1999 Massachusetts Youth Risk Behavior Survey Results
Tobacco Use Among Massachusetts High School Students
Tobacco use is the leading preventable cause of death in the United States, yet in 1998 an estimated 60 million Americans (28% of the population age 12 and older) were current cigarette smokers.1 Tobacco use is responsible for one in every five deaths in the United States; cancer, chronic respiratory illness, heart disease, stroke, and other tobacco-related problems claim the lives of over 430,000 Americans each year2. Additionally, smokeless tobacco use (chewing tobacco or snuff) causes oral cancer and other health problems3.
Tobacco use among young people poses especially serious risks. Research evidence indicates that the earlier young people begin to smoke, the greater their permanent lung damage and the more likely they are to be come heavily addicted.4, 5 Adolescent tobacco use not only threatens health, but it is also associated with drinking and illicit drug use and with poor school performance.5, 6 Unfortunately, every day more than 6,000 young people under 18 try their first cigarette and more than 3,000 become daily smokers.7 Nationally, adolescent cigarette smoking increased from 1990 to 1997.8, 9, 10
In 1992, Massachusetts voters approved an excise tax on tobacco products, with funds from the tax going toward the Tobacco Control Program (Department of Public Health); the Health Protection Fund (Department of Elementary and Secondary Education), which supports comprehensive health education programs in Massachusetts schools; and other tobacco-prevention efforts. Massachusetts middle and high schools have significantly increased attention to tobacco prevention education and other health education topics since 1993.11 Additionally, the Massachusetts Education Reform Law of 1993 made it illegal for students, school staff, and visitors to smoke on school property at any time. School districts are required to submit their local tobacco policies, including consequences for tobacco use on school property, to the Massachusetts Department of Elementary and Secondary Education.
Every two years, the Massachusetts Department of Elementary and Secondary Education conducts the Massachusetts Youth Risk Behavior Survey (MYRBS) to examine the recent rates of adolescent health risk behaviors, including rates of tobacco use. The 1999 MYRBS, administered in randomly chosen public high schools in the Commonwealth in Spring 1999, included questions that asked students to report their history and recent use of cigarettes and smokeless tobacco both on and off school property. For the first time, the MYRBS included a question about recent cigar smoking as well. The MYRBS also asked about students' attempts to quit smoking and about their customary method of obtaining cigarettes. Results reported here can be generalized to provide an accurate estimate of tobacco use among Massachusetts high school students as a whole.
The standard youth risk behavior survey instrument was developed by the U.S. Centers for Disease Control and Prevention (CDC) to monitor adolescent risk behaviors associated with the major causes of morbidity and mortality. Since 1990, the Massachusetts Department of Elementary and Secondary Education has administered the MYRBS in a scientifically-selected sample of public high schools across the Commonwealth. Since 1993, the survey has included students from Boston schools as well as from other districts and has had high enough school and student response rates to be considered representative of the state as a whole.
The 1999 MYRBS employed a two-stage cluster sample design to produce a representative sample of Massachusetts public high school students. At the first sampling stage, 67 schools were randomly selected with probability proportional to school enrollment size. The second stage of the sampling consisted of randomly selecting three to five intact classes of a required course (e.g., English or 2nd period). All students in the selected classes were eligible to participate in the survey. In March through June 1999, the MYRBS was administered by Department of Elementary and Secondary Education staff in 64 cooperating Massachusetts public high schools and was completed by 4,415 students in grades 9 through 12. Student participation was anonymous and voluntary; less than one percent of students in selected classes declined to participate.
Survey results were weighted to ensure that the results would accurately reflect the actual population of Massachusetts public high school students. Initial frequency analyses were conducted by the CDC, and subsequent statistical analyses were conducted by the Massachusetts Department of Elementary and Secondary Education, using a specialized weighting procedure to account for the multistage sampling design.13
Key Findings From The 1999 MYRBS
- Lifetime cigarette use, smoking before age 13, recent smoking, daily smoking, and smoking on school property have declined since 1995. These positive findings, while not statistically significant, demonstrate consistent declines in risk behaviors. Recent smokeless tobacco use both on and off school property has declined steadily and significantly since 1993.
- Over two-thirds of Massachusetts high school students (67%) have tried smoking cigarettes, at least one or two puffs (lifetime use). One quarter of all students (23%) smoked a whole cigarette for the first time before they were 13.
- During the 30 days prior to the survey
- Three in ten students (30%) smoked cigarettes at least once (recent use).
- One in eight students (13%) smoked cigarettes every day (daily use).
- One in six students (16%) smoked cigarettes on school property.
- One in six students (16%) smoked a cigar or cigarillo.
- Five percent of students used smokeless tobacco (chewing tobacco or snuff) at least once, and 3% did so on school property.
- Over one third of students (35%) used some form of tobacco.
- Male and female adolescents had similar rates of cigarette smoking, but males were much more likely than females to report smoking cigars or using smokeless tobacco.
- In general, tobacco use of all kinds was higher among White students and students of other/ mixed ethnicity than it was among Black, Hispanic, or Asian students.
- Most recent smokers (58%) and daily smokers (74%) report having tried to quit smoking at least once. Of all students who described themselves as ever having been regular smokers, only one in six (17%) had successfully quit smoking.
- Of adolescents who smoked any cigarettes in the month prior to the survey, 36% usually obtained their cigarettes by buying them in a store. This represents a significant decline from 1995, when nearly half (48%) bought their cigarettes in a store.
- The percent of adolescents who were asked for proof of age when they tried to buy cigarettes in a store decreased from 1997 to 1999 (61% to 55%).
Results: Lifetime Cigarette Smoking
- Over two thirds of Massachusetts high school students (67%) have tried smoking (at least one or two puffs) at some time (lifetime use).
* Statistically significant decline from 1993 and 1995 to 1999, p. < .05.
- Lifetime cigarette smoking, which had risen significantly in the early 90's, has decreased slightly but steadily since then, from 72% (1995) to 67% (1999). (See Figure A, above.)
- More 12th grade students (71%) than 9th grade students (63%) reported any cigarette smoking in their lifetime.
- Lifetime smoking rates were roughly equivalent for male and female adolescents (68% vs. 67%). (See Figure B, below.)
- White students and those with other/multiple ethnicity had somewhat higher lifetime smoking rates than Black, Hispanic, and Asian students. (See Figure C, page 7. Also see Note 14 in "References and Notes" for an explanation of racial/ethnic categories.)
Results: Recent Cigarette Smoking
- Three in ten high school students (30%) smoked cigarettes at least once in the 30 days prior to the survey (recent cigarette use, sometimes also termed "current" use).
- Approximately one in six students (16%) smoked cigarettes frequently (on at least 20 of the past 30 days).
- On average, students who smoked consumed approximately 2 to 5 cigarettes per day.
- Recent cigarette smoking, which had risen from 1993 to 1995, has decreased substantially since then, from 36% (1995) to 34% (1997) to 30% (1999).
* Statistically significant difference between male and female adolescents, p <.05
- From 1995 to 1999, recent smoking dropped for both male (35% to 30%) and female (36% to 31%) students.
- From 1995 to 1999, the decline in recent cigarette smoking was statistically significant for White youth (40% to 33%). Only minor changes occurred in recent smoking rates among other racial/ethnic groups.
- Despite the decline in smoking among White students, their rates of current cigarette use still remain higher than those of Black, Hispanic, and Asian adolescents.
- One in six students (16%) reported smoking on school property during the month prior to the survey, a decline from the 19% reported for both 1995 and 1997.
Results: Daily Cigarette Smoking
- Rates of daily smoking dropped slightly between 1997 and 1999 (15% to 13%).
- Daily smoking increased with grade level, from 8% among 9th grade students to 17% among high school seniors.
- Daily smoking, like recent smoking, was higher among White and other/multiple ethnicity students than among Black, Hispanic, or Asian students.
- Male and female students were equally likely to report smoking cigarettes every day.
- Among students who smoked every day, 42% smoked at least half a pack a day (11 or more cigarettes), a proportion that has not changed since 1997.
Results: Cigarette Smoking before Age 13
- Almost one quarter of Massachusetts students (23%) reported smoking their first whole cigarette before age 13. Pre-teen smoking has remained virtually unchanged since 1993.
- Male students were somewhat more likely than female students to have smoked their first cigarette before age 13 (25% vs. 22%).
- Cigarette smoking before age 13 was more common among White students (24%) and students of other/mixed ethnicity (35%) than among Black (19%), Hispanic (22%) or Asian students (18%).
- Of all students who had ever smoked a whole cigarette, those who first did so before age 13 were significantly more likely than their peers who started later to be recent cigarette smokers (67% vs. 51%), daily smokers (36% vs.16%), recent cigar smokers (34% vs. 19%) and smokeless tobacco users (12% vs. 6%).
Results: Cigar Smoking and Smokeless Tobacco Use
- One in six adolescents (15.6%) reported smoking cigars or cigarillos in the month prior to the survey. The Massachusetts YRBS did not include questions concerning cigar smoking among high school students before 1999.
- Males were significantly more likely than females to have smoked cigars or cigarillos recently (23% vs. 8%).
- Past month cigar smoking was most commonly reported by adolescents of other/mixed ethnicity (26%), followed by White (16%), Black (15%), Asian (11%), and Hispanic (10%) youth.
- Smokeless tobacco (chewing tobacco or snuff) was used by 4.9% of students in the month before the survey. Half of this group (2.7%) also reported using smokeless tobacco on school property.
- Asian and other/mixed ethnicity youth reported more recent smokeless tobacco use (both 7%) than did White (5%), Hispanic (3%), or Black (3%) adolescents.
See Note 14 in "References and Notes" for explanation of racial/ethnic categories and numbers of students in each.
- Male adolescents were over five times more likely than females to report smokeless tobacco use (8.1% vs. 1.4%) and smokeless tobacco use on school property (4.5% vs. 0.8%).
- There has been a steady and significant decline in adolescent smokeless tobacco use from 1993 (9.4%) to 1999 (4.9%). All of the decline in this time period occurred among male students, whose rates were cut in half, from 17% to 8.1%. Female rates have remained low and virtually unchanged.
- Rates of smokeless tobacco use were relatively "flat" across grade levels; students in each grade were within one percent of the 4.9% average rate.
Results: Any Recent Tobacco Use
- Over one third of adolescents (35%) reported using some form of tobacco (cigarettes, cigars, and/or smokeless tobacco) in the month prior to the survey.
- Male students were more likely than females to have used some form of tobacco in the past month (38% vs. 32%), a difference due to their higher rates of cigar smoking and smokeless tobacco use.
- Tobacco use increased with grade level, from 28% in 9th grade to 44% in grade 12.
- Most adolescents who had smoked cigars (71%) or used smokeless tobacco (78%) in the past month were also current cigarette smokers.
Results: Smoking Cessation
- Nearly one quarter of all students (24%) reported having been "regular smokers," that is, at some time they had smoked daily for at least a month.
- Almost three-quarters (73%) of these "ever regular" smokers had tried to quit smoking at least once and three in ten (31%) had tried to quit three or more times.
- At the time of the survey, only 17% of adolescents who described themselves as ever having been regular (daily) smokers had quit successfully and had not smoked any cigarettes in the past 30 days. Most ever-regular smokers (83%) reported smoking cigarettes recently and half (51%) smoked cigarettes every day.
- Most students who used cigarettes had tried to quit smoking. Among students who reported daily smoking, nearly three-quarters (74%) had tried to quit at least once. Over one-third (36%) had made three or more (unsuccessful) attempts to quit. One out of 14 daily smokers (7%) had tried to quit smoking ten or more times.
Results: Obtaining Cigarettes
- Over one third (36%) of students who had smoked cigarettes in the past month usually obtained their cigarettes by buying them in a store (convenience store, supermarket, or gas station). This represents a significant drop from 1995, when 48% of recent smokers reported that they bought their cigarettes in a store. (See Figure D, above.)
- Although sale of tobacco products to underage youth is illegal in Massachusetts, 27% of students who had smoked in the past month and who were age 17 or younger reported that they usually got their cigarettes by buying them in a store.
- From 1995 to 1997, adolescents increasingly reported being asked for proof of age when they tried to buy cigarettes in a store (49% to 61%). Unfortunately, this positive trend was reversed in 1999, when only 55% of youth trying to buy cigarettes were asked for proof of age.
Summary Of Results
Every measure of tobacco use among Massachusetts high school students has decreased since 1995. Cigarette smoking among Massachusetts high school students, which had risen in the early 90's, has declined in the past four years. Smokeless tobacco use among adolescents has continued to drop steadily and significantly since 1993. Smoking cigarettes and using smokeless tobacco on school property have also declined. Cigar smoking, never before assessed by the MYRBS, was reported by nearly one sixth of students.
Smoking cigarettes or cigars increases from 9th to 12th grade, but smokeless tobacco use is relatively level across grades. Male and female students have similar levels of cigarette smoking, but males are much more likely to report smoking cigars or using smokeless tobacco. Most measures of tobacco use are higher among White youth and those of Other/Mixed Ethnicity than among Black, Hispanic, or Asian adolescents.
Adolescent cigarette smokers were less likely in 1999 than in 1995 to get their cigarettes by buying them in stores. Rates of being asked for proof of age to buy cigarettes, however, slipped downward somewhat in the past two years. Most high school students who do smoke have made one or more attempts to stop, although most of these attempts appear not to have been successful.
The 1999 MYRBS results point to substantial progress in reducing tobacco use among Massachusetts youth. Although the decline in recent cigarette smoking from 35.7% (1995) to 30.3% (1999) does not quite reach statistical significance, it nevertheless represents almost 14,000 fewer high school smokers than would have been the case had rates remained level. Massachusetts can also be encouraged about the significant drop in adolescent smokeless tobacco use, which has been cut almost in half since 1995. Unfortunately, however, unacceptably high numbers of Massachusetts youth continue to endanger their health by consuming tobacco products.
The findings reported here highlight the importance of early and repeated tobacco prevention education, beginning well before high school and reinforced at every grade level. Tobacco tax revenues approved by Massachusetts voters in 1992 have supported stronger youth tobacco prevention and comprehensive school health programs across the state. Currently, virtually all districts have required health education courses which include tobacco prevention components.11, 12 We can be encouraged by the finding that high school students in 1999, whose exposure to strong school and community anti-smoking messages started earliest and has been most consistent, reported lower recent smoking and smokeless tobacco use than has been true in previous years.
Changing widespread patterns of tobacco use among adolescents is a difficult and complex task, but 1999 MYRBS results support the view that such changes are taking place. Research evidence suggests that providing information about the harmful effects of tobacco use is rarely enough, by itself, to curb adolescent smoking.15 Rather, effective tobacco prevention education programs are those that focus on helping students recognize peer and media pressure and on helping them develop the skills to resist such pressure.15, 16 Additionally, because tobacco use is associated with other risk behaviors, tobacco prevention education should be integrated into comprehensive school health programs. The new Massachusetts Comprehensive Health Curriculum Framework,17 approved in September 1999, is a useful starting place to help districts develop school health education programs that encourage young people to make healthy choices.
In addition to classroom instruction about tobacco, vigorous enforcement of regulations concerning tobacco purchasing and use are also important. Although fewer adolescents purchase cigarettes in stores than was true previously, the recent upturn in youth buying cigarettes without being asked for proof of age is troubling. On the other hand, the decrease reported for smoking and smokeless tobacco use on school property suggests that progress is being made in this area.
Most students who smoke, especially those who have ever developed a regular smoking habit, have tried to quit at least once. Unfortunately, the nicotine in tobacco is an addictive substance, and most of these attempts have not been successful. School- and/or community-based cessation programs aimed at adolescents would offer these students more support and guidance. Although nearly two-thirds of school districts currently offer smoking cessation programs,18 relatively few adolescent smokers take advantage of these programs; they should be encouraged to do so.
References and Notes
- Substance Abuse and Mental Health Services Administration (1999). Summary of findings from the 1998 National Household Survey on Drug Abuse. DHHS Publication. Washington, DC: Superintendent of Documents, US Government Printing Office.
- Centers for Disease Control and Prevention (1997). Smoking-attributable mortality and years of potential life lost - United States, 1994. Morbidity and Mortality Weekly Report, 46, 444-451.
- Public Health Service (1986). The health consequences of using smokeless tobacco: A report of the advisory committee to the Surgeon General. NIH Pub. No. 86-2874. Bethesda, MD: US DHHS.
- Wiencke, J. (1999). Journal of the National Cancer Institute, 91.
- Public Health Service (1994). Preventing tobacco use among young people: A report of the Surgeon General. Washington, DC: US Department of Health and Human Services.
- Johnston, LD, O'Malley, PM, and Bachman, JG (1987). National trends in drug use and related factors among American high school students and young adults, 1975-1986, DHHS Pub. No (ADM) 87-1535. Rockville, MD: National Institute on Drug Abuse.
- Crump, C., Packer, L., & Gfroerer, J. (1998). Incidence of initiation of cigarette smoking - United States, 1965-96. Morbidity and Mortality Weekly Report, 47.
- Centers for Disease Control and Prevention (1998). Tobacco use and sources of cigarettes among high school students - United States, 1995. Morbidity and Mortality Weekly Report, Vol. 45, No. 20, May 24, 1996.
- Centers for Disease Control and Prevention (1998). ) Tobacco use among high school students - United States, 1997. Morbidity and Mortality Weekly Report, April 3, 1998.
- Johnston, LD, Bachman, JG, and O'Malley, PM (1997) Monitoring the Future Study, 1997. Ann Arbor, MI: Institute for Survey Research, University of Michigan.
- Massachusetts Department of Elementary and Secondary Education (1999). The 1998 Massachusetts School Health Education Profile Report. Malden, MA: Author.
- Massachusetts Department of Elementary and Secondary Education (1999). Year V Evaluation of the Health Protection Fund. Malden, MA: Author.
- The Centers for Disease Control supplied design-effect weights for all major variables, calculated using SUDAAN, a statistical software program designed to accommodate multi-stage sampling.
- Race/ethnicity was determined by student self-report, and students were allowed to indicate multiple answers. For the 1999 MYRBS, 3316 students categorized themselves as White only; 292 as Black only; 485 as Hispanic (including those who also included any other racial/ethnic designation as well); and 278 as Asian or Pacific Islander. An additional 164 students, constituting a "Other/Mixed Ethnicity" category, included 42 adolescents who indicated that they were American Indian/Alaskan Native and 122 adolescents who checked multiple races (not including Hispanic). Eighty students did not answer the race/ethnicity question.
- Reid, DK, McNeill, AD, and Glynn, TJ (1995). Reducing the prevalence of smoking in youth in Western countries: An international review. Tobacco Control, 4, 266-277.
- Centers for Disease Control and Prevention (1994). Guidelines for school health programs to prevent tobacco use and addiction. Morbidity and Mortality Weekly Review, 43 (No. RR-2).
- Massachusetts Department of Elementary and Secondary Education (1999). Massachusetts comprehensive health curriculum framework. Malden, MA: Author.
- Massachusetts Department of Elementary and Secondary Education (1999). Second comprehensive school health tobacco control status report. Malden, MA: Author
Results on tobacco use presented here will also be included as part of the 1999 Massachusetts Youth Risk Behavior Survey Results Report, which focuses on behaviors associated with major causes of morbidity and mortality among youth and adults. The full report will also include findings related to adolescent alcohol and illegal drug use, sexual behavior that might lead to sexually transmitted disease (including HIV/AIDS) or unintended pregnancy, behaviors leading to intentional and unintentional injury (such as fighting, drunk driving, or suicidal behavior), poor dietary behavior, and lack of physical activity.
Carol Goodenow, Ph.D., 1999 Massachusetts Youth Risk Behavior Survey Coordinator, was the principal investigator and author of this report.
The Massachusetts Department of Elementary and Secondary Education expresses its appreciation to the 4,415 high school students who participated in the 1999 Youth Risk Behavior Survey, and to the teachers, principals, and superintendents of the 64 high schools these students represented.