MMWR. 2002;51:409-412
2 tables omitted
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. 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. 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.
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.
