Customize your JAMA Network experience by selecting one or more topics from the list below.
2 tables omitted
Cigarette use is the leading preventable cause of death in the United
States.1 One of the national health objectives
for 2010 is to reduce the prevalence of current cigarette use among high school
students to ≤16% (objective no. 27-2b).1 To
examine changes in cigarette use among high school students in the United
States during 1991-2003, CDC analyzed data from the national Youth Risk Behavior
Survey (YRBS). This report summarizes the results of that analysis, which
indicated that although (1) the prevalence of lifetime cigarette use was stable
among high school students during the 1990s and (2) the prevalence of both
current and current frequent cigarette use increased into the late 1990s,
all three behaviors had declined significantly by 2003. Prevention efforts
must be sustained to ensure this pattern continues and the 2010 objective
The national YRBS, a component of CDC's Youth Risk Behavior Surveillance
System, used independent three-stage cluster samples for the 1991-2003 surveys
to obtain cross-sectional data representative of public and private school
students in grades 9-12 in all 50 states and the District of Columbia. During
1991-2003, sample sizes ranged from 10,904 to 16,296, school response rates
ranged from 70% to 81%, student response rates ranged from 83% to 90%, and
overall response rates ranged from 60% to 70%. For each cross-sectional national
survey, students completed an anonymous, self-administered questionnaire that
included identically worded questions about cigarette use.
For this analysis, temporal changes for three behaviors were assessed:
(1) lifetime cigarette use (i.e., ever tried cigarette smoking, even one or
two puffs), (2) current cigarette use (i.e., smoked cigarettes on ≥1 of
the 30 days preceding the survey), and (3) current frequent cigarette use
(i.e., smoked cigarettes on ≥20 of the 30 days preceding the survey). For
current cigarette use, temporal changes and subgroup differences in 2003 were
analyzed by sex, race/ethnicity, and grade. 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, and SUDAAN was used
for all data analyses. Temporal changes were analyzed by using logistic regression
analyses that assessed linear and quadratic time effects simultaneously and
controlled for sex, race/ethnicity, and grade. Quadratic trends indicated
significant but nonlinear trends in the data over time. When a significant
quadratic trend accompanied a significant linear trend, the data demonstrated
a nonlinear variation (e.g., leveling off or change in direction) in addition
to an overall increase or decrease over time. T-tests were used to examine
differences in current cigarette use in 2003 by sex, race/ethnicity, and grade.
All results are statistically significant (p<0.05) unless otherwise noted.
Significant linear and quadratic trends were detected for lifetime and
current cigarette use. The prevalence of lifetime cigarette use, although
stable during the 1990s, declined significantly, from 70.4% in 1999 to 58.4%
in 2003 (Table 1). The prevalence of current cigarette use increased from
27.5% in 1991 to 36.4% in 1997 and then declined significantly to 21.9% in
2003. A significant quadratic trend was detected for current frequent cigarette
use; the prevalence increased from 12.7% in 1991 to 16.7% in 1997 and 16.8%
in 1999, then declined significantly to 9.7% in 2003.
Significant linear and quadratic trends were detected in current cigarette
use among both sexes (Table 2). Among female students, the prevalence of current
cigarette use peaked during 1997-1999 and then declined significantly to 21.9%
in 2003. Among male students, the prevalence of current cigarette use peaked
in 1997 and then declined significantly to 21.8% in 2003. Similarly, among
white, white female, Hispanic, Hispanic female, Hispanic male, and 9th- and
11th-grade students, current cigarette use prevalence peaked by 1997 and then
declined significantly in 2003. Significant quadratic trends were detected
among white male, black, black female, black male, and 10th- and 12th-grade
students, indicating that the prevalence of current cigarette use peaked by
1999 and then declined significantly.
During 2003, white students were significantly more likely than black
and Hispanic students to report current cigarette use. More white female students
than black and Hispanic female students and more Hispanic female than black
female students reported current cigarette use. The prevalence of current
cigarette use was not significantly different among white, black, and Hispanic
male students. By grade level, significantly more 10th-, 11th-, and 12th-grade
students than 9th-grade students and more 12th-grade than 10th-grade students
reported current cigarette use.
Office on Smoking and Health; Div of Adolescent and School Health, National
Center for Chronic Disease Prevention and Health Promotion, CDC.
The findings in this report indicate that the prevalence of current
cigarette use has declined substantially since the late 1990s and is at the
lowest level since YRBS was initiated in 1991. These findings are consistent
with trends observed in other national surveys, although the other surveys
suggest the rate of decline might be slowing.2-4 Factors
that might have contributed to the decline in cigarette use include (1) a
90% increase in the retail price of cigarettes during December 1997–May
2003,5 (2) increases in school-based efforts
to prevent tobacco use, and (3) increases in the proportion of young persons
who have been exposed through the mass media to smoking-prevention campaigns
funded by states or the American Legacy Foundation.6 Factors
that might have slowed the rate of decline in cigarette use among young persons
include (1) tobacco industry expenditures on tobacco advertising and promotion,
which increased from $5.7 billion in 1997 to $11.2 billion in 20017; (2) reductions in Master Settlement Agreement
funds used for tobacco-use prevention; and (3) the frequency with which smoking
was depicted in films.8
The findings in this report are subject to at least two limitations.
First, these data apply only to youths who attend high school. Nationwide,
among persons aged 16-17 years, approximately 6% 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 test/retest reliability.10
Although the declines in cigarette use are encouraging, prevention efforts
must be sustained if the nation is to reach its 2010 national health objective.
In 2003, approximately one in five high school students were current smokers,
and one in 10 were current frequent smokers. Reducing the prevalence of cigarette
use further among young persons will require continued efforts in (1) devising
targeted and effective media campaigns, (2) reducing depictions of tobacco
use in entertainment media, (3) instituting campaigns to discourage family
and friends from providing cigarettes to young persons, (4) promoting smoke-free
homes, (5) instituting comprehensive school-based programs and policies in
conjunction with supportive community activities to prevent smoking initiation
and encourage smoking cessation, and (6) decreasing the number of adult smokers
(e.g., parents) to present more nonsmoking role models.
Cigarette Use Among High School Students—United States, 1991-2003. JAMA. 2004;292(5):558–559. doi:10.1001/jama.292.5.558
Browse and subscribe to JAMA Network podcasts!
Create a personal account or sign in to: