Tobacco Use Among Middle and High School Students -- United States, 1999

The prevalence of cigarette smoking nationwide among high school students increased during the 1990s (1); more than 80% of current adult tobacco users started smoking cigarettes before age 18 years (2). To determine the prevalence of cigarette, smokeless tobacco (i.e., chewing tobacco and snuff), cigar, pipe, bidi, and kretek use among middle school and high school students nationwide, the American Legacy Foundation, in collaboration with the CDC Foundation, conducted the National Youth Tobacco Survey (NYTS) during the fall of 1999. This report summarizes data from the NYTS on current use of tobacco products, which indicate that 12.8% of middle school students and 34.8% of high school students use any type of tobacco; that the low prevalence of current cigarette smoking observed among black high school students throughout the 1990s is not found among middle school students (1); and that the percentages of high school students who currently use bidis and kreteks (two new forms of tobacco in the United States) are almost as high as the proportion who use smokeless tobacco.

The school-based 1999 NYTS employed a three-stage cluster sample designed to produce a nationally representative sample of students in grades 6-12. The first-stage sampling frame contained 1306 primary sampling units (PSUs), each comprising a large county or a group of smaller adjacent counties. From the 1306 PSUs, 66 were selected from 16 strata formed on the basis of the degree of urbanization and the relative percentage of black and Hispanic students in the PSU. PSUs were selected with probability proportional to weighted school enrollment. At the second sampling stage, 145 schools from the 66 PSUs were selected with probability proportional to weighted school enrollment. To ensure separate analysis of black and Hispanic students, schools with substantial numbers of black and Hispanic students were sampled at higher rates than all other schools through a weighted measure of size. The third stage of sampling consisted of randomly selecting approximately five intact classes of a required subject (e.g., English or social studies) across grades 6-12 from each participating school. All students in the selected classes were eligible to participate. A weighting factor was applied to each student record to adjust for nonresponse and for the varying probabilities of selection, including those resulting from the oversampling of black and Hispanic students. Numbers of students in racial/ethnic groups other than black, white, and Hispanic were too small for meaningful analysis. The weights were scaled so that the weighted count of students equaled the total sample size and the weighted proportions of students in each grade matched national population proportions. For the 1999 NYTS, 15,058 students in 131 schools completed questionnaires. The school response rate was 90%, and the student response rate was 93%, resulting in an overall response rate of 84%.

For the NYTS, students completed an anonymous, self-administered questionnaire that included questions about tobacco use, exposure to environmental tobacco smoke, minors' ability to purchase or otherwise obtain tobacco products, knowledge and attitudes about tobacco, and familiarity with pro- and anti-tobacco media messages. SUDAAN was used to compute 95% confidence intervals, which were used to determine differences between subgroups at the pless than 0.05 level. Differences between prevalence estimates were considered statistically significant if the 95% confidence intervals did not overlap. Current use of bidis, cigarettes, cigars, kreteks, pipes, and smokeless tobacco was defined as use on one or more of the 30 days preceding the survey. Any current tobacco use was defined as using any of these products on one or more of the 30 days preceding the survey.

Middle School Students

Among middle school (grades 6-8) students, the overall prevalence of any current tobacco use was 12.8% (Table 1). Cigarettes (9.2%) were the most prevalent type of tobacco used, followed by cigars (6.1%). Cigarette smoking rates were similar among boys and girls and among racial/ethnic groups. Boys were significantly more likely than girls to use smokeless tobacco (4.2% and 1.3%, respectively), smoke cigars (7.8% and 4.4%, respectively), and smoke tobacco in a pipe (3.5% and 1.4%, respectively). Black students were significantly more likely than white students to smoke cigars (8.8% and 4.9%, respectively).

High School Students

Among high school (grades 9-12) students, the overall prevalence of any current tobacco use was 34.8%. Cigarettes (28.4%) were the most prevalent type of tobacco used, followed by cigars (15.3%). Boys were significantly more likely than girls to use smokeless tobacco (11.6% and 1.5%, respectively), smoke cigars (20.3% and 10.2%, respectively), smoke tobacco in a pipe (4.2% and 1.4%, respectively), and smoke bidis (6.1% and 3.8%, respectively). White and Hispanic students were significantly more likely than black students to smoke cigarettes (32.8%, 25.8%, and 15.8%, respectively). White students were significantly more likely than black and Hispanic students to use smokeless tobacco (8.7%, 2.4%, and 3.6%, respectively).

Reported by: C Healton, DrPH, P Messeri, PhD, J Reynolds, MPH, C Wolfe, The American Legacy Foundation, Washington, DC. C Stokes, MEd, CDC Foundation, Atlanta, Georgia. J Ross, MS, K Flint, MA, W Robb, MS, Macro International Inc., Calverton, Maryland. M Farrelly, PhD, Research Triangle Institute, Research Triangle Park, North Carolina. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note:

This report is the first to measure the prevalence of current tobacco use among a nationally representative sample of middle school students and the first to report the prevalence of current bidi and kretek use among a nationally representative sample of middle and high school students. Although previous national surveys have shown that cigarette smoking rates among black high school students have been increasing, black students still were smoking at much lower rates than other high school students (1,3,4). However, the findings in this report indicate that current cigarette smoking prevalence among middle school black students was similar to rates among white and Hispanic students and that current cigar use prevalence among middle school black students was significantly higher than among white students. Future surveys should evaluate whether the rate of increase in smoking rates among black students has accelerated and whether the difference in smoking rates between black and white high school students are disappearing. In addition, more research is needed to determine whether black youth are finding smoking appealing and socially acceptable.

Current use of novel tobacco products, such as bidis and kreteks, is an emerging public health problem among U.S. youth (5). Cigarettes remain the most widely used tobacco product by youth; however, recent trends underscore the importance of monitoring the rates at which youth adopt other tobacco products. The social and cultural factors related to differing patterns of tobacco product use across sex and racial/ethnic groups require additional study.

The 1999 NYTS estimates for high school students will be compared with those of the Monitoring The Future (MTF) study and the Youth Risk Behavior Survey (YRBS), the other national school-based surveys. Comparison of NYTS estimates with those of other national surveys must be interpreted with caution for several reasons. First, YRBS and MTF were conducted during spring 1999, and NYTS was conducted during September-October 1999, a different academic year. Within each grade, the fall school population is approximately 6 months younger than the spring school population. This difference can be expected to lead to higher estimates of ever smoking in the spring surveys and may lead to higher estimates of current smoking. Second, the tobacco industry increased the wholesale price of tobacco products during 1999, but also provided substantial price discounts during the same period, making determination of the precise effect of retail prices on smoking rates difficult. However, preliminary per capita consumption estimates from the U.S. Department of Agriculture suggest cigarette consumption has decreased in 1999, suggesting that the prevalence among youth also may have decreased (6). Third, the NYTS is a single-topic survey (tobacco), and MTF and YRBS are multi-topic surveys. The effect of the number of topics surveyed on the resulting estimates is unknown. Finally, NYTS had a 90% school response rate, a higher reported school response rate than YRBS and MTF. Some schools that participated in the NYTS may not participate in YRBS or MTF.

The findings in this report are subject to at least two limitations. First, these data apply only to youth who attended middle or high school and are not representative of all persons in this age group. Few persons aged less than 16 years do not attend school and, in 1997, only 4% of 16-year-olds and 6% of 17-year-olds who had not completed high school were not enrolled in a high school program (7). The dropout rate for young adults aged 16-24 years varies greatly by race/ethnicity (7.6%, white; 13.4%, black; and 25.3%, Hispanic) (7). Second, "any current tobacco use" might be underestimated in this report because it does not include a measure of "roll-your-own" tobacco smoking.

To evaluate the potential impact of the expanding levels of tobacco prevention efforts nationwide and in the individual states, surveillance of trends in tobacco use among youth must be continued and expanded. YRBS has provided national and state-specific surveillance of tobacco use among high school students since 1991 (8). The NYTS and state-specific youth tobacco surveys are extending this surveillance effort to middle school students and across a wider range of evaluation variables, including knowledge and attitudes about tobacco, exposure to environmental tobacco smoke, familiarity with pro-smoking and antismoking media messages, and exposure to tobacco-use prevention curriculum in schools. CDC has prepared "Best Practices" guidelines to help states determine funding priorities and to plan and carry out effective comprehensive tobacco-use prevention and control programs (9). If current patterns of smoking behavior persist, an estimated 5 million U.S. persons who were aged less than or equal to 18 years in 1995 could die prematurely from smoking-related illnesses (10). Implementation of the "Best Practices" guidelines, along with nationwide prevention efforts, enforcement of the proposed Food and Drug Administration rules, increases in the excise tax on tobacco products, and increased availability of smoking cessation treatment options, could dramatically reduce these projected deaths.

References

1. CDC. Tobacco use among high school students--United States, 1997. MMWR 1998;47:229-33.
2. CDC. Preventing tobacco use among young people: report of the Surgeon General. Atlanta, Georgia: 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. CDC. Tobacco use among U.S. racial/ethnic minority groups--African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: a report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1998.
4. University of Michigan. Monitoring the Future Survey. World-Wide Web site http://monitoringthefuture.org/data/99data.html#1999data_cigs. Accessed December 17, 1999.
5. CDC. Bidi use among urban youth--Massachusetts, March-April 1999. MMWR 1999;48:796-9.
6. USDA. Cigarette production, exports, and domestic consumption down in 1999. World-Wide Web site http://usda.mannlib.cornell.edu/reports/erssor/specialty/tbs-bb/1999/tbs245s.asc. Accessed December 21, 1999.
7. National Center for Education Statistics. Dropout rates in the United States, 1997. Washington, DC: US Department of Education, 1999 (NCES 99-082).
8. CDC. Youth risk behavior survey--United States, 1997. MMWR 1998;47(no. SS-3).
9. CDC. Best practices for comprehensive tobacco control-August 1999. Atlanta, Georgia: US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1999.
10. CDC. Projected smoking-related deaths among youth--United States. MMWR 1996;45:971-4.

TABLE 1. Percentage of students in middle school (grades 6-8) and high school (grades 9-12) currently* using tobacco products, by type of tobacco product, sex, and race/ethnicity -- United States, National Youth Tobacco Survey, 1999

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