Introduction

This chapter addresses the important question of why young people begin to use tobacco. The immediate and long-term health consequences of use have been extensively documented over the past 50 years. Why anyone would begin to smoke or use smokeless products may therefore not seem “rational.” This chapter (and Chapter 5, “The Tobacco Industry’s Influences on the Use of Tobacco Among Youth”) examines, within a theory-driven context, the risk factors associated with the onset and development of tobacco use over the course of adolescence and young adulthood. These particular stages of development within the life course are perhaps the only times in life when tobacco use might be appealing and even perceived as functional to individuals (Perry 1999). By definition, adolescence and young adulthood represent the social transition to adulthood, with accompanying risk-taking associated with trying and acquiring adult behaviors. Yet brain development is not complete, and there is immaturity in consequential thinking, impulsivity, and decision-making skills before adulthood. Notably, peer group influences emerge as powerful motivators of behavior change. These changes create a unique window of vulnerability for tobacco use onset in adolescence and young adulthood. As was shown in Chapter 3 (“The Epidemiology of Tobacco Use Among Young People in the United States and Worldwide”), by 26 years of age, nearly all people who are going to use tobacco have already begun, so the focus of primary prevention with young people really spans the ages of 12 to 25 years. This chapter provides important information on these developmental processes, examining large social and physical environments that support or discourage tobacco use, small social groups, cognitive and affective processes, and neurobiological and genetic factors.

The 1994 Surgeon General’s report on preventing tobacco use among young people discussed psychosocial risk factors for initiating tobacco use (U.S. Department of Health and Human Services [USDHHS] 1994). That report, which described the developmental stages of tobacco use from onset to regular use, set forth several sets of factors that influence the initiation of tobacco use:

• Sociodemographic factors (socioeconomic status [SES], developmental challenges of adolescence, gender, and race/ethnicity);
• Environmental factors (acceptability and availability of tobacco products, interpersonal variables, perceived environmental variables);
• Behavioral factors (academic achievement, problem behaviors, influence of peer groups, participation in activities, and behavioral skills);
• Personal factors (knowledge of the long-term health consequences of using tobacco, functional meanings of tobacco use, subjective expected utility of tobacco use, variables related to self-esteem, and personality); and
• Current behavior relative to tobacco use (intentions to smoke and smoking status).

The chapter concluded that the following factors promote the initiation and use of tobacco products of some type:

• Relatively low SES,
• Relatively high accessibility and availability of tobacco products,
• Perceptions by adolescents that tobacco use is normative, that is, usual or acceptable behavior,
• Use of tobacco by significant others and approval of tobacco use among those persons,
• Lack of parental support,
• Low levels of academic achievement and school involvement,
• Lack of skills required to resist influences to use tobacco,
• Relatively low self-efficacy for refusal,
• Previous tobacco use and intention to use tobacco in the future,
• Relatively low self-image, and
• Belief that tobacco use is functional or serves a purpose.

The same factors were also found to predict two specific behaviors: cigarette smoking and the use of smokeless tobacco. In addition, having insufficient knowledge about the health consequences of using smokeless tobacco was found to predict initiation of that behavior. The report noted that use of smokeless tobacco tended to be specific to males, and both parents and youth perceived the use of smokeless tobacco to be relatively safe and acceptable when compared with cigarette smoking (USDHHS 1994).

This chapter, which updates Chapter 4 of the 1994 report, is not meant to be an all-encompassing review. Instead, it focuses on highlighting information gleaned from research conducted after the 1994 report was written. Literature was collected in a theory-guided way, using the Theory of Triadic Influences, to emphasize findings deemed important by the scientific panel convened to write this chapter. To reflect the findings of researchers during the last decade and a half, the description of etiologic factors differs substantially from the earlier report. The chapter investigates the predictors of initiation and progression of tobacco use for two groups: adolescents (girls and boys aged 12–17 years) and young adults (women and men aged 18–25 years). The time from 12–25 years of age constitutes an extended developmental period in which independence in lifestyle is gradually achieved (note that in the United States, youth cannot buy tobacco legally until at least 18 years of age).

Cigarette smoking among adolescents and young adults is a multidetermined behavior, influenced by the unique and overlapping combinations of biological, psychosocial, and environmental factors. These factors can function as either risk or protective factors. Risk factors increase the probability of smoking initiation and the likelihood of continued use, characterized by increases in frequency and intensity. Conversely, protective factors decrease the probability of smoking initiation, as well as reduce the likelihood that experimental use will progress to regular use. An individual’s overall risk profile is determined by the interrelations of these various risk and protective factors.

Age-related processes also play a central role in determining smoking risk. Adolescence is a sensitive developmental period, characterized by extraordinary brain changes and high levels of emotionality, impulsivity, and risk-taking. The plasticity of the adolescent brain, together with the relatively immature neurobehavioral systems necessary for self-control and affect regulation, confer a heightened vulnerability for the development of smoking behavior (Steinberg 2007). Similarly, the period following early and middle adolescence (aged 18–25 years) has particular developmental significance with regard to smoking behavior. Many risk behaviors peak during this period of life, including rates of substance use, smoking, risky driving, and unsafe sex (Arnett 2000). It is also during this time period that young people may attend college or begin to take on more conventional adult roles, such as marriage, children, and occupational responsibilities. These life transitions are often associated with concomitant decreases in risky behavior (Bachman et al. 2001; Flora and Chassin 2005) and may represent a turning point in which an individual either permanently adopts smoking behavior or rejects it in favor of a nonsmoking lifestyle.

The development of youth smoking is a dynamic process in which youth progress from early cigarette trials, to intermittent use, to regular use and dependence. Understanding the factors that either interrupt progress along this trajectory or potentiate continued use is critical to intervening with smoking behavior. Importantly, the factors that influence early trials with cigarettes may be distinct from those that influence progression and persistence. Modern conceptualizations of smoking development emphasize a social ecological perspective which considers the broader social and environmental context in which youth tobacco use occurs (Cook 2003; Wilcox 2003; Wen et al. 2009; Ennett et al. 2010). This perspective recognizes that youth and young adults do not exist in isolation. Rather, they inhabit a complex system of layered social and environmental contexts, wherein they learn, socialize, and conduct their daily activities. Theoretical models that consider these multiple levels of neurobiological, sociocontextual, and environmental influence can be labeled “integrated biopsychosocial-ecological models” (Sussman and Ames 2008). In these models, intrapersonal predictors of tobacco use are “nested” within larger social and environmental structures. For example, a person’s neurobiological variables function within a set of complex cognitive-related responses and, in turn, operate within a larger context of small social groups (e.g., families, peer groups), that ultimately function within a larger socio-environmental context (e.g., schools, neighborhoods). Large-scale environmental factors might be either social or physical (e.g., communications in the mass media, access of youth to sales of tobacco products), while environmental factors on a smaller scale could include, for example, a youth’s social groups. Intrapersonal factors (e.g., cognitive processes, genetics, and brain systems and structures) could be based on biological or psychological/cognitive variables. These two kinds of predictors, environmental and intrapersonal, may affect each other. For example, a person who shows a lack of self-control related to an imbalance in neurotransmission (an intrapersonal neurobiological variable) and intends to smoke cigarettes in the future (an intrapersonal cognitive variable) would be constrained from smoking in groups of nonsmoking peers at a worksite where smoking was prohibited; here, two kinds of environmental variables would be at play: social (small groups) and physical (prohibition of smoking). Multilevel modeling techniques are commonly used to examine how factors such as intrapersonal characteristics, families, peer groups, schools, and communities, interact together to jointly influence adolescent tobacco outcomes.

The Theory of Triadic Influence (TTI) (Flay and Petraitis 1994; Petraitis et al. 1995) classifies the elements of 14 different theories about human behavior in three substantive domains. This “meta-theory” is grounded in the major behavioral theories that have been applied to tobacco use with young people. The theories, grouped by categories (in parentheses), are as follows:

• Reasoned action, planned behavior (cognitive affective);
• Social learning, social cognitive/learning (social learning);
• Social control, social development (commitment and social attachment);
• Social ecology, self-derogation, multistage social learning, family interaction (intrapersonal); and
• Problem behavior, peer cluster, vulnerability, domain (relatively comprehensive theories).

The three substantive domains are the following:

• Social/normative,
• Cultural/environmental, and
• Intrapersonal.

These three domains have different “distances” from actual tobacco use and so can be characterized as ultimate, distal, or proximal. For example, a person is affected by her or his culture (ultimate), social and physical environments (distal), and personal perceptions of those environments (proximal) that influence subsequent tobacco use (Petraitis et al. 1995; Turner et al. 2004; Sussman and Ames 2008).

This chapter divides the etiologies of tobacco use into four categories of predictors that overlap with those used by TTI and reflect how research has been undertaken in this area: large social and physical environments, small social groups, intrapersonal cognitive processes, and intrapersonal genetic and neurobiological processes.

By considering these four categories, each of which contains sets of variables, within a broad theoretical context, the etiology of tobacco use may be more completely understood, and new options for the primary prevention or cessation of tobacco use may be suggested. (Figure 5.1 in Chapter 5 provides a visual illustration of TTI.)

Large Social and Physical Environments

The large social and physical environments include influences outside the individual, family, and immediate peer group that may either promote or restrict the use of tobacco. In general, these are more distal influences, including demographic factors that in some way affect a person’s subjective perception about the acceptability of smoking, her or his beliefs about the social image that smoking conveys to others, and the availability of tobacco and places to smoke (Petraitis et al. 1995). Examples of these influences are described in detail below.

Large Social Environment

The large social environment defines the norms within a society about whether, when, and for whom smoking is acceptable. Social norms about smoking have changed substantially since the Surgeon General’s report of 1964 (U.S. Department of Health, Education and Welfare 1964); in that year, 50% of the U.S. adult male population smoked (Garfinkel 1997), and smoking was becoming increasingly prevalent among women and youth (Cummings et al. 2002). Smoking was also acceptable in nearly all locations, such as worksites, movie theaters, hospitals, and airplanes (Americans for Nonsmokers’ Rights 2005). Cigarettes were advertised in many different kinds of media and their use was tied to glamour, wealth, sex appeal, popularity, power, and good health (USDHHS 1994). Now, in the early twenty-first century, however, Americans, especially the better educated and more affluent, are much less likely to smoke (Morgan et al. 2007; Stuber et al. 2008) than in the middle of the twentieth century. According to the Centers for Disease Control and Prevention (CDC 2011), in 2010, 19.3% of adults in the United States were current smokers: 21.5% of men and 17.3% of women.

Religious and Cultural Influences

Religion

Religious doctrines can create social norms that constrain smoking behavior. However, the texts of most of the world’s major religions were written before tobacco use became prevalent worldwide. Religious scholars have interpreted the texts and have issued official statements about whether tobacco use is consistent with the doctrines that have emanated from these texts (Simpson 2005). Christianity, Judaism, Buddhism, Hinduism, and Baha’i, for example, do not specifically forbid smoking but indicate that the practice is inconsistent with the teaching and writings of these varied religions, including not deliberately harming one’s body, and religious leaders often suggest avoiding intoxicating and addictive substances that can impair judgment (World Health Organization [WHO] 1999). The Mormon religion forbids smoking and refuses smokers entry into the temple (Church of Jesus Christ of Latter-Day Saints 2006). In response to increasing evidence about the physical, social, and cultural effects of tobacco use, Islamic leaders have forbidden tobacco use in several countries (WHO, Eastern Mediterranean Regional Office 2001). In some religions, abstaining from tobacco use is viewed as a sign of the strength essential for religious piety (Bradby 2007).

In contrast, American Indian religions have used tobacco for healing and ceremonies but, in general, do not condone everyday smoking outside of spiritual contexts (Pego et al. 1995). A challenge for tobacco control in American Indian communities is to acknowledge that the sacred use of tobacco is culturally important while preventing recreational use and nicotine dependence. In some instances, tobacco control organizations have partnered with American Indian tribes to develop health education messages that distinguish the sacred use of tobacco from the habitual use of commercial tobacco products (American Indian Tobacco Education Network 2000). For other groups, religious beliefs and practices can create opportunities for smoking cessation during specific occasions such as Ramadan or Lent (Afifi 1997).

Across religious traditions, smoking tends to be less prevalent among those more likely to participate in religious activities. This association has been documented among Jews in Israel (Shmueli and Tamir 2007), Christians in the United States (Nasim et al. 2006; Mann et al. 2007; Turner-Musa and Lipscomb 2007), and adolescents who belong to various religious groups in the United States (Scott et al. 2006; Rostosky et al. 2007). Participation in religious or faith-based activities also appears to exert a uniquely protective effect against smoking escalation among adolescents who have already experimented with cigarettes (Choi et al. 2002; Van den Bree et al. 2004; Metzger et al. 2011). Some studies have distinguished between private religiosity (e.g., frequency of prayer, importance of religion) and public religiosity (e.g., frequency of attendance at religious services, frequency of youth group attendance) (Nonnemaker et al. 2003, 2006). These studies found that both domains were protective but that private religiosity was more protective against smoking onset while public religiosity was more important for smoking escalation. By encouraging the bonding of adolescents to conventional social institutions and norms, religious involvement may discourage young people from affiliating with irreligious peers, who might introduce them to smoking. Furthermore, adolescents in observant families may be relatively more likely to be monitored closely by their parents, have more adult role models, and be more apt to participate in conventional community activities (Whooley et al. 2002; Bartkowski and Xu 2007).

Race, Ethnicity, and Culture

Chapter 3 of this report describes the epidemiology of smoking across racial and ethnic groups. This section focuses on people’s subjective reactions to their racial, ethnic, and cultural identity, including perceived discrimination, the development of ethnic identity, and ethnic pride, in the context of tobacco use.

Research has identified multiple pathways through which race, ethnicity, and culture may influence youth smoking. Among other factors, patterns of youth smoking across racial and ethnic groups have been linked to processes of acculturation, racial/ethnic discrimination, ethnic identity, and cultural norms. Across several immigrant groups in the United States, tobacco use among adolescents increases as the groups acculturate to U.S. ways of living (Epstein et al. 1998; Chen et al. 1999a,b; Unger et al. 2000; Kaplan et al. 2001; Bethel and Schenker 2005; Weiss and Garbanati 2006; Choi et al. 2008). Compared with adolescents who are more oriented toward their families’ culture of origin, adolescents who speak English, embrace the individualistic culture of the United States, and prefer U.S. media and customs are more likely to use tobacco (Lara et al. 2005). Among several ethnic minority groups, perceptions of discrimination are associated with an increased risk of smoking (Landrine and Klonoff 2000; Harris et al. 2006; Borrell et al. 2007; Chae et al. 2008; Horton and Loukas in press), perhaps because people are attempting to reduce the resulting emotional stress through self-medication. Conversely, ethnic pride was found to protect against smoking among African American youth (Wills et al. 2007), and a strong ethnic identity was found to be associated with a lower risk of tobacco use among youth in several ethnic/racial minority groups, including African Americans and Hispanics (Brook et al. 2007).

A person’s subjective experiences of cultural identity and corresponding place in society may also be associated with whether and how often they use tobacco. Cultural norms against youth smoking within the African American community are thought to contribute to lower rates of youth smoking in this subgroup (Mermelstein 1999; Ellickson et al. 2004; Skinner et al. 2009; Oredein and Foulds 2011). For example, Clark and colleagues (1999) found that antitobacco socialization practices were more common in African American families than in White families. Relative to White households, African American households were more likely to set clear ground rules about smoking and to have had discussions with their children about these rules. Furthermore, Xue and colleagues (2007) found that African American youth living in predominantly African American neighborhoods were less likely to smoke than those living in predominantly White neighborhoods, suggesting that cultural norms in the African American community may operate to constrain youth smoking. Unfortunately, the adolescent advantage seen among African American youth with regard to smoking behavior is not carried into adulthood (Gardiner 2001).

As noted in Chapter 3, African Americans are more likely to smoke menthol cigarette brands than other major subgroups. The reasons probably include several factors (Allen and Unger 2007; Tobacco Products Scientific Advisory Committee 2011). First, the tobacco industry has advertised menthol cigarettes directly to African Americans by associating them with attractive or popular African American role models, including jazz and rap musicians (Gardiner 2004). Second, some African Americans may associate the taste and smell of menthol with folk remedies (e.g., menthol rubs and treatments for sore throat) that are popular in the southern United States. This association between menthol and folk medicine may cause some African Americans to believe, erroneously, that menthol cigarettes are less harmful than nonmenthol cigarettes (Castro 2004). Tobacco advertising perpetuates this belief by labeling menthol cigarettes as “cool” and “smooth.” Third, because smoking menthol cigarettes has become normative among African Americans, some members of this minority group may smoke mentholated brands simply because their parents or older siblings smoked them or because they are readily available at home and from friends. The result perpetuates the stereotype that menthol cigarette brands are for African Americans, even among those who are several generations removed from the culture in which menthol was used medicinally.

Among youth in the United States, American Indians and Alaska Natives have the highest prevalence of tobacco use among all racial/ethnic subgroups (see Chapter 3), with usage rates comparable to those of adult American Indians and Alaska Natives (Hodge 2001). Traditionally, American Indians have used tobacco in ceremonial practices to protect and heal sick individuals and, as a ceremonial tool, it is important in ritualistic exchanges used for social and peaceful purposes. This population also uses tobacco as an educational tool and often links it with storytelling (Hodge 2001). Strong social norms within these communities may support tobacco use, which can be even more of a problem when these communities, or individuals within them, are relocated to urban environments (Hodge and Nandy 2011). However, unlike the studies noted above for other populations, ethnic pride may not protect against tobacco use in this subgroup (LeMaster et al. 2002; Yu et al. 2005). It is also important to note that in epidemiologic and etiologic studies of tobacco use among American Indian and Alaska Native youth, “recreational” use of tobacco is typically not separated from ceremonial use in the design of the research study. Rather, the outcome variable in these studies is simply current (i.e., in the past 30 days) use of tobacco products (LeMaster et al. 2002; Yu et al. 2005; Osilla et al. 2007; Beebe et al. 2008; Yu 2011), and may overlook important differences in the etiology of tobacco use for these groups.

Cultural norms influence smoking in numerous other cultures as well. For example, in China, cigarettes are typically offered to guests as gifts, and refusing cigarettes is viewed as impolite. In that country, men and adolescent boys smoke together after meals as a way of cementing social bonds (Pan 2004; Chen et al. 2006; Grenard et al. 2006; Weiss et al. 2006). In addition, Westernization of developing countries, such as India, has been associated with more tobacco use (Stigler et al. 2010).

Gender

As discussed in Chapter 3, among adolescents there are only small differences by gender in the prevalence of cigarette smoking. In contrast, far larger differences are seen for two other forms of tobacco use. Boys are 4 to 10 times as likely as girls to have used smokeless tobacco in the past month (depending on age), and they are twice as likely as girls to have smoked cigars in the past month (Substance Abuse and Mental Health Services Administration [SAMHSA] 2009; Eaton et al. 2010; Johnston et al. 2011a). Differences between the genders in the prevalence of tobacco use also exist worldwide, but the magnitude of the disparities varies across countries (Warren et al. 2008). According to the 2000–2007 Global Youth Tobacco Surveys (GYTS), the prevalence of cigarette smoking was significantly higher among boys (than girls) in Africa, the Eastern Mediterranean, Southeast Asia, and the Western Pacific but not in the Americas and Europe. Among 151 GYTS sites, 87 showed no differences in cigarette smoking between the genders, 59 demonstrated a higher prevalence among boys, and 5 revealed a higher prevalence among girls. Boys were significantly more likely than girls to report using other tobacco products—pipes, water pipes, smokeless tobacco, and bidis—in the Americas, Europe, and Southeast Asia, but differences between the genders in the use of other tobacco products were not significant in other regions.

Qualitative and quantitative studies conducted in several cultural groups—including Indonesian adolescent boys (Ng et al. 2007), Korean American men (Kim et al. 2005), and Vietnamese young adults (Morrow et al. 2002)—indicate that smoking is viewed as a sign of manhood while being seen as inappropriate for females. In Europe, a study of three generations of women residing in Scotland found that those born in the 1950s associated smoking with femininity, but women born in the 1930s and 1970s did not (Hunt et al. 2004). This suggests generational fluctuations in gender-related norms, but other interpretations are possible.

As immigrant groups acculturate to the United States, gender-related differences in smoking prevalence for these groups may begin to diminish, often because increases are observed among females but not among males. For example, some research has found that acculturation is associated with an increase in smoking among Hispanic girls but not among boys (Epstein et al. 1998), and increases have been observed among Asian American girls but not among boys (Weiss and Garbanati 2006; Choi et al. 2008; Zhang and Wang 2008).

Socioeconomic Status

The SES of youth is derived from such measures as parental income or occupation, parental education, and access to resources. Population-based studies typically use indicators of SES (e.g., education or income) or self-reported measures (e.g., perceived social class or wealth relative to others), or both, to measure SES. Some studies also use measures of neighborhood- or school-level SES as the basis for individual SES.

Numerous studies worldwide have assessed the association between SES and smoking among adults and youth. Low SES has been associated with a high prevalence of smoking in population-based studies in France (Baumann et al. 2007), Germany (Haustein 2006), India (Neufeld et al. 2005; Thankappan and Thresia 2007; Mathur et al. 2008), and the United States (Flint and Novotny 1997). Moreover, even after controlling for individual-level sociodemographic factors, several studies found that the prevalence of smoking was highest in low-income neighborhoods in the the Czech Republic (Dragano et al. 2007), Germany (Dragano et al. 2007), New Zealand (Barnett 2000), the United Kingdom (Kleinschmidt et al. 1995; Shohaimi et al. 2003), and United States (Cubbin et al. 2001; Tseng et al. 2001; Chuang et al. 2005a,b; Datta et al. 2006; Stimpson et al. 2007).

A growing body of evidence suggests that social and organizational characteristics of disadvantaged neighborhoods may contribute independently to higher rates of smoking, above and beyond the aggregate demographic profile of the community’s residents. The “area effect” of smoking has been documented in both national and international studies (Kleinschmidt et al. 1995; Reijneveld 1998; Duncan et al. 1999). However, few studies have directly examined area effects in relation to youth and young adults. Some studies have found that low SES at the neighborhood level (based on income level by U.S./Canada Census block group) or school level was associated with an increased risk of adolescent smoking (Scarinci et al. 2002; Scragg et al. 2002; Matheson et al. 2011). Another study (Lee and Cubbin 2002) found that individual-level, but not neighborhood-level, SES was inversely associated with the prevalence of adolescent smoking. In contrast, one study (Chuang et al. 2005b) found that adolescents in low-SES neighborhoods had a low prevalence of smoking because they received more parental monitoring. Neighborhood characteristics such as social capital (i.e., community cohesion, civic engagement, social ties) have also been examined in relation to smoking. Evans and Kutcher (2010) examined the role of social capital in buffering the effects of neighborhood deprivation on youth smoking outcomes. They found that youth living in low-income communities with high levels of social capital had no excess risk of smoking compared to their more affluent counterparts. Conversely, Matheson and colleagues (2011) found that the effect of neighborhood-level deprivation on youth smoking risk was more pronounced among youth with a strong sense of community belonging, suggesting that in some cases community norms in disadvantaged neighborhoods may function to promote smoking behavior.

The association between SES and adolescent smoking may be moderated by racial, ethnic, and cultural factors. For example, in the National Longitudinal Study of Adolescent Health, neighborhood poverty was a risk factor for smoking among White, but not Black, adolescents (Nowlin and Colder 2007). In a similar analysis of data from the National Longitudinal Study of Adolescent Health, Goodman and Huang (2002) found that low SES was a risk factor for smoking among White adolescents but that high SES was a risk factor for smoking among non-White adolescents. In a study of adolescents in Ontario, Canada (Georgiades et al. 2006), low SES at the family level was a risk factor for smoking among adolescents, but this association was limited to native-born Canadians.

Although one assumes that low SES increases smoking rates, the relationship may actually be bidirectional, with early smoking leading to the attainment of low SES. For example, in a longitudinal study in Finland (Paavola et al. 2004), parents’ SES was not a risk factor for adolescents’ smoking behavior at age 13 years, but early smoking was a risk factor for adolescents’ own low SES in the future (at ages 21 and 28 years). Early smoking also appeared to predict educational attainment later in life. For example, persons who smoked by age 13 years showed lower educational attainment by the age of 28 years.

Several studies have associated adolescents’ access to spending money with their risk of smoking (e.g., Darling et al. 2006; Wong et al. 2007). A study of adolescents in Ontario, Canada (Wong et al. 2007), found that compared with students who had less than $10 in spending money per week, students with more than $20 per week were significantly more likely to be experimental smokers, students with more than $30 per week were significantly more likely to be current smokers, and students with more than $60 per week smoked significantly more cigarettes per day. In a New Zealand study (Scragg et al. 2002), students in low-SES schools reported receiving more spending money than students in high-SES schools, and their possession of spending money was a risk factor for smoking. In addition, adolescents who held jobs while going to school were found to have an increased risk of smoking (Wu et al. 2003), possibly because they had money to buy cigarettes or were influenced by their coworkers to smoke, or both.

Economic stress within a family may also be a risk factor for smoking. Unger and colleagues (2004) found that job loss by a parent predicted subsequent smoking among adolescents during a 1-year period. Other studies have found that unemployment (Haustein 2006) and self-reported financial stress in the household (Siahpush et al. 2003) were risk factors for smoking among adult family members, which might then affect children in the household. Employment status also represents a key risk factor for smoking among young adults. Young adults who are unemployed are more likely to be current, daily, and heavy smokers (Novo et al. 2000; Merline et al. 2004; Lawrence et al. 2007).

Educational and Academic Achievement

Among children and adolescents, low academic achievement is associated with smoking. Several studies have found that middle and high school students who smoked had lower grades than those who did not smoke (Dewey 1999; Sutherland and Shepherd 2001; Diego et al. 2003; Scal et al. 2003; Cox et al. 2007; Forrester et al. 2007; Tucker et al. 2008). In one study, this association appeared to be bidirectional, with poor grades preceding the onset of smoking and smoking preceding poor grades (Tucker et al. 2008). Youth who experience difficulties in school may also feel less connected to their school than do their high-achieving peers, putting them at greater risk for smoking. Connectedness with school (e.g., commitment to school, good relationships with teachers, and a feeling of belonging in school) (Libbey 2004) has been consistently associated with a reduced risk of smoking in the literature (Battistich and Hom 1997; Dornbusch et al. 2001; Scal et al. 2003; Dierker et al. 2004; Rasmussen et al. 2005; Bond et al. 2007).

Among young adults, college students have a lower prevalence of smoking than their peers who do not attend college. For example, in the 2003 Tobacco Use Supplement to the Current Population Survey (Green et al. 2007), current smoking prevalence among 18- to 24-year-olds who were enrolled in college or had college degrees was 14%, compared with 30% among those who did not attend college. In addition, those who did not go to college initiated smoking at younger ages and were less likely to have made quit attempts. According to the 2010 Monitoring the Future study (Johnston et al. 2011b), only 3.9% of college students reported smoking one-half pack or more of cigarettes per day, compared with 15.0% of their peers not in college. The disparity in smoking rates between college students and those not in college appears to precede actual college attendance. In their report, Johnston and colleagues (2011a) also found that the prevalence of smoking one-half pack of cigarettes or more per day was three times as high among high school seniors who were not planning to attend college (12%) as it was among seniors planning to attend college (3.1%). Table 4.1 demonstrates a strong relationship between educational attainment and smoking, with 57.0% of school dropouts aged 16–19 years estimated to be current smokers versus an estimate of 18.6% for those who remained in school (data are from 2006–2010).

Table 4.1

Prevalence of smoking in previous month among adolescents aged 16–19 years who have not completed 12th grade, by enrollment status in school; National Survey on Drug Use and Health (NSDUH) 2006–2010; United States.

School Environment

Youth spend approximately one-third of their time in the school environment (Hofferth and Sandberg 2001). The school setting is frequently used to educate youth about the risks of tobacco use and to implement anti-tobacco policies. See Chapter 6 (“Efforts to Prevent and Reduce Tobacco Use Among Young People”) for a comprehensive discussion of school-based prevention programming. The current discussion is limited to features of the school environment that either promote or protect against youth smoking behavior. One such feature is the tolerance of smoking activity among students or teachers anywhere on the school grounds (Sussman et al. 1995; Ennett et al. 1997; Poulson et al. 2002). Youth who witness adolescents or adults smoking in public (e.g., school) are more likely to perceive smoking as a socially acceptable behavior (Alesci et al. 2003). In this regard, perceptions of prevalent tobacco use on school grounds may promote social norms that encourage smoking uptake and persistence. Studies comparing schools with high versus low smoking rates have found that attending a school with a relatively high smoking rate increases susceptibility to smoking among nonsmoking students (Leatherdale et al. 2006) and increases the odds of ever smoking and current smoking (Ennett et al. 1997; Leatherdale and Manske 2005; Leatherdale et al. 2005). School-based antitobacco policies provide school officials with a mechanism to create a tobacco-free school environment and reduce perceived acceptability of smoking (USDHHS 1994). A growing body of evidence suggests that school smoking restrictions can curb youth smoking behavior, both on and off school premises, when strictly enforced (Evans-Whipp et al. 2004). Studies have shown that consistent enforcement of school tobacco policies results in fewer observations of smoking on school grounds, as well as lower rates of ever smoking and current smoking (Wakefield et al. 2000; Griesbach et al. 2002; Piontek et al. 2008; Adams et al. 2009; Lipperman-Kreda et al. 2009; Lovato et al. 2010). Importantly, Leatherdale and colleagues (2005; Leatherdale and Manske 2005) noted that social influences (e.g., peer smoking, parental smoking) and school factors (e.g., school smoking prevalence) make independent contributions to youth smoking behavior and thus recommend that interventions target both at-risk schools and at-risk students.

Schools are regulated by laws and policies at national, state, district, and school levels. Thus, a district may have more stringent or specific policies than the state in which it resides. Further, individual schools may implement policies beyond those required by the state or district. CDC’s School Health Policies and Programs Study, which collects data on school policies from all states and representative samples of school districts and schools every 6 years, shows that the majority of states (90.2%) and districts (99.4%) prohibited cigarette smoking by students in school buildings in 2006 (Jones et al. 2007). However, fewer prohibited cigarette smoking by faculty and staff in school buildings (74.5% of states and 94.3% of districts). Further, the prevalence of restrictions on smoking in other settings and smokeless tobacco use was lower. Only 38.0% of states and 55.4% of sampled districts prohibited all tobacco use during any school-related activity. Similarly, 63.6% of schools (elementary, middle, and high schools) prohibited all tobacco use during school-related activities in 2006.

In addition to school characteristics, increasing attention is being paid to the role of contextual factors within the school neighborhood. Density of tobacco outlets in proximity to schools has been investigated as a possible risk factor for youth smoking. Henriksen and colleagues (2008) found that the prevalence of smoking was 3.2 percentage points higher among students in schools with the highest density of surrounding tobacco retailers compared with students in schools without any tobacco retail outlets. Chan and Leatherdale (2011) found that the number of tobacco retailers surrounding a school increased students’ susceptibility to future smoking. Leatherdale and Strath (2007) found a positive association between the density of tobacco retailers surrounding a school and the likelihood that underage minors would purchase their own cigarettes. Between-school variability in smoking prevalence has also been associated with exposure to tobacco industry promotional and advertising activities in school neighborhoods. Tobacco retail outlets located near schools with higher smoking prevalence had significantly lower cigarettes prices, fewer government-sponsored health warnings, and more in-store tobacco promotions, relative to those located near schools with lower smoking prevalence (Lovato et al. 2007).

Extracurricular and Organized Activities

Adolescents’ normative development often includes participation in a wide range of organized group activities (e.g., athletics, school clubs, extracurricular) (Dye and Johnson 2006; Mahoney et al. 2006). Empirical studies have been conducted to examine the effects of different organized activities on adolescents’ involvement in substance use, including cigarette smoking. Overall, participation in organized group activities appears to be protective against youth tobacco use (Elder et al. 2000). In particular, team sports involvement has been linked to lower levels of adolescent cigarette smoking (Page et al. 1998; Melnick et al. 2001), with consistent sports involvement (involvement over consecutive years) having a greater influence on smoking behavior than does intermittent participation (Rodriguez and McGovern 2004). In one of the only prospective studies of activity involvement using multiple waves of data (baseline, 15 months, and 24 months), Metzger and colleagues (2011) examined the relation between involvement in organized activities, problem peer associations, and smoking escalation among a sample of experimenting smokers. Participation in team sports directly reduced smoking behavior among current users for boys but not for girls. Among girls, participation in school clubs indirectly reduced smoking behavior via reduced exposure to problem peers.

Small Social Groups

The family and peer groups are the two most important small social groups in the development of young people and their use of tobacco. This section focuses on the influence of these social groups on youth and, when research is available, on young adults.

Cognitive and Affective Processes

Genetic Factors and Neurobiological and Neurodevelopmental Processes

This section considers the role of genetic factors and their interaction with measured environmental factors; neurobiological processes, including addiction to nicotine; and neurodevelopmental processes (USDHHS 2010). The term “genetics” refers to a person’s biological coding scheme, which may become a phenotype (expression) that at times depends on context and previous experience and exposures. The term “neurodevelopmental processes” refers to the influences of environmental experiences and maturation processes on cognitive function and, in this case, the likelihood that a person may yield to perceived social influences or curiosity and use tobacco products. Neurobiological processes are neurologic transmissions across brain structures that may predispose a person to seek out the use of tobacco or other drugs or that may be affected by tobacco or other drug use. Importantly, adolescence is a time of considerable neurodevelopmental plasticity and change (Steinberg 2007; Windle et al. 2008; Giedd and Rapoport 2010). Brain development in regions associated with impulsivity, motivation, and addiction continues well into young adulthood (Lebel and Beaulieu 2011). Maturational changes that occur during adolescence may contribute to neurologic factors that underlie vulnerability to addiction, such as increases in novelty seeking and impulsivity (Chambers et al. 2003). Some individual traits such as sensation-seeking and temperament might predispose young people toward certain problem behaviors in particular social contexts (Wills et al. 2000; Bisol et al. 2010).

Evidence Summary

This chapter covered four general levels of predictors related to the etiology of tobacco use among youth. Risk factors at each of these levels are particularly potent for adolescents and young adults as they transition from childhood to adulthood. The changes in social expectations for these age groups, the further expansion of brain functioning, and the influence of peers provide a changing and challenging context with added vulnerability to tobacco use from 12 to 25 years of age.

Conclusions

1. Given their developmental stage, adolescents and young adults are uniquely susceptible to social and environmental influences to use tobacco.
2. Socioeconomic factors and educational attainment influence the development of youth smoking behavior. The adolescents most likely to begin to use tobacco and progress to regular use are those who have lower academic achievement.
3. The evidence is sufficient to conclude that there is a causal relationship between peer group social influences and the initiation and maintenance of smoking behaviors during adolescence.
4. Affective processes play an important role in youth smoking behavior, with a strong association between youth smoking and negative affect.
5. The evidence is suggestive that tobacco use is a heritable trait, more so for regular use than for onset. The expression of genetic risk for smoking among young people may be moderated by small-group and larger social-environmental factors.

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