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DOI: 10.1542/peds.101.2.e4
1998;101;4- Pediatrics
Dorothy L. Faulkner and Robert K. Merritt Lifestyle Behaviors and Demographic Factors
Race and Cigarette Smoking Among United States Adolescents: The Role of
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reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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Race and Cigarette Smoking Among United States Adolescents:
The Role of Lifestyle Behaviors and Demographic Factors
Dorothy L. Faulkner, PhD, MPH, and Robert K. Merritt, MA
ABSTRACT. Objective. Cigarette smoking is on the
rise among adolescents in the United States. Although
both African-American and white adolescents have expe-
rienced increases in cigarette smoking over time, the
prevalence of smoking has remained consistently lower
among African-American adolescents than their white
counterparts. The purpose of this study was to determine
whether the race differential in the prevalence of ciga-
rette smoking is attributed to differences in selected life-
style behaviors and demographic factors.
Design. A cross-sectional study was conducted
among African-American and white adolescents (aged 12
to 17 years) who participated in the Youth Risk Behavior
Survey supplement to the 1992 National Health Inter-
view Survey. Analyses were restricted to those who had
complete data on all study variables (n 55569). Logistic
regression analysis was used to estimate the prevalence
odds ratios (POR) of current smoking for white adoles-
cents (versus African-American adolescents) before and
after adjustment for confounding factors.
Results. The crude POR of current smoking for white
adolescents compared with African-American adoles-
cents was 2.8 (95% confidence interval 52.1 to 3.9).
Simultaneous adjustment for confounding factors re-
sulted in a POR of 2.6 (95% confidence interval 51.8 to
3.7).
Conclusions. Selected lifestyle behaviors and demo-
graphic factors do not account for the race differential in
the prevalence of adolescent cigarette smoking. This
study underscores the need for more research on contrib-
utors to the race gap. Such research could advance theo-
retical understanding of the etiology of cigarette smok-
ing among adolescents and lead to more effective
smoking prevention programs for all youths. Pediatrics
1998;101(2). URL: http://www.pediatrics.org/cgi/content/
full/101/2/e4; smoking, adolescence, African-Americans,
prevalence.
ABBREVIATIONS. YRBS, Youth Risk Behavior Survey; NHIS,
National Health Interview Survey; POR, prevalence odds ratio.
Cigarette smoking is on the rise among adoles-
cents in the United States. Although both
African-American and white adolescents have
experienced increases in cigarette smoking over
time, the prevalence of smoking has remained con-
sistently lower among African-American adolescents
than among white adolescents.1
Previous studies have not been able to explain the
race differential.2–4 However, these studies did not
take into account the collective contribution of
health-compromising (eg, nonuse of seat belts), in-
tentional injury (eg, weapon carrying), and other
drug use behaviors (eg, binge drinking) that covary
with cigarette smoking.
In response, a cross-sectional study was conducted
among African-American and white adolescents
(aged 12 to 17 years) who participated in the Youth
Risk Behavior Survey (YRBS) supplement to the 1992
National Health Interview Survey (NHIS). The pur-
pose of this study was to determine whether the race
differential in the prevalence of cigarette smoking is
attributed to differences in lifestyle behaviors and
demographic factors.
Specifically, the objectives were to: 1) estimate the
prevalence of cigarette smoking among African-
American and white adolescents, 2) calculate the
crude prevalence odds ratio (POR) of current smok-
ing for white adolescents (versus African-American
adolescents), and 3) estimate the POR of current
smoking for white adolescents after simultaneous
adjustment for lifestyle behaviors and demographic
factors.
METHODS
Study Population and Data Collection
The 1992 NHIS was conducted among a representative sample
of the civilian noninstitutionalized US population, using a multi-
stage cluster-area probability design of approximately 128 000
persons representing approximately 49 000 households. The YRBS
was conducted as a supplement to the 1992 NHIS among a rep-
resentative sample of US adolescents and young adults drawn
from sampled households.5Based on information collected at the
time of the basic NHIS interview, a roster was prepared listing all
youths aged 12 to 21 years and their school status. From this
roster, one in-school youth and up to two out-of-school youths
from each family were randomly selected to the NHIS-YRBS.
Participation was voluntary. For adolescents aged 12 to 17 years,
the consent of a parent or another responsible adult was re-
quired.5,6
Interviews took place approximately 2 months after the basic
household interview, from April 1992 through March 1993. Using
headsets, respondents listened to a tape recording of the question-
naire and recorded their responses on a standardized answer
sheet. A weighting factor was applied to each record to adjust for
nonresponse and the oversampling of out-of-school youths.5,6
The NHIS-YRBS interviews were completed for 10 645 youths
aged 12 to 21 years, representing an overall response rate of
73.9%.5For this analysis, the eligible population consisted of
African-American and white adolescents from 12 to 17 years of
age (n 56242). Six hundred seventy-three respondents (10.8%)
were excluded because of missing data on at least one study
From the Office on Smoking and Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia.
Received for publication Oct 7, 1997; accepted Oct 7, 1997.
Reprint requests to (D.L.F.) PCS Health Systems, Mail Code 034, 9501 East
Shea Blvd, Scottsdale, AZ 85260–6719.
PEDIATRICS (ISSN 0031 4005). Copyright © 1998 by the American Acad-
emy of Pediatrics.
http://www.pediatrics.org/cgi/content/full/101/2/e4 PEDIATRICS Vol. 101 No. 2 February 1998 1of5
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variable. Thus, the final study population consisted of 5569 ado-
lescents for whom information was complete.
Study Variables
In this study, race was the exposure variable; and current
smoking was the outcome variable. Based on a question about
main racial background and ethnic origin, respondents to the
NHIS-YRBS described themselves as non-Hispanic white or non-
Hispanic African-American. To determine smoking status, re-
spondents were asked, “During the past 30 days, on how many
days did you smoke cigarettes?” Respondents who had not
smoked in the last month were considered nonsmokers, and those
who had smoked on 1 or more days were classified as current
smokers.
Various demographic and behavioral correlates of cigarette
smoking among adolescents7were selected as control variables for
this study. The demographic factors included: gender (female,
male); age (12 to 13 years, 14 to 15 years, 16 to 17 years), and
parental education (,12 years, 12 years, 13 to 15 years, 16 or more
years).
Behavioral factors were classified as health-compromising, in-
tentional injury, or drug use behaviors. The health-compromising
behaviors included nonuse of seat belts and physical inactivity.
Respondents to the NHIS-YRBS were asked, “How often do you
wear a seat belt when riding in a car driven by someone else?”
Response options were: “always,” “most of the time/sometimes,”
and “rarely/never.” Physical activity was assessed by asking re-
spondents, “On how many of the past 7 days did you exercise or
participate in sports activities that made you sweat and breathe
hard, such as basketball, jogging, fast dancing, swimming laps,
tennis, fast bicycling, or similar aerobic activities?” Responses
options were: “3 or more days,” “1 to 2 days”, and “0 days.”
The intentional injury behaviors included weapon carrying and
physical fighting. The NHIS-YRBS assessed weapon carrying by
asking respondents, “During the past 30 days, on how many days
did you carry a weapon such as a gun, knife, or club?” Response
options were “0 days,” “1 to 5 days,” and “6 or more days.”
Physical fighting was measured by asking respondents, “During
the past 12 months, how many times were you in a physical
fight?” Response options were: “0 times,” “1 to 3 times,” and “4 or
more times.”
The drug use behaviors included binge drinking, use of mari-
juana, and use of other illegal drugs. Binge drinking was assessed
by asking respondents, “During the past 30 days, on how many
days did you have 5 or more drinks of alcohol in a row, that is,
within a couple of hours?” Response options were: “not during
life,” “0 days,” 1 to 2 days,“ and ”3 or more days.“ Marijuana use
was measured by asking respondents, ”During the past 30 days,
how many times did you use marijuana?“ Response options were:
”not during life,“ ”0 times,“ and ”1 or more times.“
Other illegal drug use was determined by respondents’ an-
swers to two questions: “During your life, how many times have
you used any form of cocaine, including powder, crack, or free-
base?” and “During your life, how many times have you used any
other type of illegal drug such as LSD, PCP, ecstasy, mushrooms,
speed, ice, heroin, or pills without a doctor’s prescription?” Those
who answered “0 times” to both questions were considered never
users; all others were considered ever users.
Statistical Analysis
First, weighted percentages were used to estimate the preva-
lence of current smoking among the two groups of adolescents.
Then, logistic regression analysis8was used to estimate the PORs
of current smoking for white adolescents versus African-
American adolescents before and after simultaneous adjustment
for lifestyle behaviors and demographic factors. For the multivar-
iate model, correlations among control variables were moderate
and did not present problems of multicolinearity.8,9 SUDAAN,10 a
procedure for analyzing complex sample survey data, was used to
calculate weighted percentages and their corresponding 95% con-
fidence intervals and to estimate the PORs and their correspond-
ing 95% confidence intervals.
RESULTS
The distribution of the covariates by race is dis-
played in Table 1. Although the gender and age
distributions of the two groups of adolescents were
similar, there were considerable race differences in
years of parental education. White adolescents were
more than twice as likely as African-American ado-
lescents to have parents with 16 or more years of
education.
The two groups also differed with respect to the
health-compromising, intentional injury, and drug
use behaviors. African-American adolescents were
more likely than white adolescents to rarely or never
wear seat belts, to have engaged in no physical ac-
tivity during the last 7 days, and to be involved in 1
to 3 physical fights during the past 12 months. On the
other hand, white adolescents were more likely than
African-American adolescents to have participated
in binge drinking on 3 or more days in the past
month, to have used marijuana at least once in the
past 30 days, and to have ever used other illegal
drugs. There were no significant race differences in
weapon carrying.
In 1992, 9.5% of African-American adolescents
were current smokers, compared with 23.0% of white
adolescents. The crude POR was 2.8 (95% confidence
interval 52.1 to 3.9).
In Table 2, the crude POR is adjusted for multiple
confounding factors. The adjusted POR of 2.6 (95%
confidence interval 51.8 to 3.7) was virtually iden-
tical with the crude POR. In addition to race, other
significant correlates of current smoking included
age, seat belt use, physical activity, weapon carrying,
physical fighting, binge drinking, use of marijuana,
and use of other illegal drugs.
DISCUSSION
These data suggest that racial differences in se-
lected lifestyle behaviors and demographic factors
do not account for the race differential in the preva-
lence of adolescent cigarette smoking. The present
findings are consistent with previous studies2–4 and
contribute new knowledge by adjusting for a broad
range of lifestyle behaviors.
The exclusion of 10.8% of the study participants
because of missing data is not likely to have affected
the results. The crude POR reported here (2.8) ex-
cludes those with missing values. However, when
the crude POR was recalculated for the whole pop-
ulation (individuals with and without missing val-
ues), the POR was still 2.8.
Two limitations of this study must be considered.
First, the data are cross-sectional, meaning that there
is no way of knowing whether any of the demo-
graphic, health-compromising, intentional injury, or
drug use behaviors actually predict smoking initia-
tion. Second, differential misclassification could be
operating; that is, African-American adolescents may
be more likely than white adolescents to underreport
their smoking habits,11,12 resulting in an overestima-
tion of effect. Differential misclassification alone,
however, is not likely to fully account for the ob-
served association between race and current smok-
ing. Investigators have found that the race differen-
tial in cigarette smoking among adolescents persists,
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even when biochemical measures of cigarette smok-
ing are used.11
More research is needed to identify other factors
that might contribute to the race differential in ado-
lescent smoking. One potentially fruitful area of re-
search would be an examination of race differences
in parental control of tobacco use. Studies suggest
that when parents establish and reinforce a standard
of no tobacco use for their children, adolescents are
less likely to take up the habit.13
Studies also suggest that African-American par-
ents take stronger actions against their children’s
cigarette smoking than white parents.14–16 For exam-
ple, Koepke et al14 found that African-American par-
ents were more likely than white parents to believe
that it was extremely important for them to be in-
volved in the smoking prevention activities at their
children’s school. When asked how they could best
help their children not to smoke, African-Americans
were more likely than whites to report that they
would threaten their children with punishment.
Questions were also asked about home-smoking
policies. African-American parents were more likely
than white parents to report that only adults were
allowed to smoke in the home.
If African-American parents take stronger actions
against cigarette smoking than white parents, and if
a high degree of parental control of tobacco use is
associated with reduced adolescent smoking, then
race differences in parental control of tobacco use
may help explain the race gap in teen smoking.
There are other possible explanations for why
African-American youths are less likely to smoke
cigarettes than white youths. One is that African-
American adolescents may be more likely to believe
that tobacco products are being marketed specifically
to them.16 Another is that African-American females
may be less likely to use smoking as a weight-control
strategy,17,18 and finally, African-American youths
may be less likely to consider cigarette smoking to be
fun.16
In conclusion, this study found that the POR of
current smoking for white adolescents compared
with African-American adolescents persisted, even
after multivariate adjustment for confounding fac-
tors. These findings underscore the need for more
TABLE 1. Distributions of Covariates Among African-American and White Adolescents—United States, 1992*
Race
African-American (n 5962) White (n 54607)
Variable %* (95% Confidence Interval) % (95% Confidence Interval)
Gender
Female 50.0 (46.5, 53.6) 49.7 (48.2, 51.3)
Male 50.0 (46.4, 53.5) 50.3 (48.7, 51.8)
Age
12–13 years 34.5 (30.8, 38.2) 34.2 (32.7, 35.8)
14–15 years 35.3 (31.8, 38.8) 33.5 (31.9, 35.0)
16–17 years 30.2 (26.9, 33.6) 32.3 (30.7, 33.9)
Parental education
Less than 12 years 20.6 (17.6, 23.6) 11.9 (10.3, 13.5)
12 years 42.6 (38.5, 46.8) 34.5 (32.6, 36.4)
13–15 years 23.8 (20.2, 27.3) 24.2 (22.8, 25.7)
16 or more years 13.0 (10.3, 15.7) 29.3 (27.5, 31.1)
Seat belt use
Always 26.2 (22.6, 29.7) 34.4 (32.4, 36.4)
Most of the time/sometimes 52.1 (48.6, 55.6) 50.0 (48.3, 51.8)
Rarely/never 21.7 (18.0, 25.5) 15.6 (14.1, 17.1)
Physical activity in past 7 days
3 or more days 58.3 (54.8, 61.7) 64.8 (63.1, 66.5)
1–2 days 18.5 (15.8, 21.2) 19.2 (17.9, 20.5)
0 days 23.3 (20.3, 26.3) 16.0 (14.6, 17.4)
Weapon carrying in past 30 days
0 days 86.8 (84.3, 89.4) 84.9 (83.6, 86.1)
1–5 days 9.3 (7.2, 11.3) 9.0 (8.0, 9.9)
6 or more days 3.9 (2.2, 5.6) 6.2 (5.2, 7.1)
Physical fights in past 12 months
0 times 43.4 (39.1, 47.6) 57.5 (55.8, 59.2)
1–3 times 43.0 (39.3, 46.6) 30.7 (29.2, 32.2)
4 or more times 13.7 (10.8, 16.6) 11.8 (10.7, 12.9)
Binge drinking in past 30 days
Not during life 60.1 (56.0, 64.1) 48.6 (46.8, 50.4)
0 days 33.9 (30.2, 37.7) 33.6 (32.0, 35.2)
1–2 days 4.3 (2.6, 5.9) 10.9 (9.9, 11.9)
3 or more days 1.7 (0.9, 2.6) 6.9 (6.0, 7.7)
Marijuana use in past 30 days
Not during life 88.8 (86.2, 91.4) 83.6 (82.3, 84.8)
0 times 7.3 (5.2, 9.4) 8.7 (7.8, 9.7)
1 or more times 3.9 (2.4, 5.4) 7.7 (6.8, 8.6)
Other illegal drug use in lifetime
Never 97.7 (96.5, 98.9) 90.6 (89.7, 91.4)
Ever 2.3 (1.1, 3.5) 9.4 (8.6, 10.3)
* Weighted percentages, adjusted for sampling design and nonresponse.
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research on contributors to the race differential in
adolescent smoking. Such research could advance
theoretical understanding of the etiology of cigarette
smoking among adolescents and lead to more effec-
tive smoking prevention programs for all youths.
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TABLE 2. Adjusted Prevalence Odds Ratio (POR) of Current Smoking for White Versus African-American Adolescents—United
States, 1992*
Variable N % POR (95% Confidence Interval)
Race
African-American 89 9.5 1.0
White 1029 23.0 2.6 (1.8, 3.7)
Gender
Female 552 20.1 1.0
Male 566 21.5 0.9 (0.8, 1.1)
Age
12–13 years 175 8.8 1.0
14–15 years 386 22.3 1.7 (1.3, 2.2)
16–17 years 557 32.2 1.6 (1.2, 2.2)
Parental education
Less than 12 years 186 22.0 1.0
12 years 411 22.1 1.0 (0.7, 1.5)
13–15 years 272 21.8 0.9 (0.6, 1.4)
16 or more years 249 17.6 0.9 (0.6, 1.3)
Seat belt use
Always 242 14.4 1.0
Most of the time/sometimes 576 20.9 1.3 (1.0, 1.6)
Rarely/never 300 33.2 1.5 (1.1, 2.0)
Physical activity in past 7 days
3 or more days 631 18.7 1.0
1–2 days 260 24.4 1.6 (1.2, 2.0)
0 days 227 24.5 1.4 (1.0, 1.8)
Weapon carrying in past 30 days
0 days 786 17.2 1.0
1–5 days 195 40.1 1.7 (1.2, 2.4)
6 or more days 137 44.4 1.5 (1.0, 2.2)
Physical fights in past 12 months
0 times 439 14.8 1.0
1–3 times 425 23.5 1.4 (1.1, 1.7)
4 or more times 254 41.0 2.6 (1.8, 3.9)
Binge drinking in past 30 days
Not during life 112 4.3 1.0
0 days 467 26.6 4.6 (3.5, 6.1)
1–2 days 314 59.0 10.5 (7.1, 15.6)
3 or more days 225 64.9 7.7 (5.1, 11.6)
Marijuana use in past 30 days
Not during life 538 12.2 1.0
0 times 269 58.1 3.8 (2.8, 5.1)
1 or more times 311 78.2 5.3 (3.7, 7.7)
Other illegal drug use in lifetime
Never 806 16.4 1.0
Ever 312 69.7 2.0 (1.4, 2.7)
* Current smoking defined as having smoked on 1 or more days in the past 30 days. Percentages reflect weighted prevalence of current
smoking in each subgroup. Crude POR 52.8 (95% confidence interval 52.1 to 3.9).
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DOI: 10.1542/peds.101.2.e4
1998;101;4- Pediatrics
Dorothy L. Faulkner and Robert K. Merritt Lifestyle Behaviors and Demographic Factors
Race and Cigarette Smoking Among United States Adolescents: The Role of
This information is current as of March 15, 2007
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