Current Trends Reasons for Tobacco Use and Symptoms of Nicotine Withdrawal Among Adolescent and Young Adult Tobacco Users -- United States, 1993

Cigarettes and other forms of tobacco are addictive because of the presence of nicotine (1). Among adults in the United States who have ever smoked daily, 91.3% tried their first cigarette and 77.0% became daily smokers before age 20 years (2). Among high school seniors who had ever tried smokeless tobacco (SLT), 73% did so by the ninth grade (2). To further characterize the development of nicotine addiction among persons aged 10-22 years, CDC analyzed data from the 1993 Teenage Attitudes and Practices Survey (TAPS-II). This report summarizes the results of that analysis and focuses on assessments of reasons for using tobacco and symptoms of nicotine withdrawal.

For TAPS-II, data about knowledge, attitudes, and practices of tobacco use were collected by telephone interviews; persons who could not be contacted by telephone were contacted in person. The TAPS-II sample for this analysis had two components: 1) of the 9135 respondents (aged 12-18 years) to the 1989 TAPS telephone interview * , 7960 (87.1%) participated in TAPS-II (these respondents were aged 15-22 years); and 2) an additional 4992 persons from a new probability sample of 5590 persons aged 10-15 years (89.3% response rate) participated in TAPS-II. Data were weighted to provide national estimates, and 95% confidence intervals (CIs) were calculated using SUDAAN (3).

Persons who had smoked cigarettes (n=2121) or who had used SLT (n=470) during the 30 days preceding the survey were asked if they used tobacco because "it relaxes or calms me" and if they used it because "it's really hard to quit" (either answer indicates an influence of the psychopharmacologic properties of nicotine {1}). Smokers who had tried to quit and persons who had quit smoking (n=1925) ** were asked, "When you quit/tried to quit did you feel a strong need or urge to have a cigarette; feel more irritable; find it hard to concentrate; feel restless; feel hungry more often; feel sad, blue, or depressed?" SLT users who had tried to quit and persons who had discontinued use (n=1216) were asked similar questions adapted to SLT use.

Lifetime history of tobacco use was assessed through three categories for cigarette smoking (20 or fewer cigarettes smoked during lifetime, 21-98 cigarettes smoked, and 100 or more cigarettes smoked) and with two categories for SLT use (never used regularly versus ever used regularly). Frequency of use was measured by the number of days on which cigarettes were smoked or SLT was used during the preceding month (0, 1-14, 15-29, or 30 days). Intensity of use was measured by the average number of cigarettes smoked per day during the preceding 7 days (five or fewer, 6-15, or 16 or more) and by the number of times SLT was used on the days it was used (1-2, or three or more).

For persons who had smoked during the preceding 30 days and for those who had used SLT during the preceding 30 days, the frequency of reporting that tobacco was used because it is relaxing or because it is hard to quit increased in relation to increasing lifetime use, frequency of use, and intensity of use Table_1; this pattern characterized the overall sample and persons in both age categories (10-18 years and 19-22 years). The percentages of persons who reported smoking cigarettes or using SLT for these two reasons also were similar across age groups. Among smokers and SLT users with the greatest lifetime use or intensity of use, the proportions who reported using tobacco to relax were similar to those who reported using it because it was hard to quit. Among those with the lowest lifetime use or frequency or intensity of use, relaxation was more commonly cited as a reason for use than was difficulty quitting. For every category of usage frequency, cigarette smokers were more likely to report use for relaxation than were SLT users. Regardless of age, approximately three fourths of daily cigarette smokers (73.8%) and daily SLT users (74.2%) reported that one of the reasons they used tobacco was because it was hard to quit.

The likelihood of reporting symptoms of nicotine withdrawal increased in relation to frequency Table_2 and intensity Figure_1 of use. Younger and older smokers were equally likely to report increasing nicotine withdrawal symptoms as exposure to nicotine increased Table_2. The same pattern characterized SLT users among both age groups combined (group-specific analyses are not presented because of limitations in sample sizes of persons who used SLT during the preceding 30 days). Among persons aged 10-22 years, those who smoked cigarettes and those who used SLT on a daily basis were equally likely to report symptoms of nicotine withdrawal (with the exception of depression, which was less prevalent among SLT users). Among persons who reported using tobacco on 1-14 days during the preceding 30 days, those who smoked cigarettes were generally more likely to report symptoms of nicotine withdrawal than were persons who used SLT. At least one symptom of nicotine withdrawal was reported by 92.4% of daily cigarette smokers and 93.3% of daily SLT users who had previously tried to quit. Persons who smoked six or more cigarettes per day were more likely than those who smoked five or fewer cigarettes per day to report difficulty concentrating, feeling more irritable, and craving cigarettes during a previous quit attempt; however, among persons who smoked five or fewer cigarettes per day, 28.7% reported difficulty concentrating; 47.5%, feeling more irritable; and 56.9%, craving cigarettes during a previous quit attempt Figure_1. Reported by: D Barker, MHS, Robert Wood Johnson Foundation, Princeton, New Jersey. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: This analysis of TAPS-II underscores the relation between use of tobacco and reasons for using tobacco -- a relation that reflects the psycho- pharmocologic properties of nicotine. In addition, the frequency of smoking and of using SLT strongly correlated with self-reported symptoms of nicotine withdrawal. These findings are consistent with previous studies that indicated high prevalences of symptoms of nicotine addiction among adolescent and adult smokers (2,4,5).

Previous reports indicate that adolescents initially tried cigarettes for reasons related to social norms, advertising, social pressure, and curiosity (2,6). However, once the behavior becomes established, regular smokers are more likely than beginning smokers to report that they smoke for pleasure and because they are addicted (2,6). Among students who were high school seniors during 1976-1986, a total of 44% of daily smokers believed that in 5 years they would not be smoking; however, follow-up indicated that 5-6 years later, 73% of these persons remained daily smokers (2). This finding suggests that many of these persons could not overcome the social, psychological, and chemical influences that maintain or advance the smoking behavior once it is established (2) and indicates that many adolescents do not understand the personal risks of smoking, including nicotine addiction (7).

The findings in this report are subject to at least two limitations. First, because of small sample sizes, the prevalence of SLT withdrawal symptoms could not be analyzed in relation to lifetime history of cigarette smoking; however, SLT users who tried to quit were probably less likely to experience symptoms of nicotine withdrawal if they concurrently smoked cigarettes (1). Second, the relation of nonpharmacologic (e.g., social and psychological) influences on tobacco use were not quantified; however, the findings are consistent with previous reports documenting the psychopharmacologic effects of nicotine on tobacco use and tobacco withdrawal (1,2,4).

In 1992, approximately two thirds of adolescent smokers reported that they wanted to quit smoking, and 70% indicated that they would not have started smoking if they could choose again (8). Most adults probably could be prevented from becoming tobacco users if they could be kept tobacco-free during adolescence (2). Four strategies that may assist in supporting tobacco-free adolescence include 1) strict enforcement of the prohibition of sales to minors (sales to persons aged less than 18 years are illegal in all 50 states), 2) reduction of advertising and promotion practices that stimulate demand, 3) increases in the real (i.e., inflation-adjusted) prices of tobacco products, and 4) school health education programs that are reinforced by media-based and other community programs (2).

The Institute of Medicine recently published recommendations for a comprehensive national strategy to prevent nicotine addiction among youth (9). These recommendations especially address tobacco-free policies; restrictions on tobacco advertising and promotion; tobacco taxation; enforcement of youth access laws; regulation of the labeling, packaging, and contents of tobacco products; further research on nicotine addiction and on prevention and cessation programs; and the coordination of policies and research. Copies of this report can be purchased from National Academy Press, telephone (800) 624-6242 or (202) 334-3313.

References

1. CDC. The health consequences of smoking: nicotine addiction -- a report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1988; DHHS publication no. (CDC)88-8406.

2. US Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994.

3. Shah BV, Barnwell BG, Hunt PN, LaVange LM. Software for Survey Data Analysis (SUDAAN) version 5.5 {Software documentation}. Research Triangle Park, North Carolina: Research Triangle Institute, 1991.

4. McNeill AD, West RJ, Jarvis M, Jackson P, Bryant A. Cigarette withdrawal symptoms in adolescent smokers. Psychopharmocology 1986;90:533-6.

5. Giovino GA, Shelton DM, Schooley MW. Trends in cigarette smoking cessation in the United States. Tobacco Control 1993;2(suppl):S3- S10.

6. Sarason IG, Mankowski ES, Peterson AV, Dinh KT. Adolescents' reasons for smoking. J School Health 1992;62:185-90.

7. Leventhal H, Glynn K, Fleming R. Is the smoking decision an "informed choice"?: effect of smoking risk factors on smoking beliefs. JAMA 1987;257:3373-6.

8. George H. Gallup International Institute. Teen-age attitudes and behavior concerning tobacco: report of the findings. Princeton, New Jersey: George H. Gallup International Institute, 1992.

9. Institute of Medicine. Growing up tobacco free: preventing nicotine addiction in children and youths. Washington, DC: National Academy Press, 1994.

* TAPS respondents who completed the survey by mail questionnaire were not eligible for TAPS-II. TAPS-II included household interviews of persons who did not respond by telephone. 

** Persons who reported that they had never smoked regularly were excluded from these analyses.

TABLE 1. Prevalence of selected reasons for using cigarettes and smokeless tobacco, by age group and use history -- United States,
Teenage Attitudes and Practices Survey, 1993
==================================================================================================================================
                                    "It relaxes or calms me"                             "It's really hard to quit"
                           -------------------------------------------------    ------------------------------------------------
Tobacco product/              10-18 yrs        19-22 yrs        10-22 yrs         10-18 yrs        19-22 yrs       10-22 yrs
  Use history              %   (95% CI *)    %   (95% CI)     %   (95% CI)      %   (95% CI)     %   (95% CI)     %   (95% CI)
----------------------------------------------------------------------------------------------------------------------------------
Cigarettes
  Lifetime use +
       <= 20 cigarettes    30.5  (+/- 7.5)   18.1 (+/-10.0)   26.9 (+/- 6.1)     8.2 (+/- 4.7)    3.8 (+/- 6.1)    7.0  (+/-3.8)
       21-98 cigarettes    48.7  (+/- 9.1)   39.5 (+/- 9.8)   45.0 (+/- 6.8)    21.1 (+/- 7.3)   10.4 (+/- 6.0)   16.7  (+/-5.2)
       >=100 cigarettes    66.8  (+/- 3.4)   69.2 (+/- 3.0)   68.1 (+/- 2.2)    63.1 (+/- 4.1)   64.8 (+/- 3.3)   64.1  (+/-2.7)

  Frequency of use &
        1-14 days          40.6  (+/- 5.0)   37.8 (+/- 5.7)   39.4 (+/- 3.8)    17.7 (+/- 4.0)   18.3 (+/- 4.8)   18.0  (+/-3.2)
       15-29 days          60.8  (+/- 7.2)   75.7 (+/- 6.6)   68.2 (+/- 5.0)    50.5 (+/- 7.8)   56.2 (+/- 8.2)   53.4  (+/-5.5)
          30 days          73.3  (+/- 4.2)   72.4 (+/- 3.7)   72.8 (+/- 2.8)    74.3 (+/- 4.4)   73.5 (+/- 3.3)   73.8  (+/-2.7)

  Intensity of use @
       <= 5 cigarettes     57.3  (+/- 5.1)   61.5 (+/- 5.7)   59.1 (+/- 3.8)    39.6 (+/- 5.4)   34.6 (+/- 6.2)   37.4  (+/-4.1)
       6-15 cigarettes     69.7  (+/- 5.8)   74.4 (+/- 4.8)   72.4 (+/- 3.8)    72.4 (+/- 5.9)   73.4 (+/- 4.6)   73.0  (+/-3.7)
       >=16 cigarettes     75.4  (+/- 7.0)   71.1 (+/- 5.9)   72.5 (+/- 4.4)    82.6 (+/- 6.8)   78.8 (+/- 4.8)   80.1  (+/-3.9)

Smokeless tobacco
  Lifetime use **
    Never regular user     10.5  (+/- 6.2)   19.3 (+/-12.8)   13.8 (+/- 6.0)     5.0 (+/- 4.2)    1.7 (+/- 2.5)    3.8  (+/-2.9)
    Ever regular user      43.2  (+/- 8.7)   55.1 (+/- 7.3)   49.7 (+/- 6.0)    47.5 (+/- 8.7)   54.2 (+/- 8.1)   51.2  (+/-5.2)
  Frequency of use ++
      1-14 days            17.7  (+/- 6.8)   33.4 (+/-10.1)   24.5 (+/- 5.6)    10.0 (+/- 5.4)   12.9 (+/- 6.0)   11.2  (+/-4.0)
     15-29 days            41.5  (+/-15.7)   56.6 (+/-15.2)   48.5 (+/-11.7)    31.9 (+/-14.3)   38.5 (+/-13.2)   35.0  (+/-9.6)
        30 days            49.4  (+/-13.4)   56.8 (+/- 9.4)   53.8 (+/- 8.7)    74.4 (+/- 9.6)   74.0 (+/- 9.2)   74.2  (+/-6.5)
  Intensity &&
        1-2 times          22.3  (+/- 7.0)   39.2 (+/- 9.3)   29.4 (+/- 5.9)    13.3 (+/- 5.8)   15.3 (+/- 6.9)   14.1  (+/-4.1)
        >=3 times          43.1  (+/-11.0)   52.9 (+/- 8.8)   48.6 (+/- 7.5)    56.7 (+/-10.3)   61.9 (+/- 9.3)   59.7  (+/-6.3)
----------------------------------------------------------------------------------------------------------------------------------
 * Confidence interval.
 + Lifetime number of cigarettes smoked.  Sample sizes (n=2042-2047) are for persons aged 10-22 years. Sample sizes for
   the 10-18-year category and the 19-22-year category are approximately half of the total sample size. Sample sizes
   vary because of variation in missing values for each item.
 & Days smoked during preceding 30 days; n=2072-2079.
 @ Cigarettes smoked per day.  Samples (n=1634-1637) exclude persons who smoked during the preceding 30 days but not
   during the preceding 7 days.
** Based on responses to the questions, "Are you now a regular user of chewing tobacco or snuff?" and "Was there ever a
   time when you considered yourself to be a regular user of chewing tobacco or snuff?"; n=458-467.
++ Days used during preceding 30 days; n=457-466.
&& Times used per day; n=452-460.
==================================================================================================================================

TABLE 2. Percentage of cigarette smokers and smokeless tobacco users who reported experiencing symptoms of nicotine withdrawal during previous attempts to
discontinue use, by age group and frequency of use -- United States, Teenage Attitudes and Practices Survey, 1993
=====================================================================================================================================================================
                                                                                              Strong
                                Find it hard to       Feel hungry         Feel more        need/urge to                            Feel sad, blue,
Tobacco user/                     concentrate          more often         irritable         smoke/chew          Feel restless       or depressed       Any indicator
  Age group                       % (95% CI *)         % (95% CI)         % (95% CI)         % (95% CI)           % (95% CI)         % (95% CI)          % (95% CI)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cigarette smokers +
  Frequency &
    10-18 yrs (n=943-967)
          0                     11.8  (+/- 3.3)      24.4 (+/- 4.9)     21.4 (+/- 4.1)     21.9  (+/- 4.7)      17.0 (+/- 4.2)     09.3   (+/-3.1)     44.4 (+/- 5.4)
       1-14                     22.8  (+/- 6.6)      35.4 (+/- 7.5)     36.5 (+/- 8.1)     36.3  (+/- 7.8)      30.3 (+/- 7.2)     17.9   (+/-6.0)     66.0 (+/- 7.6)
      15-29                     39.2  (+/- 9.5)      43.0 (+/- 9.6)     55.8 (+/- 9.4)     71.2  (+/- 8.7)      49.9 (+/- 9.9)     24.4   (+/-8.2)     88.1 (+/- 6.0)
         30                     46.1  (+/- 5.9)      49.0 (+/- 6.6)     77.0 (+/- 5.1)     81.6  (+/- 4.8)      62.6 (+/- 6.0)     28.6   (+/-5.6)     93.3 (+/- 3.3)

    19-22 yrs (n=931-951)
          0                     14.6  (+/- 3.9)      30.0 (+/- 5.3)     29.2 (+/- 4.9)     28.1  (+/- 4.9)      27.2 (+/- 4.8)     11.7   (+/-3.8)     50.0 (+/- 5.5)
       1-14                     16.9  (+/- 6.7)      40.5 (+/- 8.6)     32.5 (+/- 8.6)     43.8  (+/- 8.7)      32.2 (+/- 8.6)     11.5   (+/-5.4)     68.7 (+/- 8.2)
      15-29                     26.9  (+/- 9.5)      52.8 (+/-10.1)     49.9 (+/-11.0)     63.4  (+/-10.1)      54.6 (+/-10.6)     18.5   (+/-8.2)     86.0 (+/- 7.0)
         30                     47.3  (+/- 4.9)      50.5 (+/- 5.1)     70.9 (+/- 4.6)     78.1  (+/- 4.0)      60.8 (+/- 4.9)     23.1   (+/-4.3)     91.7 (+/- 2.8)

    10-22 yrs (n=1880-1918)
          0                     13.0  (+/- 2.3)      26.8 (+/- 3.7)     24.7 (+/- 3.2)     24.6  (+/- 3.4)      21.3 (+/- 3.2)     10.3   (+/-2.4)     46.8 (+/- 4.0)
       1-14                     20.5  (+/- 5.0)      37.4 (+/- 5.6)     35.0 (+/- 6.0)     39.2  (+/- 6.0)      31.0 (+/- 5.6)     15.4   (+/-4.2)     67.0 (+/- 5.7)
      15-29                     32.8  (+/- 6.6)      48.0 (+/- 7.2)     52.7 (+/- 7.5)     67.2  (+/- 6.9)      52.4 (+/- 7.6)     21.3   (+/-6.0)     87.0 (+/- 5.0)
         30                     46.8  (+/- 3.8)      49.9 (+/- 4.2)     73.5 (+/- 3.2)     79.6  (+/- 3.0)      61.6 (+/- 3.8)     25.5   (+/-3.4)     92.4 (+/- 2.1)

Smokeless tobacco users
  Frequency @
  10-22 yrs (n=1199-1213)
          0                      5.4  (+/- 1.6)       7.7 (+/- 1.9)      8.0 (+/- 1.9)      8.5  (+/- 2.0)       6.0 (+/- 1.7)      3.3   (+/-1.2)     17.6 (+/- 2.9)
       1-14                     10.2  (+/- 5.3)      12.4 (+/- 6.4)      8.5 (+/- 5.1)     20.5  (+/- 7.6)      11.2 (+/- 5.4)      3.1   (+/-3.5)     35.4 (+/- 8.6)
      15-29                     23.9  (+/-11.7)      48.6 (+/-13.0)     47.1 (+/-13.7)     44.5  (+/-13.4)      34.8 (+/-12.7)     10.5   (+/-9.0)     72.6 (+/-12.3)
         30                     41.1  (+/-10.0)      38.9 (+/-10.9)     62.9 (+/- 9.6)     85.4  (+/- 7.0)      55.2 (+/-10.3)      9.0   (+/-6.4)     93.3 (+/- 4.2)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------
* Confidence interval.
+ Excludes persons who voluntarily reported that they had never smoked regularly.
& Days smoked during preceding 30 days. Sample sizes vary because of variation in missing values for each item.
@ Days used during preceding 30 days.  Sample sizes vary because of variation in missing values for each item.
=====================================================================================================================================================================

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