9% had ever smoked a cigarette, and 33.5% met the criteria for being susceptible to cigarette use (Tables 1-3). Table 4 presents all statistically significant variables across the 3 logistic regression models (P ≤ .05).

Ever use of cigarettes. The NCYTS results indicated a relationship between ever use of various tobacco products and ever use of cigarettes. High school students who had ever smoked cigars were 9.62 times as likely to have ever smoked cigarettes (95% CI, 7.01-13.19), and students who had ever used smokeless tobacco were 2.95 times as likely to have ever smoked cigarettes (95% CI, 1.71-5.09). Furthermore, female sex, older age, and minority race were each associated with increased odds of ever having used cigarettes, as were certain attitudes about tobacco companies. High school students who said they would wear or use something that promoted a tobacco company were 1.77 times as likely to have ever smoked cigarettes (95% CI, 1.35-2.31). Students who agreed that tobacco companies got too much blame for young people smoking were 1.45 times as likely to have ever smoked (95% CI, 1.05-1.99). Exposure to smoking also increased the odds of ever having smoked, as high school students who lived with a smoker were 1.75 times as likely to have ever smoked (95% CI, 1.39-2.21). Similarly, as the number of close friends who smoke cigarettes increased, the odds of ever having smoked also increased (OR, 1.58 [95% CI, 1.41-1.77]).

Current use of cigarettes. Again, a relationship was found between current use of various tobacco products and being a current smoker. High school students who currently smoked cigars were 7.60 times as likely to currently use cigarettes (95% CI, 4.98-11.60), and current users of smokeless tobacco were 2.62 times as likely to currently use cigarettes (95% CI, 1.51-4.57). Female sex and older age also increased the odds of current smoking. However, nonminority high school students were more likely to be current smokers (OR, 2.04 [95% CI, 1.34-3.11]).

A relationship also existed between certain attitudes about tobacco companies and current use of cigarettes. High school students who would use or wear something that promotes a tobacco company were 2.05 times as likely to be a current smoker (95% CI, 1.31-3.22). Students who received or bought something in the previous 12 months that had a tobacco company name or logo on it were 1.92 times as likely to be a current smoker (95% CI, 1.40-2.63). Another attitude related to current smoking involved the statement that it is safe to smoke for a year or two if one then quits. High school students who agreed with this statement were 4.33 times as likely to be a current smoker (95% CI, 2.44-7.70).

One variable that was associated with lower odds of smoking was awareness of slogans from the state-sponsored media campaign. Students who were aware of these slogans were one-third less likely to be current smokers (OR, 0.66 [95% CI, 0.43-1.01]; P = .05).

Susceptibility to use of cigarettes. The logistic regression model for high school students’ susceptibility to using cigarettes shared similar variables with models of ever use and current use of cigarettes, although a smaller subset of variables was statistically significant. Factors making high school students more susceptible to smoking included receiving or buying something that had a tobacco industry name or logo on it, believing that young people who smoked looked cool or fit in, and having close friends who smoked. However, students who reported that their parents talked to them about the dangers of tobacco use were 17% less likely to be susceptible to smoking (OR, 0.83 [95% CI, 0.73-0.96]).

This analysis of the 2007 NCYTS yields important findings for North Carolina public health, prevention, and tobacco-control advocates. It is alarming that North Carolina female high school students now have higher odds than their male peers of ever use and current use of cigarettes. The 1994 US surgeon general’s report on preventing tobacco use among young people indicated that, while higher rates of tobacco use had previously been found among males, the difference in prevalence between males and females had narrowed [7]. While the prevalence in North Carolina is similar between males and females (21% and 17%, respectively), females are at much higher odds for initiation of and continued cigarette use.

Several factors may explain this shift. One probable reason is the targeted marketing of tobacco products to female youths [8]. Other reasons include psychosocial factors specific to adolescent females. Research suggests that females who have poor family relations are more likely to experiment with cigarettes and that those with a low level of activity in their lives will continue experimenting, while females who are concerned about dieting and have less social success are more likely to rapidly progress to regular smoking [9, 10]. Our findings suggest that North Carolina needs to segment countermarketing efforts on issues that are relevant to adolescent females.

Our research also suggests that efforts to prevent tobacco use must take into account that North Carolina students are using multiple forms of tobacco. Being a current cigar smoker substantially increased the odds of being a current cigarette smoker, with the same pattern holding true for ever use. While the relationship was less pronounced for smokeless-tobacco use, it nevertheless showed increased odds for current use and ever use of cigarettes. Because national data have shown that young people living in the southern United States are at risk for use of multiple forms of tobacco [11], there is a clear need to expand prevention efforts in North Carolina to include multiple forms of tobacco.

Furthermore, our research shows that tobacco-related prevention efforts must counter the marketing practices of the tobacco industry. Wearing, receiving, or buying something with an industry logo was related to all 3 outcomes of interest (ie, current use, ever use, and susceptibility to use of cigarettes). Receptivity to tobacco promotions has been shown in previous research to be related to use and susceptibility to use of tobacco [12]. With the Master Settlement Agreement in 1998 prohibiting the tobacco industry from directly marketing to youths [13], this finding suggests that North Carolina youths are still being reached through indirect methods and are being influenced by industry promotions. It is essential that antitobacco programs, especially those in tobacco-producing states, find ways to further reduce youth exposure to tobacco advertising, while deglamorizing industry practices through media campaigns and school-based prevention efforts.

Perceptions of smoking are apparently an important factor in use and susceptibility to use of cigarettes. High school students who believe that it is safe to smoke for a couple of years are now more likely to currently use cigarettes. Furthermore, perceptions that smoking is socially desirable relate to an increased susceptibility risk. High school students who believe that smoking makes young people look cool or fit in are more likely to be susceptible to smoking. It is clear that many North Carolina students still equate smoking with being cool. This finding is not surprising, given that this result has been found in other research studies [14, 15]. However, it is unclear why high school students have reduced perceptions about the risks of smoking. Focus groups and other formative research on youths in grades 9-12 might point to more-targeted interventions to sustain risk perceptions, as well as shed light on what can be done to further counteract the “coolness” of smoking.

Parent communication appears to play an important role in determining the smoking habits of young people. Our results suggest that parent communication about the dangers of tobacco use is working to some extent: as the frequency of communication increases, the odds of being susceptible to smoking decrease. However, Harakeh and colleagues [16] suggest that it is quality (eg, respectful and constructive discussions), not quantity, that counts when it comes to talking to youths about smoking. Parents need to have open dialogue with their children about the dangers of tobacco, before their children start experimenting with cigarettes, and the conversation needs to be conducted in a way that their children will be receptive to the message. Prevention efforts should focus on providing parents with the resources and information they need to have effective communications with their children about not smoking.

Unfortunately, it appears that a family structure that tolerates smoking serves as a risk factor for smoking. High school students are more likely to try cigarettes when they live with someone (such as a parent or sibling) who smokes. A family member who smokes offers youths the opportunity to model behavior, makes smoking appear socially desirable, and provides youths with easy access to cigarettes [17]. Furthermore, although research suggests that parents who smoke do communicate with their children about the dangers of tobacco, they are unlikely to ban smoking in the home, for fear of appearing hypocritical [18]. Strategies to prevent tobacco use need to focus more on the family structure, and they must begin to encourage families to use cessation programs to become smoke-free.

A final variable associated with ever use, current use, or susceptibility to use of cigarettes among North Carolina youths appears to be peer smoking. Past research has shown a direct relationship between peer smoking behavior and a youth’s smoking status [18]. North Carolina youths appear to be no different: as the number of friends who smoke increases, the odds of current use, ever use, and susceptibility to use also increase. Past research suggests that, as adolescents mature, they adopt group behaviors [19]; thus, there is a strong need for adolescents to become more autonomous in making smoking-related decisions. However, since prevention efforts that focus on refusal skills have been shown to be ineffective among youths [20], it may be up to parents to get the message across. Again, the need for open and honest communication between parents and their children is essential for tobacco prevention.

While many variables were related to an increase in the odds of current cigarette smoking among high school students, one variable, awareness of any of the prevention slogans in the state-sponsored media campaign was associated with a decreased odds of cigarette smoking. Past research has suggested that comprehensive media campaigns can be an effective deterrent to teenage smoking [21]. The state media campaign that began in 2004 and received expanded funding in 2006 is a multicomponent campaign that includes television and radio ads, school programs, and a central Web site (available at: The campaign remains an important component of the statewide teen tobacco initiative, and it will be interesting to examine data from future administrations of the NCYTS, to determine how sustained exposure to the campaign has influenced smoking among students.

Several limitations exist in these data. As the NCYTS is a cross-sectional survey, causality cannot be inferred. Thus, the results should be considered descriptive in nature and not causal. Furthermore, since this analysis comes from youths in North Carolina, the results may not be generalizable to youths in other regions of the country. Another limitation is that these data involve self-reported measures and are subject to the honesty of the high school students who participated. Also, several implications discussed above need formative research to test whether youths would respond to improved messages targeted at changing factors of cigarette use and susceptibility to cigarette use.

Variables associated with use and susceptibility to use of cigarettes among North Carolina high school students are multifaceted. Demographic characteristics, such as sex, race, and age; multiple forms of tobacco use; certain attitudes relating to the safety and social desirability of smoking; and peer influence need to be taken into account when targeting youths for antitobacco prevention initiatives. Investment of state funds in comprehensive tobacco-control programs has been shown to be successful in reducing tobacco consumption among youths in North Carolina [7]. With the historic action of House Bill 2, which reduces youth and adult exposure to secondhand smoke in public places, now is the time to provide a greater focus on deterring youths from cigarette use [22]. State efforts should consider using increased portions of the Master Settlement Funds to focus initiatives on the predictors highlighted in this research, to further reduce cigarette use among young people in North Carolina.

We thank North Carolina school district superintendents, Safe and Drug-Free Schools coordinators, administrative staff, teachers, and students, for their participation; and the North Carolina Tobacco Prevention and Control Branch, for coordinating the administration of the Youth Tobacco Survey.

Financial support. North Carolina Health and Wellness Trust Fund.

Potential conflicts of interest. All authors have no relevant conflicts of interest.

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Kelly L. Kandra, PhD assistant professor, Department of Psychology, Benedictine University, Lisle, Illinois.

Adam O. Goldstein, MD, MPH professor, Department of Family Medicine, School of Medicine, University of North Carolina–Chapel Hill, Chapel Hill, North Carolina.

Scott Proescholdbell, MPH director of surveillance and evaluation, Tobacco Prevention and Control Branch, Division of Public Health (DPH), North Carolina Department of Health and Human Services (DHHS), Raleigh, North Carolina (current affiliation: head, Injury Epidemiology and Surveillance Unit, Injury and Violence Prevention Branch, DPH, North Carolina DHHS, Raleigh, North Carolina).

Address correspondence to Dr. Kelly L. Kandra, Department of Psychology, Benedictine University, 5700 College Rd, Lisle, IL 60532 (