CHAPTER 6
ALCOHOL, TOBACCO, AND YOUTH

SURVEYS OF STUDENT DRUG, ALCOHOL, AND
TOBACCO USE

Three surveys provide comprehensive coverage of the use of drugs, alcohol, and tobacco by American youth, as well as their attitudes about using these substances. The surveys presented in this chapter include:

• Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings 2003 and Monitoring the Future National Survey Results on Adolescent Drug Use 1975-2003, Vol. 1: Secondary School Students 2003. Prepared by the Institute for Social Research of the University of Michigan for the National Institute on Drug Abuse (NIDA), the annual Monitoring the Future survey tracks the use of drugs, including alcohol and tobacco, among students in the eighth, tenth, and twelfth grades. It is considered an authoritative source on drug use among students. In all, approximately fifty thousand students in about 420 public and private secondary schools complete the self-administered questionnaire each year.
• PRIDE Questionnaire Report: 2003-2004 National Summary, Grades 6 through 12. In addition to asking about substance use, the annual PRIDE (Parents' Resource Institute for Drug Education) survey also questions students about when and where they use the substances, how hard the drugs are to obtain, and what other risk behaviors are present, such as violence, poor grades, and weapon carrying.
• Youth Risk Behavior Surveillance—United States 2003. In addition to asking about the use of alcohol, tobacco, and illicit drugs, the biennial Youth Risk Behavior Surveillance, published by the Centers for Disease Control and Prevention (CDC), reports on other types of risk behavior, such as violence at school, weapon carrying, and sexual conduct.

These three surveys collect self-reported data—that is, behavior reported by the students themselves. Therefore, the data should be used as indicators primarily to identify perceived prevalence trends and patterns of use.

ALCOHOL USE

Current Users

In 2003 approximately 75% of high school students had consumed at least one alcoholic drink in their lifetime, according to the CDC's Youth Risk Behavior Surveillance Report—United States 2003. (See Table 6.1.) Nearly 45% had consumed alcohol at least once in the thirty days prior to the survey. Slightly more than 28% were current episodic heavy drinkers (having five or more drinks on at least one occasion over the previous thirty days, also known as binge drinking).

In 2003 high school males and females were about as likely to be using alcohol at the time of the survey. For example, among students in eleventh grade, 47.3% of males were current alcohol users compared with 46.8% of females, and in twelfth grade, 56.0% of males were current alcohol users compared with 55.5% for females. In previous years, young men were much more likely than young women to use alcohol; that difference was small in grades eleven and twelve in 2003. In fact, in grades nine and ten, the data show a larger percentage of females engaged in current alcohol use than males. Regarding episodic heavy drinking, high school males were more likely to binge drink than high school females except in grade nine, when 20.9% of girls were binge drinkers while 18.8% of males were. (See Table 6.1.)

Table 6.1 also shows that in 2003 Hispanics were more likely than whites or African-Americans to have consumed alcohol in their lifetime (79.5% as opposed to 75.4% and 71.4%, respectively), but whites were more likely to have engaged in episodic heavy drinking (31.8% versus 15.3% of African-Americans and 28.9% of Hispanics).

DOWNWARD TRENDS.

The Monitoring the Future survey offers a look at teenage alcohol consumption

over a long period of time, although it polls different grade levels than the Youth Surveillance Report. Overall, both annual and current (within the past thirty days) alcohol consumption decreased among eighth, tenth, and twelfth graders during 2001-2003 over previous years. (See Table 6.2.) Approximately one-fifth (19.7%) of eighth graders reported having consumed a drink in the past thirty days (down from 22.4% in 2000 and 25.1% in 1991), while 35.4% of tenth graders reported having done so (down from 41.0% in 2000 and 42.8% in 1991), and 47.5% of twelfth graders reported having done so (down from 50% in 2000 and 54% in 1991). During the year prior to the survey, a majority of tenth and twelfth graders reported having a drink (59.3% and 70.1%, respectively), but these numbers decreased since 1991 as well. In 1991 more than 70% of tenth graders had a drink and close to 80% of twelfth graders had done so.

Heavy Drinking

According to Monitoring the Future, 6.7% of eighth graders, 18.2% of tenth graders, and 30.9% of twelfth graders reported being drunk during the previous month in 2003. These figures are down from 1991 levels, although there were spikes in the rates, particularly for tenth graders from 1992-97. The highest rate for eighth graders occurred in 1996, when 9.6% reported having been drunk in the last 30 days. The highest rate for tenth graders came in 2000, when the rate hit 23.5%, although it fell to 18.3% two years later. The highest rate for high school seniors hit 34.2% in 1997. (See Table 6.2.)

Figure 6.1 shows the percentage of each grade that reported binge drinking (having five or more drinks) during the two weeks prior to the survey. After increases during the 1990s, binge drinking rates generally declined between 2000 and 2003.

CIGARETTES

The results of the 2003 Youth Risk Behavior Surveillance offered insight into current tobacco use by high school students. The report showed that 27.5% of high school students were current tobacco users in 2003. (See Table 5.2 in Chapter 5.) Prevalence of current use was lowest in ninth grade, and it increased through grades ten, eleven, and twelve. Males were more likely to be current tobacco users than females. They were also much more likely to smoke cigars or use smokeless tobacco. As has been shown in other studies, a greater percentage of white high school students were current tobacco users than African-American or Hispanic students. African-American students had the lowest prevalence rate.

Downward Trends

In the Monitoring the Future 2003 survey (see Table 6.2) the prevalence of cigarette smoking rose for eighth, tenth, and twelfth graders from 1991 to 1996, and declined from 1997 to 2003. For eighth graders, thirty-day prevalence rates (the proportion of those who used cigarettes in the thirty days prior to the survey) grew from 14.3% in 1991 to 21% in 1996 and then dropped to 10.2% in 2003. For tenth graders, the increase was from 20.8% to 30.4% during 1991-1996, falling to 16.7% in 2003. For twelfth graders, the rate rose from 28.3% in 1991 to a high of 36.5% in 1997, declining to 24.4% in 2003.

Figure 6.2 shows CDC data on the percentage of high school students who had ever smoked during their lifetime, who were current smokers (smoked at least once over the previous thirty days), or were current frequent smokers (smoked on twenty or more of the previous thirty days) from 1991 to 2003. The CDC data show the same trend as the MTF survey: there was an increase among current and frequent smokers in the early 1990s, but rates dropped between 1999 and 2003. The rate for lifetime smokers fell from 70.4% to 58.4%; the rate for current smokers fell from 34.8% to 21.9%; and that for current frequent smokers fell from 16.8% to 9.7%.

GENDER, RACIAL, AND ETHNIC DIFFERENCES

Results from the Monitoring the Future 2003 survey offer other insights into teenage use of alcohol and tobacco. In general, the older the students, the more likely they are to consume alcohol and tobacco. Just under half (47.5%) of high school seniors had consumed alcohol in the previous month, while 35.4% of tenth graders and 19.7% of eighth graders had done so in 2003. (See Table 6.3.) About one-quarter (24.4%) of seniors used cigarettes, while 16.7% of tenth graders and 10.2% of eighth graders did so. These rates were all down from 1999 levels.

In general, males in the tenth and twelfth grades were more likely to use alcohol and tobacco than females, while females in the eighth grade were more likely to use these products than males. Smokeless tobacco (chewing tobacco) appears overwhelmingly to be a product for young men: 12.5% of male seniors were current users, while just 1% of their female counterparts were. This is not the case with cigarettes. Tenth grade girls had slightly higher prevalence rates than tenth grade boys (17% for girls compared with 16.2% for boys), and eighth grade girls had higher prevalence rates than eighth grade boys (10.6% for girls compared with 9.6% for boys). Likewise, eighth grade girls were slightly more likely to have used alcohol than eighth grade boys (19.8% for girls and 19.4% for boys), though this appeared to change with age: the same percentage of tenth grade males and females used alcohol, while senior girls were nearly 8% less likely than senior boys to have used alcohol in the past thirty days.

Smoking and drinking rates were lower in the Western regions of the United States and higher in the Northeast, North Central, and Southern regions. (See Table 6.3.) Smoking and drinking rates were also higher in more rural regions called non-MSAs (metropolitan statistical area, an area with at least one county of a population of ten thousand or more people).

Table 6.3 also shows that the educational back-ground of parents plays some role in a young person's decisions about alcohol and tobacco. In general, alcohol and tobacco use decreased among students as parental education increased. Of eighth graders whose parents had graduated from or completed most of high school, 14.8% had used cigarettes in the previous month. For those whose parents had college or advanced degrees, the prevalence rates dropped dramatically: 6.7% and 6%, respectively. For high school seniors, curiously, the alcohol rate seemed to climb with parents' higher education. High school seniors with highly educated parents reported a higher prevalence rate (49.3%) than those whose parents had the least education (43.6%). They were also more likely to have been drunk in the previous month (33.4% for those whose parents had achieved a high level of education compared with 25.6% for those with only a grade school education).

In 2002-2003 white students in the twelfth grade had the highest prevalence rates for alcohol and tobacco in every category. (See Table 6.4.) Among eighth graders, however, Hispanics reported the highest prevalence rates in most categories. African-American students typically reported the lowest rates of alcohol and tobacco use.

ATTITUDES ABOUT USING ALCOHOL
AND TOBACCO

Why They Start Using

There are a number of reasons why teenagers start using alcohol and tobacco. It may be to appear cool or rebellious, or they may succumb to peer pressure. Young women may be particularly susceptible to these pressures, according to some researchers. Author and lecturer Shannon McLinden points out that girls go through a tremendous emotional and hormonal change around the time they enter seventh grade. "The change comes at a time when being your own person and trying to stand on your own feet is really important" (Laura Alys Ward, "Study: Peer Pressure Worse for Teen Girls," Daily Star Online, January 27, 2001, http://www.thedailystar.com/news/stories/2001/01/27/peer.html).

The study cited in the article was conducted by Bruce Simons-Morton and his colleagues for the National Institutes of Health. The researchers surveyed thousands of sixth- to eighth-grade students to determine the effect of peer and parent influences on adolescent substance use. They found that peer pressure was strongly associated with drinking for girls but not for boys, and that adolescents whose parents were involved in their children's lives were far less likely to smoke or drink (Health Education and Behavior, vol. 28., no. 1, February 2001). Findings from a 2003 nationwide survey of thirteen- to seventeen-year-olds by the Roper Youth Report support these data. Sixty-nine percent of respondents cited parents as the most influential factor in their decision to smoke and drink or not.

The second-most important factor influencing a young person's decision to smoke or drink, according to the Roper Youth Report, was best friends. The attitudes of one's peer group can hold tremendous sway over a young person's alcohol and tobacco choices. Findings from the Simons-Morton research agree with this conclusion, reporting that teens with friends who smoked and drank were nine times more likely to participate in these behaviors than those with friends who did not smoke and drink.

When They Start Using

First use of alcohol and tobacco happens rather early. According to the 2002 Final Report of the Office of National Drug Control Policy, the average age of the first use of cigarettes was 15.4 years in 1998. The average age of first use of alcohol was 16.3 years.

The average age of a first-time user of alcohol has dropped in recent years. In the 1980s the average age at first consumption of alcohol fluctuated between 16.6 and 17.1 years. In 1992 it stood at 16.9, from which it has decreased almost steadily, according to the National Household Survey on Drug Abuse. More recent data suggests it is not uncommon for initiation to happen much earlier. According to the Youth Risk Behavior Surveillance Report, 29.1% of students had first consumed alcohol (more than a few sips) before age thirteen.

DO THEY SEE THE DANGERS?

Tobacco

According to the 2003 Monitoring the Future survey, the percentage of eighth, tenth, and twelfth graders who perceived smoking a pack or more of cigarettes a day as harmful had increased substantially since 1991. (See Table 6.5 and Table 6.6.) The perceived risk of smoking grew most between 1999 and 2000. This increase came on the heels of the $206 billion settlement between the states' attorneys general and the tobacco industry. The Truth campaign was also launched about this time. This campaign featured provocative statistics and information about the dangers of smoking and the history of the tobacco industry. In fact, teenagers helped create these ads, which perhaps speaks to their effectiveness among adolescents.

Substantial proportions of students at all three grade levels thought that regular use of smokeless tobacco was harmful as well, although at levels noticeably lower than those for cigarette smoking. For example, 72.1% of seniors thought that smoking one or more packs of cigarettes per day was harmful, while only 43.3% thought the regular use of smokeless tobacco was harmful. (See Table 6.6.)

The PRIDE Survey questions students in grades six through twelve about their attitudes regarding and experiences with tobacco, drugs, and alcohol. The data from the 2003-2004 PRIDE National Summary show that only 4.2% of students in grades six through twelve believed that smoking cigarettes causes no harm to health. Slightly more than 51% thought that using cigarettes is very harmful to health. Fewer students believed that smoking cigars is harmful. (See Table 6.7.)

Alcohol

Results from the 2003 Monitoring the Future survey revealed that most students do not perceive taking one or two regular drinks of alcohol as risky behavior; this has been the case for some time. Students were also less likely to think that having five or more drinks once or twice each weekend (a quantity described as binge drinking) was harmful than they had in earlier years of the survey. (See Table 6.5, Table 6.6, and Figure 6.3.) Of eighth graders, 56.5% thought that having five or more drinks on the weekend was unhealthful, down from 59.1% in 1991. Of tenth graders, 51.6% saw five drinks or more on the week-end as harmful in 2003, down from a high point of 55.9% in 1992. In 2003, 43.5% of high school seniors perceived having five or more drinks once or twice on the weekend as risky, the lowest level in the twelve years shown. The highest level for twelfth graders perceiving health risk in binge drinking was 49.5% in 1996.

It is useful to reframe the findings of this survey. According to the data shown in Table 6.5 and Table 6.6, in 2003, 43.5% of eighth graders did not see five or more drinks on one occasion (binge drinking) as risky behavior. Of tenth graders, 48.4% did not see this as risky behavior. In addition, the majority of twelfth graders (56.5%) did not see this as risky behavior.

Results of the 2003-2004 PRIDE survey (see Table 6.7) show that fewer students in grades six through twelve think that using liquor is harmful to health compared with cigarettes. On average, 8% of students think that using liquor poses no harm to health, while only 38.8% view using liquor as very harmful. Even fewer students believe that it is harmful to use beer—only 30.9% of students overall in grades six through twelve thought that using beer was very harmful to health.

Changing Attitudes

Table 6.8 and Table 6.9 show rates of student disapproval of others who use alcohol and tobacco, and illustrate how the attitudes of eighth, tenth, and twelfth graders have changed over time. In 2003, 84.6% of eighth graders disapproved or strongly disapproved of smoking at least one pack of cigarettes a day, while 81.4% of tenth graders and 74.8% of twelfth graders shared this view.

In the most recent years of the survey, more students in all three grades expressed tolerance for the regular consumption of alcohol than they did in the early 1990s. In 2003, 77.1% of eighth graders, 74.2% of tenth graders, and 68.9% of twelfth graders disapproved of taking one or two drinks nearly every day. Disapproval rates for binge drinking were higher than for regular drinking for eighth graders, but lower among tenth and twelfth graders. (See Table 6.8 and Table 6.9.)

DRINKING AND DRIVING

In 2003 a total of 7,884 drivers aged fifteen to twenty were involved in fatal crashes, a 5% increase from the 7,484 involved in 1993. Thirty-one of the drivers fifteen to twenty years of age who were killed in crashes were intoxicated, according to Traffic Safety Facts 2003—Young Drivers (Washington, DC: National Highway Traffic Safety Administration). For young male drivers, fatalities dropped 5% between 1993 and 2003, compared with an 8% increase for females.

When alcohol is involved, the severity of a traffic accident generally increases. According to Traffic Safety Facts 2003—Young Drivers, of those who survived the 7,484 crashes in 1993, 4% had blood alcohol concentration

(BAC) levels between 0.01 and 0.09 grams per deciliter (g/dl), and 13% had BAC levels of 0.08 g/dl or higher. For those fatally injured, 6% had BAC levels between 0.01 and 0.07 g/dl, and 25% had levels of 0.08 g/dl or higher.

The National Highway Traffic Safety Administration (NHTSA) defines a traffic accident as alcoholrelated if either the driver or an involved pedestrian has a BAC of 0.01 g/dl of blood or greater. All states plus Puerto Rico and the District of Columbia have lowered the legal BAC limit for driving to 0.08. The NHTSA estimates that between 1975 and 2002 the minimum drinking age laws have reduced traffic fatalities involving drivers aged eighteen to twenty by 13%, saving approximately 21,887 lives since 1975. (See Figure 6.4.)

All states and the District of Columbia have "zero-tolerance" laws for drinking drivers under age twenty-one. It is illegal for drivers under twenty-one to drive with BAC levels of 0.02 g/dl or greater. The National Conference of State Legislatures reported that early evidence on the results of the law is encouraging. In the first four states to adopt the zero-tolerance standard, nighttime alcohol-related fatal crashes involving drivers under age twenty-one dropped 34%.

TOBACCO AND HEALTH

Health Consequences of Early Tobacco Use

The likelihood of future health problems due to the use of tobacco, especially cigarettes, is a matter of great concern. According to the CDC of the U.S. Department of Health and Human Services (HHS), and the 2004 Surgeon General's Report: The Health Consequences of Smoking, the use of smokeless tobacco and smoking are both closely associated with health problems such as heart disease, lung disease, and cancer.

John K. Wiencke et al., in "Early Age at Smoking Initiation and Tobacco Carcinogen DNA Damage in the Lung" (Journal of the National Cancer Institute, April 1999), indicate that the age at which smoking is initiated is a significant factor in the risk of developing lung cancer. Smoking in the teen years appears to cause permanent genetic changes in the lungs, increasing the risk of lung cancer—even if the smoker quits. The younger a person starts smoking, the more lasting damage is done to his or her lungs. Such damage is less likely among smokers who start in their twenties.

An earlier study, "Preventing Tobacco Use among Young People: A Report of the Surgeon General—Executive Summary" (Morbidity and Mortality Weekly Report, March 1994), indicated that cigarette smoking during adolescence seems to retard lung growth and reduce maximum lung function. As a result, young smokers are less likely than their nonsmoking peers to be physically fit and more likely to experience shortness of breath, coughing spells, wheezing, and overall poorer health. These health problems pose a clear risk for developing other chronic conditions in adulthood, such as chronic obstructive pulmonary disease, including emphysema and chronic bronchitis. Early smoking has also been linked to an increased risk of cardiovascular diseases, such as high cholesterol and triglyceride levels, atherosclerosis (arterial plaque), and early onset of heart disease. Teenagers who smoke are also three times more likely than nonsmokers to use alcohol, eight times more likely to use marijuana, and twenty-two times more likely to use cocaine.

Smokeless tobacco also has undesirable health effects on young users. Adolescent use is linked to the development of periodontal disease, soft-tissue damage, and oral cancers. In addition, young people who use smokeless tobacco are more likely than their nonusing peers to become cigarette smokers.

PROJECTED SMOKING-RELATED DEATHS.

According to 2004 Surgeon General's Report: The Health Consequences of Smoking, cigarette smoking is the leading cause of preventable death in the United States and produces substantial health-related economic costs to society. The report noted that smoking caused an estimated 440,200 deaths in the United States each year from 1995-1999.

The percentage of high school students who claimed to be regular smokers declined from 36.4% in 1997 to 28.5% in 2001. The CDC estimates that more than five thousand people under eighteen try smoking for the first time each day; roughly half of them are thought to become daily smokers. Kids are believed to smoke nine hundred million packs of cigarettes each year. If current rates continue, an estimated 6.4 million people under eighteen will die prematurely from smoking-related diseases (Tobacco Control State Highlights 2002: Impact and Opportunity, Atlanta, GA: CDC).

AVAILABILITY OF ALCOHOL AND TOBACCO
TO MINORS

The sale of alcohol to persons under the age of twenty-one and tobacco to persons under the age of eighteen is illegal. However, results of surveys cited in this chapter show that an overwhelming majority of young people reported that both were readily available to them.

According to the 2003-2004 PRIDE survey, 34.2% of junior high students and 68.9% of high school students found it fairly easy or very easy to get cigarettes. (See Table 6.10.) Cigars were not as easy for students to obtain, with 21.3% of junior high students and 55.8% of high school students finding it fairly easy to very easy to get them.

Among alcoholic beverages, beer was most available, with 34.5% of junior high students and 66.8% of high school students saying that it was fairly or very easy to obtain. One out of four (25.5%) junior high students found liquor fairly or very easy to get, as did a considerable proportion of high school students (63.4%). These levels are lower than in previous years of the survey, however, suggesting that minors are having more difficulty obtaining alcohol in more recent years.

Results from the 2003 Youth Risk Behavior Surveillance revealed that 18.9% of high school-age smokers were able to purchase cigarettes at a store or gas station, suggesting that they were not asked to show proof of age. (See Table 6.11.) Females were less likely to have purchased cigarettes at a store or gas station (13.8% versus 24.2% of males).

According to various CDC studies, illegal cigarette vending machine sales to minors ranged from 82 to 100% in 1989 and 1992. Before legislation was passed in 1992 and 1996 to curb tobacco sales to minors, vending machines were a major source of sales to minors. The CDC reports that more than two-thirds of states restrict cigarette vending machines, but many

of these restrictions are weak. Only Vermont and Idaho have total bans on vending machines. However, many jurisdictions have restricted vending machine locations to bars and clubs where minors are not permitted to enter.

ALCOHOL AND TOBACCO USE AMONG
COLLEGE STUDENTS AND OTHER
YOUNG ADULTS

The 2003 Monitoring the Future survey questioned college students and other young adults (ages nineteen to twenty-eight) not in college about various risk behaviors. From 1991 to 2003 a higher percentage of college students and young adults consistently reported binge drinking (five or more drinks in a row in the last two weeks) than did younger survey participants. In 2003 college students reported somewhat higher binge drinking prevalence rates than did young adults (38.5% versus 35.8%). (See Table 6.12.)

How is binge drinking being addressed among college students? One of the most popular programs

in recent years has been a policy known as social norms marketing. The program uses T-shirts, posters, and other methods to encourage moderate drinking. Such a policy came about after surveys of college students showed they thought their peers drank more than they actually did. The policy, which is used by nearly half of the nation's four-year colleges, differs from many other alcohol-education programs because it encourages moderate drinking, as opposed to discouraging or prohibiting drinking altogether.

A study by the Harvard University School of Public Health (Henry Wechsler et al., "Perception and Reality: A National Evaluation of Social Norms Marketing Interventions to Reduce College Students' Heavy Alcohol Use," Journal of Studies on Alcohol, vol. 64, no. 4, July 2003) found social norms drinking programs to be ineffective. Research results revealed that by seven measures drinking had not declined on campuses that used the advertisements. By two measures—percentage of students who had a drink in the previous month and those who had twenty drinks over the previous month—drinking had actually increased. Henry Wechsler, director of the study, commented, "If social norms were a drug, the FDA would not allow it on the market. There's no proof that it's doing any good" (Diana Jean Schemo, "Study of Campuses Faults Some Anti-Drinking Drives," New York Times, July 24, 2003).

Regarding tobacco use, Table 6.12 shows a decline in rates of use among college students and young adults in the most recent years of the survey (1999-2003). Only 13.8% of college students reported any cigarette use in 2003, down from 19.3% in 1999, and equaling the low reported in 1991. The level of cigarette use among young adults was rather consistent for the period from 1991-2003. It is interesting to note that young adults were much more likely to smoke half a pack of cigarettes daily than their college student counterparts over the past decade.

According to the CDC, in the late 1990s there was a noticeable increase in people who smoked only occasionally. These individuals have been described as "part-time" or "social" smokers. These smokers do not see the harm in having the occasional cigarette—after a meal or with their morning coffee, for example. Dr. Marc Manley, executive director for the Center for Tobacco Reduction and Health Improvement at Blue Cross/Blue Shield of Minnesota, warns of the dangers of such thinking: "Everyone who becomes addicted does so because it sneaks up on them. There are a lot of people who don't consider themselves smokers because they only smoke on weekends. But many of them will wake up some day and realize they want a cigarette. People are playing with fire when they take on risks with nicotine" (Tom Majeski, "Young Smokers Playing with Fire," Knight Ridder/Tribune News Service, July 25, 2003).