Current Trends Reasons for Tobacco Use and Symptoms of Nicotine Withdrawal Among Adolescent and Young Adult Tobacco Users -- United States, 1993
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Centers for Disease Control and Prevention, Current
Trends Reasons for Tobacco Use and Symptoms of Nicotine
Withdrawal Among Adolescent and Young Adult Tobacco
Users -- United States, 1993 , MMWR, 43(41);745-750, October
21, 1994
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Article: Current Trends Reasons for Tobacco Use and Symptoms of Nicotine Withdrawal Among Adolescent and Young Adult Tobacco Users -- United States, 1993Editorial Note
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References
Cigarettes and other forms of tobacco are addictive because of the presence of nicotine.1 Among adults in the United States who have ever smoked daily, 91.3% tried their first cigarette and 77.0% became daily smokers before age 20 years.2 Among high school seniors who had ever tried smokeless tobacco (SLT), 73% did so by the ninth grade.2 To further characterize the development of nicotine addiction among persons aged 10-22 years, CDC analyzed data from the 1993 Teenage Attitudes and Practices Survey (TAPS-II). This report summarizes the results of that analysis and focuses on assessments of reasons for using tobacco and symptoms of nicotine withdrawal.
For TAPS-II, data about knowledge, attitudes, and practices
of tobacco use were collected by telephone interviews; persons
who could not be contacted by telephone were contacted in
person. The TAPS-II sample for this analysis had two components:
1) of the 9135 respondents (aged 12-18 years) to the 1989
TAPS telephone interview * , 7960 (87.1%) participated in
TAPS-II (these respondents were aged 15-22 years); and 2)
an additional 4992 persons from a new probability sample
of 5590 persons aged 10-15 years (89.3% response rate) participated
in TAPS-II. Data were weighted to provide national estimates,
and 95% confidence intervals (CIs) were calculated using
SUDAAN.3
Persons who had smoked cigarettes (n=2121) or who had used SLT (n=470) during the 30 days preceding the survey were asked if they used tobacco because "it relaxes or calms me" and if they used it because "it’s really hard to quit" (either answer indicates an influence of the psychopharmacologic properties of nicotine {1}). Smokers who had tried to quit and persons who had quit smoking (n=1925) ** were asked, "When you quit/tried to quit did you feel a strong need or urge to have a cigarette; feel more irritable; find it hard to concentrate; feel restless; feel hungry more often; feel sad, blue, or depressed?" SLT users who had tried to quit and persons who had discontinued use (n=1216) were asked similar questions adapted to SLT use.
Lifetime history of tobacco use was assessed through three categories for cigarette smoking (20 or fewer cigarettes smoked during lifetime, 21-98 cigarettes smoked, and 100 or more cigarettes smoked) and with two categories for SLT use (never used regularly versus ever used regularly). Frequency of use was measured by the number of days on which cigarettes were smoked or SLT was used during the preceding month (0, 1-14, 15-29, or 30 days). Intensity of use was measured by the average number of cigarettes smoked per day during the preceding 7 days (five or fewer, 6-15, or 16 or more) and by the number of times SLT was used on the days it was used (1-2, or three or more).
For persons who had smoked during the preceding 30 days
and for those who had used SLT during the preceding 30 days,
the frequency of reporting that tobacco was used because
it is relaxing or because it is hard to quit increased in
relation to increasing lifetime use, frequency of use, and
intensity of use (Table 1); this pattern characterized the overall sample
and persons in both age categories (10-18 years and 19-22
years). The percentages of persons who reported smoking
cigarettes or using SLT for these two reasons also were
similar across age groups. Among smokers and SLT users with
the greatest lifetime use or intensity of use, the proportions
who reported using tobacco to relax were similar to those
who reported using it because it was hard to quit. Among
those with the lowest lifetime use or frequency or intensity
of use, relaxation was more commonly cited as a reason for
use than was difficulty quitting. For every category of
usage frequency, cigarette smokers were more likely to report
use for relaxation than were SLT users. Regardless of age,
approximately three fourths of daily cigarette smokers (73.8%)
and daily SLT users (74.2%) reported that one of the reasons
they used tobacco was because it was hard to quit.
The likelihood of reporting symptoms of nicotine withdrawal increased in relation to frequency (Table 2) and intensity (Figure 1) of use. Younger and older smokers were equally likely to report increasing nicotine withdrawal symptoms as exposure to nicotine increased (Table 2). The same pattern characterized SLT users among both age groups combined (group-specific analyses are not presented because of limitations in sample sizes of persons who used SLT during the preceding 30 days). Among persons aged 10-22 years, those who smoked cigarettes and those who used SLT on a daily basis were equally likely to report symptoms of nicotine withdrawal (with the exception of depression, which was less prevalent among SLT users). Among persons who reported using tobacco on 1-14 days during the preceding 30 days, those who smoked cigarettes were generally more likely to report symptoms of nicotine withdrawal than were persons who used SLT. At least one symptom of nicotine withdrawal was reported by 92.4% of daily cigarette smokers and 93.3% of daily SLT users who had previously tried to quit. Persons who smoked six or more cigarettes per day were more likely than those who smoked five or fewer cigarettes per day to report difficulty concentrating, feeling more irritable, and craving cigarettes during a previous quit attempt; however, among persons who smoked five or fewer cigarettes per day, 28.7% reported difficulty concentrating; 47.5%, feeling more irritable; and 56.9%, craving cigarettes during a previous quit attempt (Figure 1).
Reported by: D Barker, MHS, Robert Wood Johnson Foundation, Princeton, New Jersey. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.
This analysis of TAPS-II underscores the relation between use of tobacco and reasons for using tobacco -- a relation that reflects the psycho- pharmocologic properties of nicotine. In addition, the frequency of smoking and of using SLT strongly correlated with self-reported symptoms of nicotine withdrawal. These findings are consistent with previous studies that indicated high prevalences of symptoms of nicotine addiction among adolescent and adult smokers.2, 4, 5
Previous reports indicate that adolescents initially tried cigarettes for reasons related to social norms, advertising, social pressure, and curiosity.2, 6 However, once the behavior becomes established, regular smokers are more likely than beginning smokers to report that they smoke for pleasure and because they are addicted.2, 6 Among students who were high school seniors during 1976-1986, a total of 44% of daily smokers believed that in 5 years they would not be smoking; however, follow-up indicated that 5-6 years later, 73% of these persons remained daily smokers.2 This finding suggests that many of these persons could not overcome the social, psychological, and chemical influences that maintain or advance the smoking behavior once it is established2 and indicates that many adolescents do not understand the personal risks of smoking, including nicotine addiction.7
The findings in this report are subject to at least two limitations. First, because of small sample sizes, the prevalence of SLT withdrawal symptoms could not be analyzed in relation to lifetime history of cigarette smoking; however, SLT users who tried to quit were probably less likely to experience symptoms of nicotine withdrawal if they concurrently smoked cigarettes.1 Second, the relation of nonpharmacologic (e.g., social and psychological) influences on tobacco use were not quantified; however, the findings are consistent with previous reports documenting the psychopharmacologic effects of nicotine on tobacco use and tobacco withdrawal.1, 2, 4
In 1992, approximately two thirds of adolescent smokers
reported that they wanted to quit smoking, and 70% indicated
that they would not have started smoking if they could choose
again.8 Most adults probably could be prevented from
becoming tobacco users if they could be kept tobacco-free
during adolescence.2 Four strategies that may assist
in supporting tobacco-free adolescence include 1) strict
enforcement of the prohibition of sales to minors (sales
to persons aged less than 18 years are illegal in all 50
states), 2) reduction of advertising and promotion practices
that stimulate demand, 3) increases in the real (i.e., inflation-adjusted)
prices of tobacco products, and 4) school health education
programs that are reinforced by media-based and other community
programs.2
The Institute of Medicine recently published recommendations for a comprehensive national strategy to prevent nicotine addiction among youth.9 These recommendations especially address tobacco-free policies; restrictions on tobacco advertising and promotion; tobacco taxation; enforcement of youth access laws; regulation of the labeling, packaging, and contents of tobacco products; further research on nicotine addiction and on prevention and cessation programs; and the coordination of policies and research. Copies of this report can be purchased from National Academy Press, telephone (800) 624-6242 or (202) 334-3313.
1. CDC. The health consequences of smoking: nicotine addiction
-- a report of the Surgeon General. Rockville, Maryland: US
Department of Health and Human Services, Public Health Service,
CDC, 1988; DHHS publication no. (CDC)88-8406.
2. US Department of Health and Human Services. Preventing tobacco use among young
people: a report of the Surgeon General. Atlanta: US Department of Health and
Human Services, Public Health Service, CDC, National Center for Chronic Disease
Prevention and Health Promotion, Office on Smoking and Health, 1994.
3. Shah BV, Barnwell BG, Hunt PN, LaVange LM. Software for Survey Data Analysis
(SUDAAN) version 5.5 {Software documentation}. Research Triangle Park, North
Carolina: Research Triangle Institute, 1991.
4. McNeill AD, West RJ, Jarvis M, Jackson P, Bryant A. Cigarette withdrawal symptoms
in adolescent smokers. Psychopharmocology 1986;90:533-6.
5. Giovino GA, Shelton DM, Schooley MW. Trends in cigarette smoking cessation
in the United States. Tobacco Control 1993;2(suppl):S3- S10.
6. Sarason IG, Mankowski ES, Peterson AV, Dinh KT. Adolescents’ reasons for smoking.
J School Health 1992;62:185-90.
7. Leventhal H, Glynn K, Fleming R. Is the smoking decision an "informed choice"?:
effect of smoking risk factors on smoking beliefs. JAMA 1987;257:3373-6.
8. George H. Gallup International Institute. Teen-age attitudes and behavior
concerning tobacco: report of the findings. Princeton, New Jersey: George H.
Gallup International Institute, 1992.
9. Institute of Medicine. Growing up tobacco free: preventing nicotine addiction
in children and youths. Washington, DC: National Academy Press, 1994.
* TAPS respondents who completed the survey by mail questionnaire were not eligible for TAPS-II. TAPS-II included household interviews of persons who did not respond by telephone.
** Persons who reported that they had never smoked regularly were excluded from these analyses.