3 tables omitted
Tobacco use is the leading cause of preventable death in the United
States.1 Because 80% of adult smokers began
smoking as minors,2 efforts to prevent smoking
initiation have focused on adolescents. To examine trends in smoking prevalence
among adolescents, the New Hampshire Department of Health and Human Services
analyzed data from the New Hampshire Youth Risk Behavior Survey (NHYRBS) and
the New Hampshire Youth Tobacco Survey (NHYTS) during 1995-2001. This report
summarizes the results of that analysis, which indicate that smoking prevalence
in New Hampshire has declined among both middle and high school students.
When fully operational, New Hampshire's comprehensive tobacco-prevention and
-control program should lead to further reductions in smoking among adolescents
and begin to decrease smoking among adults.
NHYRBS was conducted in grades 9-12 in odd-numbered years during 1995-2001.
Although survey results for 1995, 1997, 1999, and 2001 were reviewed, weighted
data were available only from 1995; data were not weighted if the overall
response rate (i.e., the school response rate multiplied by the student response
rate) was <60%. All 81 public high schools in New Hampshire were invited
to participate in the survey. Classes in participating schools were sampled
at random, and all students in selected classrooms were eligible to participate.
NHYTS was conducted in public schools in grades 7-8 during March-May 2000
and in grades 6-12 during October-November 2001. The survey used a two-stage
cluster sample design; schools were selected with probability proportional
to size, and classrooms in schools were selected at random. All students in
selected classrooms were eligible to participate. The 2001 survey was divided
into two separate samples, one for middle schools (grades 6-8) and one for
high schools (grades 9-12). Analysis of middle school data was restricted
to grades 7-8. In all surveys, local parental consent procedures were followed
before survey administration.
Among high school students in the 2001 NHYTS, 25.3% (95% confidence
interval [CI] = 21.7%-28.9%) were current smokers (i.e., reported having smoked
cigarettes on ≥1 of the 30 days preceding the survey), which is significantly
lower than the 1995 weighted result from NHYRBS (36.0%; 95% CI = 33.2%-38.8%).
Declines were significant for females and for students in grades 9 and 11.
Among middle school students surveyed in NHYTS in 2000 and 2001, current smoking
among students in grades 7-8 declined from 12.0% (95% CI = 9.4%-14.6%) in
2000 to 6.3% (95% CI = 4.2%-8.4%) in 2001; declines were significant for males
and for students in grade 7.
S Knight, MSPH, A Pelletier, MD, E Peterson, MPH, A Walls, MEd, New
Hampshire Dept of Health and Human Svcs; J Johnson, MA, New Hampshire Dept
of Education. Div of Adult and Community Health, H Ryan, MPH, Office of Smoking
and Health, National Center for Chronic Disease Prevention and Health Promotion,
The results of this study indicate that smoking prevalence in New Hampshire
declined among middle school students during 2000-2001 and among high school
students during 1995-2001. The decline in current smoking among high school
students is consistent with the national trend.3
New Hampshire's tobacco-control program began in 1995 with federal funding.
During 1995-2001, the program was funded at <10% of the current CDC-recommended
minimum level.4 Beginning in 2001, new sources
of funding from the Master Settlement Agreement (MSA) and the American Legacy
Foundation resulted in expansion of the program; for fiscal year 2002, the
program was funded at $3.70 per capita which is 43% of the CDC-recommended
At least four explanations might account for the decline in adolescent
smoking prevalence in New Hampshire. First, during 1997-2001, the price of
cigarettes increased 100%, from $1.77 per pack to $3.53.5 Of
this increase, $1.39 was from price increases by the tobacco industry, $0.27
was from state excise tax, and $0.10 was from federal excise tax. Previous
studies indicate that increases in tobacco prices decrease smoking prevalence,
particularly among youth.6 Second, although
the state's tobacco-control program was funded at a low level during 1995-2001,
it contained some components of a comprehensive program, including efforts
to develop community programs and to begin countermarketing.4 Third,
in fiscal year 2001, the neighboring states of Maine, Massachusetts, and Vermont
had comprehensive tobacco-control programs funded above the CDC-recommended
minimum level.7 Because media markets for
these three states encompass large parts of New Hampshire, those states' countermarketing
efforts probably affected New Hampshire. Finally, national efforts at tobacco
control, along with media coverage of the tobacco industry at the time of
the adoption of MSA, also might have had an impact.
Price increases and control efforts that affect adolescents also are
expected to have an impact on tobacco use by adults. Although adult smoking
prevalence in New Hampshire, as measured by the Behavioral Risk Factor Surveillance
System, did not change significantly during 1991-2001 (23.8% [95% CI = 21.5%-26.2%]
in 1991 versus 24.1% [95% CI = 22.5%-25.6%] in 2001),8 per
capita sales declined 22% during 1997-2001, from 174 packs of cigarettes per
person in 1997 to 136 in 2001.5 An increase
of 10% in cigarette prices is generally estimated to result in a 3%-5% decline
in cigarette sales.6 Although the decline
in sales in New Hampshire was smaller than predicted, sales figures might
in part reflect sales to residents of neighboring states, where cigarettes
are more expensive.
The findings in this report are subject to at least four limitations.
First, trend analysis for smoking prevalence among high school students was
limited by the lack of weighted data from NHYRBS since 1995. Second, data
from the 2000 NHYTS did not include either students in grade 6 or those in
high school, which limited the comparison to the 2001 NHYTS to students in
grades 7-8. Third, neither survey included adolescents in private schools
or those who had dropped out of school. However, this should not affect the
analysis of trends because the percentage of students in these categories
did not change substantially during the study period (K. Schoeneman, New Hampshire
Department of Education, personal communication, 2002).9 Finally,
data used to assess changes in smoking prevalence among high school students
were obtained from two different surveys. Although both surveys contained
identical questions on smoking prevalence and were administered in the same
manner, differences might exist between the two surveys.
New Hampshire plans to repeat NHYRBS in 2003 and is attempting to increase
the response rate, particularly among schools, to ensure that the data can
be weighted. The state also intends to repeat NHYTS in grades 6-12 in 2004.
The remaining elements of New Hampshire's comprehensive tobacco-prevention
and -control program are being implemented. When fully operational, the program
should hasten the decline in smoking among adolescents and begin to decrease
prevalence among adults.
Tobacco Use Among Middle and High School Students—New Hampshire, 1995-2001. JAMA. 2003;289(5):543-544. doi:10.1001/jama.289.5.543