Source: MMWR August 25, 2000 / 49(33);750-5
One of the 10 Leading Health Indicators that reflect the major health concerns in
the United States is cigarette smoking among adolescents
(1). To examine changes in cigarette smoking among high school students in the United States from 1991 to
1999, CDC analyzed data from the national Youth Risk Behavior Survey (YRBS). This
report summarizes the results of the analysis and indicates that current smoking among
U.S. high school students increased significantly from 27.5% in 1991 to 34.8% in 1999;
however, the analysis also suggested that, later in the decade, current smoking may have
leveled or possibly begun to decline.
YRBS measures the prevalence of health risk behaviors among adolescents
through representative biennial national, state, and local surveys. The 1991, 1993, 1995, 1997,
and 1999 national surveys used independent, three-stage cluster samples to obtain
cross-sectional data representative of students in grades 9 through 12 in the 50 states and
the District of Columbia. In 1991, 1993, 1995, 1997, and 1999, the respective sample
sizes were 12,272, 16,296, 10,904, 16,262, and 15,349; school response rates were 75%,
78%, 70%, 79%, and 77%; student response rates were 90%, 90%, 86%, 87%, and 86%;
and overall response rates were 68%, 70%, 60%, 69%, and 66%.
For each cross-sectional survey, students completed an
anonymous, self-administered questionnaire that included identically worded questions
about cigarette smoking. Lifetime smoking was defined as having ever smoked cigarettes,
even one or two puffs. Current smoking was defined as smoking on
>1 of the 30 days preceding the survey. Frequent smoking was 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
groups were too small for meaningful analysis.
Data were weighted to provide national estimates. SUDAAN was used for all
data analysis. Secular trends were analyzed using logistic regression analyses that
controlled for sex, race/ethnicity, and grade and that simultaneously assessed linear and
quadratic time effects. Quadratic trends suggest a significant but nonlinear trend in the data
over time. When a significant quadratic trend accompanies a significant linear trend, the
data demonstrate some nonlinear variation (e.g., leveling or change in direction) in
addition to a linear trend.
The prevalence of lifetime smoking remained stable from 1991 to 1999 among
high school students overall and among all sex, racial/ethnic, and grade subgroups
except 10th-grade students. In 1999, 70.4% (95% confidence interval [CI]=±3.0) of all
students reported lifetime smoking. Among 10th-grade students, lifetime smoking showed
significant linear trend from 1991 (68.3% [95% CI=±3.3]) to 1999 (73.9% [95% CI=±4.1]).
From 1991 to 1999, current smoking exhibited a significant linear trend
among students overall and among all sex, racial/ethnic, and grade subgroups (Table 1).
The overall prevalence of current smoking was 27.5% in 1991 and 34.8% in 1999.
A simultaneous quadratic trend was identified for students overall, suggesting a
leveling or possible decline in current smoking. The male, black, black male, and 9th-grade
student subgroups also showed this simultaneous quadratic trend.
Each year, white students were significantly more likely than Hispanic students,
who were significantly more likely than black students, to report current smoking (except
in 1995 when white and Hispanic students were equally likely to report current
smoking, but both were significantly more likely than black students to report this behavior).
In 1991, white students were 2.5 times more likely than black students and 1.2 times
more likely than Hispanic students to report current smoking. In 1999, white students were
2.0 times more likely than black students and 1.2 times more likely than Hispanic
students to report current smoking.
The prevalence of frequent smoking showed a significant linear trend from 1991
to 1999 among students overall and in all sex, racial/ethnic, and grade subgroups,
except for Hispanic female students. The overall prevalence of frequent smoking was
12.7% (95% CI=±2.2) in 1991 and 16.8% (95% CI=±2.5) in 1999. Among Hispanic female
the prevalence of frequent smoking remained stable from 1991 to 1999. For each of
the five surveys, white students were significantly more likely than black and
Hispanic students to report this behavior.
Reported by: Office on Smoking and Health, and Div of Adolescent and School Health,
National Center for Chronic Disease Prevention and Health Promotion, CDC.
Despite a leveling or possible decline in current smoking among
youth overall during the late 1990s, this trend may have been limited to selected groups
(i.e., male, black, black male, and 9th-grade students). In addition, frequent smoking
rates overall and in all sex, racial/ethnic, and grade subgroups (except Hispanic
females) were significantly higher in 1999 than in 1991 and showed no pattern of leveling
Additional research is needed to understand how current smoking rates and
secular changes in these rates vary among racial/ethnic groups. For example, throughout
the decade, YRBS and other national surveys found that black high school students
smoked at lower rates than white and Hispanic high school students
(2,3); however, the 1999 National Youth Tobacco Survey
(2) reported that current smoking rates among
black middle school students were similar to rates among white and Hispanic middle
Among grade subgroups, data for 9th-grade students suggested a leveling or
possible decline in current smoking. Current smoking among 12th-grade students continued
to rise each year. A previous study suggested that current smoking peaked among
10th and 12th-grade students in 1996 and 1997, respectively
(3). It is unclear whether future YRBS data will show a delayed peak among 10th and 12th-grade students.
The findings in this report are subject to at least three limitations. First, these
data apply only to 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
(4). Second, the extent of underreporting or overreporting in YRBS cannot be
determined, although the survey questions demonstrate good test-retest reliability
(5). Finally, using only five data points makes it possible to characterize trends over the decade but
difficult to accurately characterize the direction current smoking will take during the next decade.
Reducing the prevalence of current smoking among adolescents to 16% is one of
the goals of the Leading Health Indicators. Achieving this goal by 2010 will require a
54% reduction in current smoking among adolescents nationwide. Data from Florida,
where comprehensive tobacco-control programs have been initiated, suggest such
declines are possible. From 1998 to 2000 in Florida, current smoking declined 40% among
middle school students and 18% among high school students
CDC recommends that communities fully implement its "Best Practices
for Comprehensive Tobacco Control Programs" by establishing comprehensive,
sustainable, and accountable tobacco-control programs
(7). In addition, communities should follow CDC's "Guidelines for School Health Programs to Prevent Tobacco Use and
Addiction," which recommend implementing school-based tobacco-use prevention programs
in grades K--12 with intensive instruction in grades 6--8 and supporting cessation
efforts for nicotine-dependant students
(8,9). Finally, comprehensive tobacco-control
programs also should reduce the appeal of tobacco products, implement mass media
campaigns, increase tobacco excise taxes, implement policy and regulation of tobacco
products, and reduce youth access to tobacco products
- US Department of Health and Human Services. Healthy people 2010 (conference ed, 2
vols). Washington, DC: US Department of Health and Human Services, January 2000.
- CDC. Tobacco use among middle and high school students---National Youth Tobacco
Survey, 1999. MMWR 2000;47:49--53.
- Johnston LD, O'Malley PM, Bachman JG. Cigarette smoking among
American teens continues gradual decline. Ann Arbor, Michigan: University of Michigan News and Information
Services. Available at http://www.monitoringthefuture.org. Accessed April 24, 2000.
- Kaufman P, Kwon JY, Klein S, Chapman CD. Dropout rates in the
United States: 1998. Washington, DC: US Department of Education, National Center for Educational Statistics, 1999.
- Brener ND, Collins JL, Kann L, Warren CW, Williams BI.
Reliability of the Youth Risk Behavior Survey questionnaire. Am J Epidemiol 1995;141:575--80.
- Bauer UE, Johnson TM, Hopkins RS, Brooks RG. Changes in youth cigarette use and
intentions following implementation of a tobacco control program. JAMA 2000;284:723--8.
- CDC. Best Practices for Comprehensive Tobacco Control Program---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.
- CDC. Guidelines for school health programs to prevent tobacco use and addiction.
MMWR 1994;43(no. RR-2).
- CDC. CDC Workgroup on Youth Tobacco-Use Cessation: defining the problem and charting
a course for action. US Department of Health and Human Services, CDC, National Center
for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health(in press).
- US Department of Health and Human Services. Reducing tobacco use: 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, 2000.