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RESEARCH AND PRACTICE |
Mei-Chen Hu is with the Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY. Mark Davies is with the New York State Psychiatric Institute and the Department of Biostatistics, Mailman School of Public Health. Denise B. Kandel is with the Department of Sociomedical Sciences, Mailman School of Public Health, the Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, NY.
Correspondence: Requests for reprints should be sent to Denise B. Kandel, PhD, Columbia University, 1051 Riverside Dr, Unit 20, New York, NY 10032 (e-mail: dbk2{at}columbia.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. We describe the epidemiology of smoking behaviors in a national young adult sample and identify common and unique demographic, social, and psychological correlates of daily smoking and lifetime and current nicotine dependence by race/ethnicity.
Methods. Data are from the National Longitudinal Survey of Adolescent Health, wave III. Dependence was measured by the Revised Fagerström Test for Nicotine Dependence. Logistic regressions were estimated.
Results. Hispanic ethnicity, low education, parental and peer smoking, novelty seeking, early age of smoking onset, and pleasurable initial smoking experiences are significantly correlated with daily smoking and lifetime nicotine dependence. Depressive symptoms are uniquely associated with lifetime and current dependence. Few factors are highly associated with current dependence. Initial sensitivity to smoking has a significantly greater impact on daily smoking than on dependence. Correlates of smoking behaviors are mostly common across racial/ethnic groups, although parental and peer smoking are significant for Whites and Hispanics but not for African Americans.
Conclusions. There are more common than unique correlates of each smoking stage and across racial/ethnic groups. Primary prevention and interventions addressing the factors tested could be uniform for most chronic smokers irrespective of dependence status and race/ethnicity.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Daily smoking and nicotine dependence are 2 major indicators of chronic smoking. Although the overwhelming majority of nicotine-dependent individuals are daily smokers, only about half of daily smokers meet criteria for dependence.18,19 Very few young adults, as few as 5%,18 become dependent before smoking daily,18,20,21 suggesting that dependence represents a later stage of involvement. Whether daily smoking and dependence represent qualitatively different stages of smoking, with daily smoking being a behavioral measure and dependence a more dynamic syndrome state, remains to be established.
We examined daily, lifetime dependent, and current dependent smokers and associated racial/ethnic differences in a young adult sample from wave III of the National Longitudinal Study of Adolescent Health (Add Health). We previously analyzed predictors of smoking onset and transition to daily smoking over 1 year in Add Health between waves I and II and observed few racial/ethnic differences.10
Psychosocial predictors of adolescent smoking behavior include peer, family, personal, and sociodemographic domains.5,22–28 Peer smoking is among the strongest predictors of adolescent smoking initiation and current smoking. Other psychosocial predictors include parental smoking, low levels of parent-child closeness, adolescent problem behavior, depression, sensation seeking, low self-esteem, and poor academic performance. There is also evidence, from small selected samples, that sensitivity to the initial smoking experience predicts smoking onset and perhaps dependence.29 Those who initially experience pleasant rather than aversive sensations are more likely to continue smoking.30 Thus, tolerance and dependence may result from preexisting individual differences in sensitivity to nicotine, in addition to extensiveness of smoking.31–34
The association between initial sensitivity to smoking and nicotine dependence has not been examined in a nationally representative sample. This opportunity exists in Add Health wave III, because we obtained a grant from the National Institute on Drug Abuse to include measures of nicotine dependence and initial sensitivity to nicotine, variables not previously measured, in the interview.
We hypothesized the following: Peer smoking would be more important for daily smoking than dependence. Parental smoking and psychological factors (especially depressive symptoms) would be more important for dependence than for daily smoking. Parental and peer smoking would be more important for Whites than for African Americans.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Excluding 120 cases missing smoking data, we analyzed 14 202 cases. Five strata were defined: (1) ever smoked, even if only 1 or 2 puffs; (2) ever smoked a whole cigarette; (3) ever smoked daily; (4) ever dependent on nicotine; (5) met criteria for last-30-day dependence.
Independent Variables
Smoking behaviors.
Ever daily smokers smoked daily for 30 days. Nicotine dependence (lifetime, current) was measured by the Revised Fagerström Test for Nicotine Dependence.37 Respondents were asked 6 questions about their smoking behavior during the last 30 days; those reporting no current symptoms but more extensive prior smoking were asked about symptoms experienced during that period. The following questions were asked: How soon after you wake up do you have your first cigarette (within 5 minutes, within 6 to 30 minutes, within 31 to 60 minutes, after 60 minutes; coded 3 to 0)? Do you find it difficult not to smoke in places where it is forbidden, for example, in church, at the library, or in theaters (no, yes)? Which cigarette would you hate most to give up (the first one in the morning, all others; coded 1,0)? How many cigarettes a day do you smoke (10 or fewer, 11 to 20, 21–30, 31 or more; coded 0 to 3)? Do you smoke more frequently during the first hours after waking than during the rest of the day (no, yes)? Do you still smoke even if you are so ill that you are in bed most of the day (no, yes)? No, yes responses were coded 0, 1. A score of 4 defined nicotine dependence.38 Current dependence refers to last-30-day symptoms (
=.65); lifetime dependence refers to current or past symptoms ( =.72).
Because of skip errors, the last-30-day and prior dependence questions were not asked consistently of all smokers, generating missing data for 275 of the 5508 ever daily smokers; additionally, 108 daily smokers did not answer at least 3 dependence questions (total missing = 383). Because 2660 (51.9%) of the remaining ever daily smokers met criteria for lifetime dependence, 199 dependent daily smokers (51.9% x 383) are presumably missing, representing 6.96% of the daily smokers estimated to be dependent (199/2660 + 199). All sample sizes are unweighted.
Current dependence among lifetime dependent smokers measures persistence of symptoms.
Covariates
Sociodemographic variables.
Race/ethnicity was Non-Hispanic African American, non-Hispanic White, Hispanic, or Other (Asian, Native American). Non-Hispanic qualifier is mostly not used in the text. Gender was male or female. Age was 18 to 19, 20, 21, 22, 23, 24, or 25 to 27 years. Education was less than 12th grade, high school graduate, some college, or college graduate. Student status was enrolled or not enrolled in school. Work status was not working, working part-time, or working full-time. Family income was annual household income logarithmically transformed. Marital status was not currently married or cohabiting, married, or cohabiting. Children was recorded as yes or no.
Social-psychological variables.
Novelty seeking was a summed score of 9 five-point items from Cloninger’s Tridimensional Personality Questionnaire39 asking how true each was for respondents (e.g., "I often do things based on how I feel at the moment") 1=not true to 5= very true ( =.87). Self-esteem was a summed score of 4 five-point items (e.g., have many good qualities); 5=strongly agree to 1= strongly disagree ( =.79). Delinquency was a summed frequency of participation in 11 delinquent behaviors in past 12 months (e.g., deliberately damaged property); 0=none, 1=1 or 2 times; 3=3 or 4 times, and 5=5 or more times ( =.77). Excluded selling marijuana or other drugs. Depressive symptoms was a combination of 9 of 20 items from the Center for Epidemiologic Studies Depression Scale.40 Summed ratings of the frequency of 9 feelings experienced the past week (e.g., poor appetite, depressed); 0=never or rarely to 3=most or all the time ( =.82).
Interpersonal variables. Parental smoking was combined from wave III youth’s reports of each residential parent’s smoking at prior interview: no parent ever smoked; both parents ever smoked; only mother; only father; no parent in household. Peer smoking was based on youth reports at waves II or I that at least 1 of 3 best friends smoked daily.
Smoking history.
Onset age of smoking a whole cigarette was age in years. Time to daily smoking was time elapsed between onset ages of smoking a whole cigarette and daily smoking. Initial sensitivity to smoking experience (Modified Pomerleau et al.30; added 2 items.) was the extent to which smokers experienced each of 9 symptoms with their first few cigarettes; scored 1=none to 4=intense experience. Three scales averaged the scores of component items: (1) dizziness; (2) pleasant symptoms (pleasant sensations, relaxation, pleasurable rush or buzz, =.77); (3) unpleasant symptoms (unpleasant sensations, nausea, coughing, difficulty inhaling, heart pounding, =.80).
Statistical Analysis
Three smoking behaviors were modeled: (1) ever smoked daily, (2) lifetime dependence, (3) current dependence. Logistic regressions estimated the association of individual characteristics with each behavior: (1) ever smoked daily among those who ever smoked a whole cigarette (n = 8373); (2) lifetime dependence among ever daily smokers (n = 5125); (3) current dependence among those ever dependent (n = 2660).
Smoking a whole cigarette defined the initial smoking experience in model 1 because age of onset of smoking was not asked of those having smoked only 1 or 2 puffs. The same covariates were included in all 3 models, but time between the ages of first smoking a whole cigarette and smoking daily was added to the dependence models. Number of cigarettes smoked daily was not included because it was a Revised Fagerström Test for Nicotine Dependence item. Metric regression coefficients of covariates were multiplied by their standard deviations to obtain standardized regression coefficients. The 3 outcomes were not independent.
Differences of effect sizes between covariates of different outcomes were tested by pooling each pair of outcomes into 1 logistic model that allowed overlap between outcomes.41,42 Each pooled model included a dummy variable for 1 smoking outcome and interaction terms between the dummy and each covariate; the interactions tested the statistical significance of differences in covariate effects on each outcome.42
Models were adjusted for design effects and sampling weights43 and were estimated for all subjects and separately for non-Hispanic Whites, non-Hispanic African Americans, and Hispanics. Interaction terms between race/ethnicity and statistically significant predictors in any models run separately for each ethnic group were included in models fitted to the total sample to assess statistically significant race/ethnic differences in risk and protective factors. Models were reestimated by retaining only significant interactions.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Racial/ethnic groups varied greatly in reaching each smoking stage (Table 1
). Differences were largest at the lowest stages of involvement and decreased with each successive stage. African Americans were the least likely to initiate smoking or to smoke a whole cigarette, once having smoked 1 or 2 puffs; Whites and American Indians were most likely to do so. Whites were most likely to smoke daily among those who ever smoked a whole cigarette and to meet criteria for lifetime dependence among ever daily smokers, except the American Indians. Hispanics were the least likely to be daily smokers, and Hispanics and Asians the least likely to meet criteria for dependence. However, African Americans and American Indians had the highest rates of current dependence.
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Males were more likely than females to have ever smoked and especially to be currently dependent.
Multivariate Models
Ever daily smoking.
At the univariate level, all variables except gender, age, and family income were highly significant correlates of having ever smoked daily. When other covariates were controlled for, all remained significant, except 3 social-psychological factors: delinquency, depressive symptoms, and self-esteem (Table 2). Race/ethnicity strongly differentiated those who progressed to daily smoking: African Americans and Hispanics were much less likely than Whites to have progressed. School status and education were negatively related to daily smoking; cohabiting and having children were positively related.
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Initial pleasant experiences and dizziness were strongly positively associated with daily smoking, whereas unpleasant experiences were negatively associated. The rate of daily smoking declined as the age of initial smoking increased.
Lifetime nicotine dependence.
Of the socio-demographic variables, race/ethnicity, school status, and education were highly significant negative correlates of dependence; no parent in household at last interview when respondents were adolescents was a positive correlate; marital status and having a child were not significant (Table 2
). Parental, peer smoking, depressive symptoms, and pleasant initial experiences were highly significant positive correlates of lifetime dependence. Unpleasant initial smoking experiences were not significant. The age at which the person first smoked a whole cigarette and the interval between onset ages of smoking a whole cigarette and daily smoking were also highly significant. The younger the age of onset and the shorter the time to daily smoking, the greater the risk of lifetime dependence. A similarly negative association was observed with onset age of daily smoking (data not presented).
Current nicotine dependence.
Significant negative correlates of current dependence included higher education and being female, Hispanic, and enrolled in school (Table 2). Maternal smoking was the only parental behavior significantly correlated with current dependence. Peer smoking was not significant. There were 4 other notable patterns. Novelty seeking and depressive symptoms were positively correlated with current nicotine dependence; unpleasant and pleasant experiences were both negatively correlated, with low levels of significance.
Common and stage-specific correlates.
The 2 sets of pooled logistic models provided tests of the commonality and uniqueness of the correlates of daily smoking, lifetime dependence, and current dependence (Table 2). However, the test of differences between 2 regression coefficients has much lower power than the tests for outcome-specific effects. Null results are especially difficult to interpret when original effects sizes are small and results of the pooled statistical tests are inconsistent. For example, test A differs from zero, test B does not, and the test of the difference between A and B is not significant (intransitive relation among the 3 tests).
Several covariates had similar associations across the 3 behaviors: race/ethnicity (Whites more positive than Hispanics); education (negative, strongest for current dependence); being a student (negative); parental smoking (positive); and novelty seeking (positive). Several positive covariates of daily smoking—cohabiting, having a child, and initial dizziness—were not significant for either dependent status, whereas depressive symptoms were significant (positive) for lifetime and current dependence but not for daily smoking. Two variables were associated with daily smoking and lifetime dependence, but not current dependence: friends’ smoking (positive, strongest for daily smoking), and older age at smoking onset (negative).
Longer intervals between onset ages of smoking a whole cigarette and smoking daily were also associated with lower lifetime dependence. Once dependent, age of onset and time to daily smoking were unrelated to current dependence. Unpleasant experiences were negatively associated with daily smoking and current dependence but at a lower level of significance. Age and initial pleasant experiences had opposite effects on lifetime (positive) and current (negative) dependence. Part-time work had a small negative association with lifetime dependence.
Racial/ethnic-specific patterns.
Patterns of association between the covariates and the smoking behaviors were similar among Whites, African Americans, and Hispanics. Relatively few interactions were significant and reflected predominantly patterns of association among Whites not observed among minorities (Table 3).
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Parental smoking (by 1 or both parents) was a highly significant correlate of lifetime dependence for Whites; smoking by both parents was significant for Hispanics. Best friends’ smoking was significant for daily smoking and lifetime dependence for Whites and Hispanics. Neither parental nor peer smoking were significant for African Americans for any smoking behavior. Delinquency was significantly associated with increased lifetime dependence among African Americans.
Pleasant sensations at smoking onset were highly significant correlates of increased lifetime dependence among Whites and Hispanics and current dependence among Hispanics; however, pleasant sensations were associated with lower current dependence among Whites and African Americans.
Age of smoking onset was highly significant among Whites: earlier onset was associated with increased daily smoking and lifetime dependence. Although the same pattern was observed among minorities, the coefficients reached statistical significance among African Americans for both behaviors and among Hispanics for lifetime dependence only when onset occurred at age 18.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Attributes from all domains of variables are highly significant correlates of each behavior, although only 5 covariates have adjusted odds larger than 2. Mostly the same factors are associated with daily smoking and lifetime dependence. Of 19 common predictors, 5 are not associated with either outcome, 9 are associated with both, 4 are uniquely associated with daily smoking, and 1 is uniquely associated with dependence. Race/ethnicity, low education, not in school, role models for smoking in one’s close interpersonal network, the trait of novelty seeking, and 2 aspects of smoking history—early age of smoking onset and pleasurable initial smoking experiences—predict daily smoking and lifetime dependence. Friends’ smoking and pleasant initial experiences are particularly important for daily smoking.
This finding confirms our initial hypothesis that peer smoking would have greater influence on daily smoking than dependence. Depressive symptoms solely distinguish dependent from nondependent daily smokers. However, daily smoking and depressive symptoms by themselves are insufficient indicators of dependence. Only two thirds of daily smokers who are highly depressed, that is, the upper 10% of the distribution, are dependent (data not presented).
Several factors are significant only for daily smoking. Unpleasant experiences at initial smoking are negatively associated with daily smoking; the converse is true for initial dizziness and 2 family-related statuses, cohabiting and having a child (positive).
Current dependence is an important indicator of persistence of dependence. Once dependent, few factors uniquely identify those who remain dependent. Education has a stronger negative association with current dependence than lifetime dependence. Pleasant initial smoking experiences are negatively related to current dependence, an association opposite to that for lifetime dependence. Older age of onset of smoking and longer duration of nondaily smoking are significant only for lifetime dependence and play no role on remaining dependent.
Parental smoking, depressive symptoms, and novelty seeking are associated with increased risk of both lifetime and persistent dependence. Covariates with the highest odds are age of onset of smoking a whole cigarette, for ever daily smoking, and lifetime dependence; duration of nondaily smoking for lifetime dependence; initial pleasant symptoms for ever daily smoking; and being Hispanic and education for all 3 stages. The negative association of education with all stages of smoking is striking.
Initial sensitivity experiences have complex associations with smoking outcomes. A wider range of initial smoking experiences correlate with daily smoking than nicotine dependence. Furthermore, pleasant experiences are positively associated with daily smoking and lifetime dependence but negatively associated with persistent dependence. Initial pleasant experiences, which create a higher risk at the earliest stage of extensive smoking, may become less important for lifetime dependence and be protective for remaining dependent.
Thus, environmental and individual factors contribute to daily smoking and nicotine dependence in addition to preexisting and genetic biobehavioral differences in response to nicotine, reflected in initial sensitivity to smoking. The unique association of negative mood with dependence suggests that they may share a common genetic risk.45
The examination of interpersonal influences on youth dependence constitutes a unique contribution of this study. The role of parental smoking on offspring dependence has rarely been investigated, and results are inconsistent.46,47 We observed significant associations of parental smoking, whether by 1 parent or both, with daily smoking and dependence. In addition, considering that best friends’ smoking was measured on average 5 years earlier, its strong effect on daily smoking and lifetime dependence is remarkable, perhaps channeled through current friends’ extensiveness of smoking. We do not know whether these friends are the same. Either peer influences in adolescence have enduring influences on youths’ development or young people continue to select similar friends over time.
The weaker interpersonal influences of parents and peers among African Americans than Whites is strongly documented by this study for daily smoking and dependence. Prior studies documented these racial/ethnic differences for smoking onset.7,10
Inferences are limited by the cross-sectional and retrospective nature of most of the data and potential censoring of smoking behaviors. Associations such as those involving depressive symptoms may be consequences as well as determinants of dependence. Furthermore, longer follow-ups are necessary to determine whether the negative associations observed with age of onset and duration of daily smoking are partially because of censoring. We did not include number of cigarettes smoked, a Revised Fagerström Test for Nicotine Dependence indicator, as a covariate of dependence. In addition, this study did not assess clinical diagnoses that may be important to take into account in treatment plans. The measure of depressive symptoms does not index mood disorders, such as a depressive episode, which requires that symptoms be present nearly every day for at least 2 weeks, or major depression.
The overall similarity in patterns of association of covariates across smoking behaviors and racial/ethnic groups, with the important exceptions of depressive symptoms and interpersonal influences, are noteworthy results of this study. Little difference by race/ethnicity in the factors tested suggests that interventions for adolescents susceptible to becoming daily smokers or dependent do not need to be tailored for these factors, although the role of parents and peers would need to be emphasized among White and Hispanic youths.
Our findings suggest that the causal factors may be similar across groups so that primary prevention addressing these factors could be uniform, but they cannot inform about the relative impact of different approaches to motivating or supporting changes in behavior.
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Acknowledgments |
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This research uses data from The National Longitudinal Study of Adolescent Health (Add Health), a program project designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris, and funded by grant P01-HD31921 from the National Institute of Child Health and Human Development, with cooperative funding from 17 other agencies. Special acknowledgment is due Ronald R. Rindfuss and Barbara Entwisle for assistance in the original design. Data used in the analyses were obtained through subcontract 12049901R with the Carolina Population Center. Persons interested in obtaining data files from Add Health should contact Add Health, Carolina Population Center, 123 W Franklin St, Chapel Hill, NC 27516–2524 (http://www.cpc.unc.edu/addhealth/contract.html).
Human Participant Protection
Nicotine Dependence Among US Youths, institutional review board protocol 4846R, and Risk Factors for Adolescent Smoking in Add Health: A Feasibility Study, institutional review board protocol 4789R, both part of research grant DA13288, were approved by the New York State Psychiatric Institute–Columbia University Department of Psychiatry institutional review board, most recently on May 28, 2004 and February 24, 2004, respectively.
Add Health obtained a certificate of confidentiality issued by the Department of Health and Human Services in accordance with the provisions of section 301(d) of the Public Health Service Act (42 USC 
241[d]).
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Footnotes |
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Contributors
M.-C. Hu conducted the analyses. M. Davies oversaw statistical issues. D. B. Kandel originated the study, received approval for the addition of dependence items in Add Health III, supervised all aspects of the study implementation, and led the writing. All authors helped to conceptualize ideas, interpret findings, and review drafts of this article.
Accepted for publication March 8, 2005.
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 J. R. DiFranza, J. A. Savageau, K. Fletcher, L. Pbert, J. O'Loughlin, A. D. McNeill, J. K. Ockene, K. Friedman, J. Hazelton, C. Wood, et al. Susceptibility to Nicotine Dependence: The Development and Assessment of Nicotine Dependence in Youth 2 Study Pediatrics, October 1, 2007; 120(4): e974 - e983. [Abstract] [Full Text] [PDF]
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P. M. Ling, T. B. Neilands, and S. A. Glantz The Effect of Support for Action Against the Tobacco Industry on Smoking Among Young Adults Am J Public Health, August 1, 2007; 97(8): 1449 - 1456. [Abstract] [Full Text] [PDF]
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