Journal of Pediatric Psychology, Vol. 28, No. 7, 2003, pp. 495-504
© 2003 Society of Pediatric Psychology
Psychosocial Risk Factors for Tobacco Use Among Adolescents with Asthma
Departments of Oncology and Pediatrics and Lombardi Cancer Center, Georgetown University Medical Center
All correspondence should be sent to Kenneth P. Tercyak, Cancer Control Program, Lombardi Cancer Center, Georgetown University Medical Center, 2233 Wisconsin Avenue, NW, Suite 317, Washington, District of Columbia 20007-4104. E-mail: tercyakk{at}georgetown.edu.
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Abstract |
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Objective To determine the prevalence of smoking among adolescents with asthma and smoking's psychosocial risk factors (environmental smoking exposure, autonomy, depression). Method Participants were 2,039 adolescents with asthma and 2,039 matched controls from the Add Health study. Results The prevalence of ever smoking among adolescents with asthma was 56%. Among ever smokers with asthma, the prevalence of current smoking was 48%, and the prevalence of current smokers having made a recent attempt to stop smoking was 57%. Having parents who have smoked, exposure to friends who smoke, and depression were significant psychosocial risk factors for ever smoking. Asthma and exposure to friends who smoke were significantly associated with current smoking, and attempts to stop smoking were significantly associated with asthma and depression. Conclusions Psychosocial risk factors for smoking among adolescents with and without asthma appear similar. Research on the role of illness in tobacco control is warranted.
Key words: asthma; adolescents; psychosocial risk factors; tobacco.
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Introduction |
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Tobacco use has been the leading preventable cause of death and disease in the United States for decades (McGinnis & Foege, 1993
; US
Department of Health and Human Services, 2000). This risky
behavior is often initiated during childhood and adolescence, as more than 70%
of adult smokers report that they started smoking on a daily basis prior to
age 18 (Lynch & Bonnie,
1994). According to the Centers for Disease Control and Prevention
(CDC), nearly 64% of high school–aged adolescents nationwide have ever
smoked, and almost 29% are current smokers
(Grunbaum et al., 2002). These
and other statistics have prompted the U.S. Public Health Service to adopt a
youth-centered tobacco control policy advocating increased tobacco prevention
and intervention programming at the national, state, and local levels
(Lynch & Bonnie,
1994). Although tobacco use is considered harmful to all children, adolescents, and adults, there are subgroups for whom smoking is particularly risky. Included among these subgroups are persons diagnosed with chronic obstructive pulmonary diseases (COPDs), including asthma. According to a 1997 report issued by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health, asthma is an inflammatory disorder of the airways resulting in frequent episodes of wheezing, breathlessness, chest tightening, and coughing. These symptoms most often begin in childhood, though they can develop throughout life. In addition to medication, self-management strategies can successfully control asthma, through such steps as identifying and avoiding environmental irritants that trigger or exacerbate asthma symptoms. As tobacco smoke tops the list of potential irritants, the NHLBI recommends that persons with asthma not smoke or be exposed to tobacco smoke in their environment.
Unfortunately, several studies have concluded that the prevalence of
smoking among persons with asthma is the same as the prevalence of smoking
among persons without asthma (Backer,
Nepper-Christensen, Ulrik, von Linstow, & Porsbjerg, 2002;
Brook & Shiloh, 1993;
Forero, Bauman, Young, & Larkin,
1992; Martin, Landau, &
Phelan, 1982), or in some instances higher
(Forero, Bauman, Young, Booth, &
Nutbeam, 1996; Kaplan & Mascie-Taylor,
1989,
1997;
Sherman, Tosteson, Tager, Speizer, &
Weiss, 1990). Though many possible explanations for this
disturbing association exist, the topic has received surprisingly little
empirical attention. In one of the few studies to directly assess reasons why
adolescents with asthma might be drawn to smoking, Zbikowski, Klesges,
Robinson, and Alfano (2002)
examined smoking status and a host of psychosocial risk factors (approval of
smoking, accessibility of cigarettes, value of smoking, rebelliousness, social
support, sadness, stress) among 3,234 adolescents ranging in age from 15 to 18
years, approximately 16% (n = 505) of whom had a positive asthma
history. In their sample, the overall prevalence of current smoking was 20%.
Adolescents with asthma were significantly more likely to smoke (17% to 22%)
than were those without asthma (17%). Factors associated with an increased
likelihood of smoking did not differ between the two groups, leading to the
conclusion that adolescents with or without asthma may smoke for similar
reasons.
Among the factors affecting the decision to smoke that have consistently
received support in the tobacco control literature are: (a) one's level of
exposure to smokers in the social environment, (b) the degree of parental
oversight or adolescent autonomy in the parent-adolescent relationship, and
(c) an adolescent's level of psychological distress. For example, exposure to
smoking among family members and among friends has been shown to highly
influence adolescent smoking practices, including initiation of smoking and
progression to greater levels of smoking
(Chassin, Presson, Rose, & Sherman,
1996; Choi, Pierce, Gilpin,
Farkas, & Berry, 1997;
Distefan, Gilpin, Choi, & Pierce,
1998; Tercyak, Goldman, Smith,
& Audrain, 2002). Wang and colleagues
(1999) reported that parental
smoking was associated with a 30% increase in the likelihood of adolescents
becoming current smokers, and the number of friends who smoked was associated
with a 44% increase. Smoking among family members and friends may increase
smoking acceptability and cigarette availability
(Flay, 1993;
Jackson, Henriksen, Dickinson, Messer,
& Robertson, 1998), thereby laying a foundation for the
adoption of regular smoking.
In terms of autonomy, data suggest that adolescents with less parental
involvement in their day-to-day activities and thus more decision-making
autonomy are more likely to experiment with tobacco and other drugs
(Baumrind, 1985;
Chilcoat & Anthony, 1996;
Cohen, Richardson, & LaBree,
1994; Griffin, Botvin,
Scheier, Diaz, & Miller, 2000). Radziszewska, Richardson,
Dent, and Flay (1996) found
that adolescents with unengaged parents (i.e., adolescents high in
decision-making autonomy) experienced the poorest adjustment as indexed by a
number of factors including smoking. This relationship was particularly
robust, as it held up across ethnic, gender, and socioeconomic status
groups.
Along with these social factors, psychological distress has been associated
with adolescent smoking as well (Brown,
Lewinsohn, Seeley, & Wagner, 1996;
Covey & Tam, 1990;
Patton et al., 1996).
Depression, the most commonly studied form of such distress, has been shown to
be a predictor of smoking initiation
(Escobedo, Kirch, & Anda,
1996), may be associated with nicotine dependence in adolescents
(Kassel, 2000), and can have a
negative impact on stopping smoking
(Glassman et al., 1990). In a
study by Kandel and Davies
(1986), it was found that
lifetime and current smoking were significantly higher in young adults (ages
24–25 years) who had had elevated depression symptoms as adolescents
(ages 15–16 years). This suggests that depression may make an individual
vulnerable to initiating smoking and maintain his or her smoking behavior over
time. Indeed, nicotine contained in cigarettes is a stimulant and may induce
feelings of euphoria and relaxation, which could ameliorate depression
symptoms (Anda et al.,
1990).
As adolescents with asthma are strongly discouraged against smoking, and
against being around others who smoke, it remains unclear how these
well-established smoking risk factors might operate in this context. For
example, are adolescents with asthma just as likely as their peers without
asthma to be exposed to parents who have smoked and/or to socialize with
friends who smoke? Or, are they less likely to experience these influences
given their illness? Further, because self-management strategies are a
critical element of asthma control, one might expect to see increased
decision-making autonomy in the relationships of adolescents with asthma with
their parents. While some degree of autonomy is likely to be beneficial in
terms of caring for asthma symptoms, the autonomy of these adolescents might
also extend to other behaviors, including tobacco use, that are more risky.
Adolescents with asthma often strive to maximize their autonomy
(Randolph & Fraser, 1999),
and smoking is viewed by adolescents as a means to achieve it
(Grube, Rokeach, & Getzlaf,
1990; Nichter, Nichter,
Vuckovic, Quintero, & Ritenbaugh, 1997). And finally, since
some adolescents with asthma experience psychological distress related to
their illness (Creer & Bender,
1995), this too might in turn affect their smoking risk.
In addition to these questions, there are uncertainties about attempts to
stop smoking made by adolescents with asthma who currently smoke. Not all
adolescents who smoke wish to continue to do so, and many regret starting.
According to the 1989 Teenage Attitudes and Practices Survey, nearly
three-quarters of youth who smoke had seriously considered stopping smoking
and almost one-half made a recent attempt to stop
(CDC, 1994, p. 120). In 2001,
57% of adolescent current smokers nationwide had tried to stop smoking within
the past year (Grunbaum et al.,
2002). Data from adult current smokers with asthma suggest that
the prevalence of their recent attempts to stop smoking is similar to that of
current smokers without asthma (Wakefield,
Ruffin, Campbell, Roberts, & Wilson, 1995). But at present, no
data on the prevalence of attempts to stop smoking among adolescents with
asthma are available. Further, it is unknown how the psychosocial risk factors
mentioned above might deter or promote attempts to stop among adolescents with
asthma relative to their peers without asthma. O'Byrne, Haddock, and Poston
(2002) found autonomy in the
parent-adolescent relationship to be positively associated with adolescents'
attempts to stop smoking, suggesting that further research in this area is
warranted.
In light of these issues, the goals of the present study were to: (a) determine the prevalence of lifetime and current cigarette smoking and recent attempts to stop smoking among adolescents with asthma, (b) compare these prevalence estimates with those of adolescents without asthma, and (c) explore potential psychosocial risk factors for smoking in these youth, compared with adolescents without asthma. Consistent with the prior literature, it was hypothesized that adolescents with asthma would be more likely to smoke relative to their peers without asthma despite the fact that smoking is strongly contraindicated among adolescents with asthma. It was further hypothesized that exposure to environmental cigarette smoking (i.e., smoking among parents and friends), greater decision-making autonomy, and greater symptoms of depression would be positively associated with smoking and negatively associated with recent attempts to stop smoking, as they are key factors shown to be related to tobacco use in prior literature.
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Method |
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All data for this study were obtained through a contractual arrangement with the proprietors of the National Longitudinal Study of Adolescent Health (Add Health) Wave I dataset (Carolina Population Center, 1998
). Some adolescents enrolled in the Add
Health study and their parents completed extensive in-home interviews about
adolescent health and well-being (Udry
& Bearman, 1998). This included information about exercise and
physical activity; drug, alcohol, and tobacco use; hereditary conditions of
health; physical disabilities; mental health; and chronic health problems. As
such, the Add Health study offers pediatric psychology an unprecedented
opportunity to identify the prevalence of tobacco use and other health
behaviors within a large and well-defined population of adolescents.
Participants
During the parent in-home interview of Wave I (conducted from September
1994 through December 1995), parents reported on a number of parent-, child-,
and family-specific factors, including whether the child was currently
experiencing the health problem of asthma or emphysema (yes/no). Based upon
parents' response to these questions, 2,073 adolescents were identified. The
in-home interview did not distinguish between asthma and emphysema as
different forms of COPD. However, it is assumed that the majority of affected
adolescents were diagnosed with asthma and not emphysema, as emphysema usually
develops in adulthood, often after many years of exposure to cigarette smoke
and other air pollutants.
Adolescents included in the control sample were randomly selected via a computer program from the Wave I dataset after the cases of adolescents with asthma had been identified. The computer program sought to exactly match controls to cases on four vital statistics: (a) gender (male or female), (b) race (Hispanic, black/African American, Asian, Native American, other, white), (c) age (11 to 21 years), and (d) the U.S. census region in which the school the adolescent attended was located (West, Midwest, South, Northeast). A total of 2,039 out of 2,051 cases (99%) could be matched in this manner. Limitations in the Add Health study dataset prevented a complete determination of the health status of these controls, other than that they did not have asthma. However, adolescents with diabetes (n = 78) could be excluded prior to the selection of the sample of controls as the Wave I in-home parent interview asked parents to identify whether their adolescent was affected with diabetes.
Procedure
In the Add Health study, the sampling frame included all high schools in
the U.S. meeting certain eligibility criteria (N = 26,666). A
systematic random sample of 80 high schools and 52 middle schools was then
selected with unequal probability of selection for participation.
Incorporating systematic sampling methods and implicit stratification into the
Add Health study design ensured that the sample was representative of U.S.
schools with respect to region of country, urbanicity, school type, ethnicity,
and school size. Overall, 79% of schools agreed to participate
(Resnick et al., 1997).
Measures
All of the following variables/scales were extracted/created from the Wave
I adolescent in-home interview. Environmental Smoking
Exposure. As exposure to smoking among family members and friends has
been shown to be strongly associated with adolescent cigarette experimentation
and continued use, two items assessing resident mother and resident father
lifetime cigarette smoking (yes/no) and one item assessing the number of best
friends who smoke at least one cigarette per day (none, one, two, or three)
were included in the analysis.
Decision-making Autonomy. Greater autonomy in decision
making has been shown to be positively related to tobacco, alcohol, and other
drug use in community samples of adolescents. As such, a decision-making
autonomy scale was constructed from seven yes/no items that asked adolescents
whether or not they viewed their parents as letting adolescents make their own
decisions about curfew, friends, clothing, television watching, and daily
routines. On this scale, higher scores indicated greater autonomy. The
multiitem scale creation process followed the example of Sieving et al.
(2001), which is recommended
when using Add Heath data. The decision-making autonomy scale had an internal
consistency (Cronbach alpha) reliability of .63.
Depression Symptoms. Resnick et al.
(1997) created a reliable
(Cronbach alpha .73) multi-item scale of psychological distress/depression
symptoms over the preceding week for the Add Health dataset. This 19-item,
3-point Likert scale (0 = never or rarely, 1 = sometimes, 2
= a lot of the time, 3 = most of the time or all of the
time) is based, in large part, on the Center for Epidemiologic Studies
Depression Scale (Radloff,
1977), which is commonly used with adolescents
(Myers & Winters, 2002);
higher scores indicated greater depression symptoms. Items include "You
felt depressed" and "You felt sad."
Tobacco Use. Adolescent tobacco use was assessed by a series of standard epidemiological items regarding lifetime and current cigarette smoking and recent attempts to stop smoking. These items included: "Have you ever tried cigarette smoking, even just 1 or 2 puffs?" "During the past 30 days, on how many days did you smoke cigarettes?" "During the past 6 months, have you tried to quit smoking cigarettes?"
For the purposes of the data analysis, three successive tobacco-use outcome
variables were created. The first variable divided the entire sample into
those adolescents who either had or had not reported a positive lifetime
history of ever having tried cigarette smoking ("ever smoker").
Among those who reported they had ever smoked, these adolescents were further
subdivided into those who were current smokers (those who had smoked
cigarettes on 5 or more days within the past 30 days) and those who were not.
As there is no consensus in the published literature on the most acceptable
definition of adolescent current smoking
(Kaufman et al., 2002;
Grunbaum et al., 2002;
Lloyd-Richardson, Papandonatos, Kazura,
Stanton, & Niaura, 2002;
Zbikowski, Klesges, Robinson, &
Alfano, 2002), a relatively stringent definition was applied.
Finally, among current smokers only, the 6-month prevalence of having made at
least one attempt to stop smoking was determined by adolescents' responses to
the single yes/no item.
Data Analysis
The first step in the data analysis was to describe the demographic
characteristics of the sample (see Table
I). Next, univariate analyses (frequency counts) were used to
determine the prevalence of tobacco use outcomes (ever smoking, current
smoking, and recent stop-smoking attempt). Bivariate analyses (chi-square
tests and Student t tests) tested for differences in these outcomes
among the illness status, demographic, smoking exposure, autonomy, and
depression variables. In addition to illness status, variables with
significant (p < .05) associations at the bivariate level were
then tested in a multivariate fashion using logistic regression. These
equations generated odds ratios (with 95% confidence intervals) in order to
estimate the variable's influence on the likelihood of an adolescent being an
ever smoker, a current smoker, and/or having made a recent attempt to stop
smoking.
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Results |
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Univariate Analyses
Fifty-six percent of the total sample of adolescents was classified as ever smokers; the prevalence of ever smoking among adolescents with and without asthma was identical. Among ever smokers overall, 45% were classified as current smokers; the prevalence of current smoking was 48% among adolescents with asthma (42% among adolescents without asthma). Among current smokers overall, 53% had made a recent stop-smoking attempt (57% among current smokers with asthma, 49% among current smokers without asthma) (see Table II).
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Bivariate Analyses
As shown in Table II, older
and white adolescents, t(3, 612) = –9.7 and
X2(1) = 54.9, respectively, were more likely to be ever
smokers than were younger and non-white adolescents. In addition, adolescents
exposed to mothers, X2(1) = 71.4, fathers,
X2(1) = 89.7, and friends who smoked, t(3, 889) =
–24.3, as well those with higher levels of decision-making autonomy and
depression, t(3, 661) = –6.7 and t(3, 985) =
–8.6, respectively, were also more likely to be ever smokers compared
with adolescents who had little or no exposure to these influences.
In terms of current smoking, a similar pattern of findings to the ones noted above emerged, with the inclusion of adolescents with asthma being more likely to be current smokers relative to adolescents without asthma, X2(1) = 5.5.
With respect to recent stop-smoking attempts, only illness status and depression yielded significant findings. Specifically, adolescent current smokers with asthma were more likely to have made at least one attempt to stop smoking compared with adolescent current smokers without asthma, X2(1) = 5.0, and adolescent current smokers with elevated levels of depression were more likely to have attempted to stop smoking compared with those with moderate levels of these symptoms, t(754) = –2.9.
Multivariate Analyses
The results of the multivariate analyses of the tobacco use outcomes are
presented in Table III. To ease
their interpretation in these models, the two parental smoking history
variables were combined into a single variable representing whether either the
resident mother, father, or both parents were ever smokers (yes), and
this was contrasted to cases where neither the mother nor the father ever
smoked (no). Similarly, exposure to smoking among friends was
dichotomized as 0 (no friends who smoke) versus 1 (one or more friends who
smoke). And finally, a mediansplit procedure was performed on the continuous
scores of the decision-making autonomy and depression scales to create groups
of adolescents with low and high autonomy and low and high depression.
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After controlling for the effects of age and race, significant predictors of ever smoking were exposure to parents who had ever smoked, smoking among friends, and depression. Specifically, parental smoking was associated with a 70% increase in the likelihood of being an ever smoker, friends' smoking was associated with a threefold increase, and high symptoms of depression was associated with a 40% increase. Among ever smokers, illness status and smoking among friends were strongly associated with being a current smoker, after the effects of age and race were controlled for; having asthma was associated with a 30% increase in the likelihood of current smoking, and exposure to one or more friends who smoked was associated with a sevenfold increase in the likelihood of being a current smoker. With respect to current smokers' attempts to stop smoking, adolescents with asthma were 40% more likely to have made at least one attempt within the past 6 months, and adolescents with high depression were 50% more likely to have made at least one attempt. The interactions between illness status and each psychosocial risk factor tested in these models were nonsignificant.
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Discussion |
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Study results suggest that the prevalence rate of ever smoking among adolescents with asthma was 56%. Among ever smokers with asthma, the prevalence rate of current smoking was 48%. Comparable prevalence rates among adolescents enrolled in the Add Health study without asthma were 56% for ever smoking and 42% for current smoking.1 The data indicate that adolescents with asthma were just as likely to experiment with smoking in their lifetimes as were adolescents without asthma. The data also indicate that adolescents with asthma were significantly more likely to be current smokers than their peers without asthma. While both of these findings are of concern, the latter is perhaps more troubling, as it suggests that asthma, in and of itself, may be a risk factor for more advanced forms of tobacco use.
The results of multivariate analyses imply that the psychosocial risk
factors for ever smoking were similar among adolescents with and without
asthma. There are several possible explanations as to why these risk factors
may be operating in the observed manner. It might be that adolescents with
asthma are psychologically reacting against the self-management of their
illness by engaging in a risky behavior known to negatively impact their
asthma control. Other work has shown that risk taking and rebelliousness are
positively associated with current smoking among adolescents with asthma
(Zbikowski et al., 2002).
Further, Creer and Bender
(1995) note that rates of
nonadherence to the pediatric asthma regimen can be as high as 70%, and that
nonadherence among pediatric asthma patients has been viewed as an attempt to
assume greater control over their illness. Though these statements regarding
nonadherence are meant to apply to medication usage, when combined with the
data on risk taking and rebelliousness, it might reflect a general tendency
among some adolescents with asthma to engage in other health-compromising
behaviors, including tobacco use.
Another possibility is that adolescents with asthma experience greater
levels of psychological distress, and that cigarette smoking represents one
(albeit unhealthy) way in which adolescents cope with this distress. Indeed,
when Forero and colleagues
(1996) reported on the health
behaviors of a large community-based sample of Australian adolescents with
asthma, they found that both tobacco and alcohol use were highest among
adolescents with asthma, and that these adolescents also reported elevated
psychological distress. Nevertheless, the results of the present study do not
support the relationship between distress and tobacco use, as depression was
not significantly related to an increased likelihood of current smoking
(p = .16). Zbikowski et al.
(2002) also did not find that
adolescents with asthma smoked to relieve distress; only adolescents without
asthma were more likely to be current smokers as a result of their beliefs
that smoking was relaxing. Also contrary to the hypothesis, the present study
did not find support for the relationship between autonomy in decision making
and tobacco use when other factors were controlled for.
Perhaps the most intriguing finding pertains to attempts to stop smoking
among current smokers. Both illness status and depression were positively
associated with having made a recent attempt to stop. It is encouraging that
adolescents with asthma were 40% more likely to try to stop smoking, but,
given the addictiveness of tobacco, it is not surprising to find that their
attempts were unsuccessful. In the adult literature, there is little relation
between previous attempts to stop smoking and the probability of success on a
current attempt (Cohen et al.,
1989); for adolescents, multiple attempts are common and should be
viewed as beneficial in that they are likely to lead to eventual success in
remaining abstinent over time (Burt &
Peterson, 1998).
Interestingly, the presence of high depression was positively associated with attempts to stop smoking. It is possible that adolescent smokers regretted having started smoking, which partly gave rise to their distress and may have motivated their stop attempt. However, as their attempt was unsuccessful, this distress may, in turn, have inhibited their ability to stop. These data suggest that the role of depression in stopping smoking among adolescents is complex, possibly serving both motivational and inhibitory functions.
Regarding the limitations of this work, it is important to keep in mind
that the Add Health study did not distinguish asthma from emphysema as
different forms of COPD, and more detailed health and diagnostic information
were unavailable. As such, the true extent of adolescents' asthma severity
cannot be determined. It was also assumed that parental reports of asthma
diagnoses were reliable and valid, and that the majority of affected
adolescents were diagnosed with asthma and not emphysema given the illnesses'
trajectories, though this too could not be confirmed. Further, though the
multi-item scale creation process followed the example of Sieving et al.
(2001), which is recommended
when using Add Health data, the validity of the decision-making autonomy and
depression scales is limited. In addition, changing patterns in the prevalence
of smoking among U.S. high school students since the time these data were
collected in the mid-1990s also limit the application of these findings.
Finally, the cross-sectional nature of this work limited the ability to draw
conclusions about the directional nature of the relationships observed. For
example, in this study it was not possible to determine if asthma caused
smoking or vice versa. However, it is more likely than not that the diagnosis
of asthma preceded the onset of tobacco use. That is because asthma is most
often first identified in childhood, whereas a majority of cigarette smoking
occurs during adolescence (Lynch &
Bonnie, 1994; NHLBI,
1997). Nevertheless, the role of tobacco as a causal factor in the
onset of asthma remains a possibility
(Backer et al., 2002;
Larsson, 1995). In the future,
additional waves of Add Health data should be able to answer these questions
more fully.
The implications of this study for the control of tobacco use among
adolescents, especially those with asthma, are clear: All should be
discouraged from smoking, and professional assistance in stopping smoking
should be provided to those who have started. Tobacco use is highly
contraindicated among adolescents with asthma
(NHLBI, 1997). Recommendations
to educate and counsel patients with asthma about the risks of smoking, and
the benefits of stopping, have been included in several professional groups'
clinical practice guidelines and policy statements, including those of the
American Academy of Pediatrics (AAP,
1998) and the Society for Adolescent Medicine
(Rosen, Elster, Hedberg, & Paperny,
1997). In the context of adolescent health care visits, such
education and counseling can be accomplished by incorporating into standard
care the "5 A's for brief intervention"
(Committee on Substance Abuse,
2001; Fiore et al.,
2000). These include: asking all adolescents about
tobacco use at every health care visit; advising all tobacco users to
stop smoking; assessing their willingness to make a stop-smoking
attempt; assisting them in stopping (via behavioral counseling,
pharmacotherapy, or both); and arranging follow-up. Klein, Levine,
and Allan (2001) reported that
the majority of adolescent health care providers ask their adolescent patients
about smoking, and most assess adolescents' motivation to stop smoking.
However, fewer provide assistance or arrange follow-up. Preliminary data
suggest that pharmacotherapy can be safely provided to adolescent smokers
(Smith et al., 1996), though
additional research is necessary. As behavioral counseling to promote stopping
smoking among adolescents often includes an emphasis on understanding the
social influences of smoking, providing coping skills training, and
identifying other, healthier sources of reward
(Sussman, Lichtman, Ritt, & Pallonen,
1999), this mode of intervention seems particularly relevant for
those with asthma in light of the psychosocial risk factors identified
herein.
The results of this study confirm that adolescents with asthma are at least as likely to be ever smokers as are adolescents without asthma, and are more likely to be current smokers. Adolescents with asthma are more likely to attempt to stop smoking, and these tobacco outcomes are mediated by psychosocial risk factors. Hence, additional research on the role of illness in tobacco control is necessary, including ways to incorporate tobacco use prevention and intervention into the care of adolescents with asthma.
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Acknowledgments |
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This research uses data from Add Health, a program project designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris and funded by a 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. Persons interested in obtaining data files from Add Health should contact Add Health, Carolina Population Center, 123 W. Franklin Street, Chapel Hill, NC 27516-2524 (www.cpc.unc.edu/addhealth/contract.html). Manuscript preparation was supported by grant CA91831 (to K. P. T.).
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Notes |
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1 In Wave I of the Add Health study, the overall prevalence of smoking on 5 or more days within the past 30 days was approximately 45%. In 1995, the prevalence of current smoking (defined as smoking
1 cigarette within the
past 30 days) was approximately 35% overall; in 2001, the prevalence of
current smoking was approximately 29% overall
(www.cdc.gov/nccdphp/dash/yrbs/about_yrbss.htm).
Thus, the current smoking prevalence estimate was actually lower than norms
circa 1995, but this is likely due to the more stringent definition of current
smoking applied to this dataset. 
Received October 18, 2002; revision received December 30, 2002; revision received February 21, 2002; accepted February 26, 2003
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