Tobacco use among middle and high school students — New Hampshire, 1995-2001

Morbidity and Mortality Weekly Report, Jan 10, 2003

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 (Table 1); 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 (Table 1). 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 scho ols (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 [grater than or equal to]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 (Table 2). 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 (Table 3).

Reported by: 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 Communizy Health, H Ryan, MPH, Office of Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note: 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 minimum level.

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 stares 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 (9; K. Schoeneman, New Hampshire Department of Education, personal communication, 2002). 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 surv eys.