The Changing Risk Profile of the American Adolescent Smoker: Implications for Prevention Programs and Tobacco Interventions

Article Outline

• Abstract
• Methods
  • Study design
  • Measures
  • Data analysis
• Results
• Discussion
• Acknowledgment
• References
• Copyright

Abstract 

Purpose

To determine how the association between cigarette smoking and other risky behaviors, such as substance use, violence, and risky sexual practices, has changed between 1991 and 2003.

Methods

Youth Risk Behavior Surveys (YRBS) from 1991 to 2003 were analyzed. For each cohort, logistic regression models controlling for gender, race/ethnicity, and school grade were used to describe the associations between smoking and other risky behaviors. Changes in the odds ratios over time were confirmed with a trend analysis.

Results

The strength of the relationship between smoking and other risky behaviors increased for lifetime number of sexual partners (1991 odds ratio [OR] 1.49; 2003 OR 1.61 (p < .001)), sexual partners in the past 3 months (1991 OR 1.77; 2001 OR 2.05 (p < .001)), and never wearing a bicycle helmet 1991 OR 1.40; 1997 OR 5.94 (p < .001). Increases were also seen for binge drinking, and physical fighting. The association between cigarette smoking and marijuana use decreased slightly.

Conclusions

Future prevention efforts and tobacco intervention programs should recognize that current adolescent smokers are even more likely to engage in risky sexual behavior, risky alcohol-related behaviors, and to not use a seatbelt or bicycle helmet than were adolescents in the early nineties.

Keywords:  Tobacco , Prevention , Risky behaviors , Survey research

Recent data show that more than 20% of American adolescents smoke and more than 2000 adolescents become established smokers each day [1]. In the United States, the prevalence of adolescent smoking among high school students increased from 27.5% in 1991 to 36.4% in 1997, and then decreased to 21.9% in 2003 [2], [3]. Although there are many reasons why these temporal changes have occurred, recent developments have contributed to this decline in adolescent smoking rates. Governmental tobacco access policies have been found to decrease youth smoking rates in local, state, and national settings [4], [5], [6]. Also, certain national anti-tobacco marketing campaigns have been shown to foster anti-tobacco attitudes in adolescents [7].

When examining temporal changes in cigarette smoking, it is also important to explore changes in co-occurring behaviors. Numerous studies have shown that adolescent smoking tends to co-occur with other risky behaviors [8], [9], [10], [11], [12], [13]. Current adolescent smokers are significantly more likely than nonsmokers to report lifetime use of other substances (alcohol, marijuana, etc.) [9], engage in physical fighting, attempt suicide, and engage in risky sexual behavior [13], [14]. Evidence also suggests that there is a dose-response relationship between the number of cigarettes smoked and the odds of using other substances [9].

Several theories have been used to explain the co-occurrence of risky behaviors among adolescents. Jessor’s “problem-behavior theory” suggests that a single common factor contributes to the coexistence of multiple risky behaviors, including sexual intercourse, alcohol use, and delinquency [15], [16]. Adolescence provides socially organized opportunities to adopt multiple risky behaviors concurrently and certain combinations of risky behaviors serve the same social function for youth [17]. The “sensation-seeking theory,” which is characterized by seeking novel or intense experiences, has also been used to describe adolescents who engage in multiple risky behaviors, especially drug use [18]. Other theories also explain the concurrent use of cigarettes and other substances. The “gateway” behavior theories explain multiple substance use by describing a progression wherein individuals start using alcohol and/or tobacco, proceed to marijuana use, and eventually to illicit drug use [19]. Some researchers disagree with this finding, believing that there is no fixed pattern of drug progression, and the use of licit drugs, such as alcohol and cigarettes, does not necessarily precede the initiation of illicit drug use [20], [21], [22].

Although many studies have explored the association between smoking and other risky behaviors, no study has examined whether the association between cigarette smoking and other risky behaviors, such as substance use, violence, and risky sexual practices, has changed over time. The changing prevalence of smoking in the last decade, and the continually increasing efforts to prevent adolescent smoking are well described, but no information has described the trends in the risk profile of youth smokers during this same time period. Furthermore, no studies have investigated changing trends in the prevalence of risky behaviors among smokers and nonsmokers. Understanding these findings has important implications for improving prevention and intervention practices as well as evaluating how tobacco control policies may have affected the practices of the average adolescent smoker. The purpose of this study is to examine how the relationship between adolescent smoking and other risky behaviors has changed between 1991 and 2003.

Back to Article Outline

Methods 

Study design 

We analyzed YRBS [Youth Risk Behavior Survey] data from 1991, 1993, 1995, 1997, 1999, 2001, and 2003. The YRBS is conducted by the Centers for Disease Control and Prevention to assess the prevalence of health risk behaviors among youth. The survey is conducted every two years and uses a three-stage cluster sample design to obtain a nationally representative sample of 9th–12th grade students. Schools with large numbers of black and Hispanic students are over-sampled. The YRBS has been shown to have adequate test-retest reliability [23], [24]. The survey is self administered, anonymous and voluntary. During 1991–2003, sample sizes ranged from 10,904 to 16,296, student response rates ranged from 83–90%, school response rates ranged from 70–81%, and overall response rates ranged from 60–70% [2], [3].

Measures 

We examined the association between smoking and four risk domains: 1) alcohol and other drug use; 2) sexual behaviors that contribute to unintended pregnancy, human immunodeficiency virus (HIV) infection, and other sexually transmitted diseases; 3) suicide attempts; and 4) behaviors that contribute to unintentional injuries and violence. Tobacco use was assessed with the question, “During the past 30 days, on how many days did you smoke cigarettes?” A current smoker was defined as a high school student who smoked cigarettes at least one day in the past 30 days. This is the definition of current smoking traditionally employed when interpreting the YRBS [2]. Current alcohol, marijuana and cocaine use were assessed similarly. Lifetime marijuana and cocaine use was assessed by asking “During your life, how many times have you used (substance)?” and binge drinking was assessed with the question “During the past 30 days, on how many days did you have five or more drinks of alcohol in a row, that is, within a couple of hours?”

Sexual behaviors were explored by asking about the number of lifetime sexual partners, the number of sexual partners in the past three months, and condom use during the last intercourse. To assess the number of sexual partners, the question “During your life/the past three months, with how many people have you had sexual intercourse?” was asked. Condom use was assessed with the question “The last time you had sexual intercourse, did you or your partner use a condom?” Respondents could answer: I have never had sexual intercourse, Yes or No. Suicide attempts were assessed with “During the past 12 months, how many times did you actually attempt suicide?” Unintentional injuries and violence were assessed by exploring seat belt and bicycle helmet use, riding with a drunk driver, driving while drunk, engaging in a physical fight, and being injured in a physical fight. Seat belt use was assessed with the question “How often do you wear a seat belt when riding in a car driven by someone else?” Respondents could indicate: Never; Rarely; Sometimes; Most of the time; or Always. Bicycle helmet use was similarly assessed for the period of the past 12 months. Drunk driving was assessed with “During the past 30 days, how many times did you ride in a car or other vehicle driven by someone who had been drinking alcohol?” and “During the past 30 days, how many times did you drive a car or other vehicle when you had been drinking alcohol?” Physical fighting and injury was assessed with the question “During the past 12 months, how many times were you in a physical fight (in which you were injured and had to be treated by a doctor or nurse)?”

Data analysis 

Data about tobacco use and other risky behaviors were analyzed from seven Youth Risk Behavior Surveys from 1991–2003. Data were weighted to give national estimates. SUDAAN 9 (RTI International, Research Triangle Park, North Carolina) was used to compute all data analyses. Data concerning not using a bicycle helmet were evaluated for subjects who had ridden a bicycle in the past year. Condom use was analyzed only for individuals who had reported having sexual intercourse.

The prevalence of current smoking was assessed for each cohort, as was the prevalence of each risky behavior among smokers and nonsmokers. Chi-square analysis was used to determine statistically significant differences in the prevalence of risky behaviors among smokers and nonsmokers. A cohort analysis was undertaken to evaluate the relationship between smoking and each risky behavior for each survey cohort, and a trend analysis was undertaken to examine the trends in the relationship between smoking and other risky behaviors. In the cohort analysis, logistic regression models that controlled for gender, race/ethnicity, and school grade were used to identify the odds ratio (OR) of each risky behavior among current smokers compared with nonsmokers for each survey year. These odds ratios are unadjusted between the different survey years.

In the trend analysis, we combined the national datasets and recoded the data for each survey year so that each was uniquely identifiable. This created an additional variable of time, which was used in a logistic regression analysis, controlled for sociodemographic factors, to determine significant trends by year. We interacted each risky behavior with the year and used the year as an indicator variable to determine significant trends. To test whether these trends were significant, we assessed whether the “Year × Risky Behavior” interaction variable for each survey cohort varied significantly from the 1991 reference year. These odds ratios are adjusted for multiple comparisons between the survey cohorts. We also compared the interaction of variable odds ratios between each survey cohort. All of the regression models used current smoking as a dependent, dichotomous variable and each risky behavior as an independent variable. The independent variables were not dichotomized in the cohort or trend analysis.

Back to Article Outline

Results 

The percentage of respondents engaging in other risky behaviors was higher for those who smoked than for nonsmokers across all cohorts (p < .05) (Table 1, Table 2, Table 3). For example, in each of the survey cohorts, only > 30% of nonsmokers had one or more drink in the past month and > 80% of the smokers did. Between 5.0% and 11.7% of adolescent nonsmokers used marijuana at least once in the past month, whereas 39.3–59.4% of smokers did (Table 1). Similarly, 33.7–45.1% of nonsmokers reported having at least one sex partner in their life, and > 67% of smokers did (Table 2). A smaller gap existed between smokers’ and nonsmokers’ bicycle helmet use, although a significantly higher percentage of smokers did not wear a helmet (p < .05) (Table 3).

Table 1. Trends in alcohol/other drug use among smokers and nonsmokers

Table 2. Trends in risky sexual behaviors/suicide among smokers and nonsmokers

Risky behavior	Year	Prevalence data				Trend analysis
		Nonsmokers (%)	Smokersa (%)	All (%)	pb	Adjusted OR	p
≥1 sex partner ever	1991	45.1	76.4	53.6		1.00
	1993	43.0	74.5	52.6		0.99	.60
	1995	42.2	72.1	52.7		1.01	.73
	1997	36.1	67.9	47.7		1.02	.50
	1999	37.9	71.9	49.7		1.03	.28
	2001	33.7	73.2	45.1		1.10	.001
	2003	36.7	76.8	45.8		1.10	.001
	Total	39.1	72.7	49.5
≥1 sex partner in	1991	29.8	56.7	37.1		1.00
past 3 months	1993	29.2	55.1	37.1		.99	.83
	1995	28.9	53.6	37.6		1.02	.74
	1997	24.6	51.8	34.5		1.12	.08
	1999	26.2	54.7	36.1		1.03	.64
	2001	23.5	56.6	33.0		1.20	.001
	2003	26.0	59.3	33.6		1.13	.04
	Total	26.8	55.0	35.5
Did not use condom during last sex†	1991	48.1	57.4	51.7		1.00
	1993	41.2	46.3	43.4	.02	1.25	.10
	1995	39.5	47.0	43.1	.01	1.20	.22
	1997	36.0	43.4	39.9	.01	1.18	.28
	1999	35.5	44.4	39.9		1.17	.28
	2001	36.7	42.1	39.2	.01	1.26	.06
	2003	31.4	39.1	34.4		1.13	.31
	Total	41.8	38.6	45.5
≥1 suicide attempt	1991	4.6	14.0	7.1		1.00
	1993	5.3	15.6	8.4		.98	.82
	1995	5.5	13.9	8.4		.91	.25
	1997	4.4	13.0	7.5		.98	.85
	1999	4.8	14.1	8.0		.99	.95
	2001	5.5	15.8	8.5		.94	.40
	2003	5.5	16.8	8.0		.97	.72
	Total	5.1	14.6	8.0

Table 3. Trends in behaviors that contribute to unintentional injury/violence

Using bivariate analysis, smoking was significantly associated with each of the other risky behaviors in each of the seven cohorts. Figure 1, Figure 2, Figure 3 examine these associations using the odds ratios resulting from multivariate logistic regression analyses from the cohort analysis. Figure 1 demonstrates that the relationship between current cigarette use and lifetime marijuana use was significant at 1.03–1.04 for all cohorts. The ORs between smoking and current marijuana use and cocaine use generally remained between 1.10 and 1.25 for all cohorts as well (≤ .05 for every survey year).

• 
  • View Large Image
  • Download to PowerPoint

• Figure 1. 

  Relationship between smoking and alcohol/other drug use. *p ≤ .001 and **p ≤ .05 for each survey year.

• 
  • View Large Image
  • Download to PowerPoint

• Figure 2. 

  Relationship between smoking and risky sexual behaviors/suicide. *p ≤ .001 and **p ≤ .05 for each survey year.

• 
  • View Large Image
  • Download to PowerPoint

• Figure 3. 

  Relationship between smoking and unintentional injury/violence. *p ≤ .001 and **p ≤ .05 for each survey year. ***p ≤ .05 for 1993–2003.

Figure 2 shows that the relationship between smoking and suicide varied between 1.47 and 1.65 (p ≤ .001 for every survey year). Figure 3 shows that the relationship between current smoking and physical fighting was slightly significant at 1.16–1.31 (p ≤ .001 for every survey year), whereas the relationship with never wearing a seatbelt varied between 3.49 and 6.49 (p ≤ .001 for every survey year).

Table 1, Table 2, Table 3 also present the ORs from the trend analysis, which are adjusted for the different survey years. There was a slight increase in the relationship between current smoking and binge drinking between 1991 and 1997 (1.00–1.11) (p < .05). The prevalence of binge drinking increased among smokers and decreased among nonsmokers during this period. When comparing 1991 and 2003, there was also an increase in the strength of the relationship between current smoking and lifetime number of sexual partners (1.00–1.10) and number of sexual partners in the past three months (1.00–1.20) (p < .001). In each of these cases, the prevalence of risky sexual activity increased among the smokers and decreased among the nonsmokers, accounting for the increasing odds of engaging in these behaviors.

There was no change in the strength of the relationship between smoking and cocaine use, although the prevalence of engaging in this behavior did increase in both nonsmokers and smokers. There was a slight decrease in the relationship with current marijuana use between 1991 and 2003 (1.00–.96) (p < .05), and the prevalence of this behavior increased more in nonsmokers than smokers.

There was an increase in the strength of the relationship between not wearing a bicycle helmet between 1991 and 2003 (1.00–4.02) (p < .05). This indicates that the prevalence of this behavior decreased more in nonsmokers than smokers. Similarly, there was a slight increase in the strength of the relationship between smoking and physical fighting between 1991 and 2003 (1.00–1.10) (p ≤ .001). In contrast, the odds ratios concerning suicide attempts remained stable across the different time cohorts.

Back to Article Outline

Discussion 

Findings show that the risk profile of adolescent smokers changed between 1991 and 2003. The association between smoking and certain risky behaviors became stronger over this period. An increase in the association between smoking and other risky behaviors was found for binge drinking, lifetime number of sexual partners, and sexual partners in the past three months. These findings could be explained by an increasing prevalence of each risky behavior in smokers with the concurrent decreasing prevalence in nonsmokers. There was also an increase in the association between smoking and not wearing a seat belt, not wearing a bicycle helmet, and physical fighting. In these cases, the prevalence of each risky behavior decreased more in nonsmokers than smokers, resulting in an increase in the odds of engaging in the behavior. In general the relationship between smoking and other drug use remained stable or slightly decreased over this time period. Although our findings do not determine the cause of these changing associations, it does help elucidate the fact that today’s adolescent smokers are more likely to engage in certain risky behaviors than were adolescents in the early nineties.

The relationship between smoking and binge drinking increased slightly between 1991 and 1997. Despite fluctuations in the prevalence of adolescent smoking in the general population, the overall prevalence of binge drinking remained unchanged during this time [25]. Although our analyses controlled for the changing prevalence of smoking and each of the other risky behaviors, it is interesting that the relationship between smoking and binge drinking was strongest in 1997, a year when youth smoking was at a record high. After 1997, there were no statistically significant changes in the relationship between smoking and binge drinking. This finding may suggest that the advent of stricter tobacco control efforts in the late nineties also may have affected behaviors that cluster with smoking by curbing the relationship between alcohol and smoking as well as curbing smoking itself.

During 1991–2003, there was an increase in the strength of the relationship between smoking and risky sexual behaviors as well. Previous studies have noted the relationship between tobacco use and multiple sexual partners, but these studies have focused on specific survey cohorts and have not compared cohorts over time [11], [26]. Studies have also shown that a history of sexual intercourse is a risk factor for the initiation of smoking [27], and smoking is a risk factor for sexual initiation as well [28]. The increasing association between smoking and sexual behaviors is particularly interesting because the prevalence of sexual experience has decreased 16%, the prevalence of multiple sexual partners has decreased 24%, and the prevalence of condom use increased between 1991 and 2001 [29]. This has been accompanied by a decrease in pregnancy and sexually transmitted disease (STD; specifically gonorrhea and chlamydia) rates among adolescents [30], [31]. However, despite overall improvements in reproductive health risk, our data suggest that adolescents who smoke are increasingly likely to engage in risky sexual activity. The decreasing prevalence of risky sexual behavior among adolescents and its increasing association with cigarette use may suggest that education and prevention efforts are somehow failing to target adolescents who engage in both of these behaviors, even if they have reached individuals who had only engaged in risky sexual practices.

Some may argue that the increasing association between smoking and certain risky behaviors suggests that smoking may be becoming a more socially deviant behavior among adolescents. Throughout the 1990s, youth have experienced stricter tobacco access laws and indoor smoking bans, as well as the initiation of national smoking counter marketing efforts (the American Legacy Foundation’s “the truth” campaign) [32]. Wasserman et al. argue that smoking restrictions, such as regulating smoking in public places or schools, might convey the message that smoking is socially unacceptable or deviant [33].This sentiment is echoed in our findings wherein we found smoking to be increasingly associated with other behaviors that are considered deviant, such as risky sexual activity and binge drinking.

The co-occurrence of smoking and other risky behaviors is echoed in popular culture as well. For example, a substantial proportion of smokers in movies also engage in other risky behaviors, perhaps as part of portraying an image of “toughness” or “rebelliousness” [34]. These portrayals arguably may influence behavior; if adolescents are attracted to tough and rebellious images they may also link desired character traits with smoking [34]. Perhaps these tough or rebellious images are portrayed via sexual activity, and alcohol use, which may explain why the prevalence of these behaviors is increasing among smoking adolescents.

Our observations suggest that the relationship between tobacco and other drug use is not becoming stronger. This calls into question whether smoking is in fact becoming more deviant, as well as whether it is still as strongly related to other substance use at all. Similar to cigarette use, the prevalence of lifetime and current marijuana use increased until the mid 1990s, after which a decline in use has been noted [35], [36]. The prevalence of cocaine use increased from 1991 to 2001 [25], [35]. In each of the separate survey cohorts, smoking was only slightly associated with marijuana and cocaine use. Furthermore, over time, the relationship between smoking and cocaine/marijuana use has either remained stable or decreased slightly. These observations question the gateway theory wherein the use of a “softer” drug (i.e., cigarettes) may initiate the use of other drugs. Instead, our evidence shows that smoking did not follow the same behavioral trajectory as marijuana and cocaine use over the past decade. Thus, smoking is not becoming more deviant in general, but is becoming increasingly linked to specific behaviors. Future research should focus on why, as tobacco control policies have become more stringent and the prevalence of adolescent smoking is decreasing, the remaining smokers are more likely to engage in certain risky behaviors, but not marijuana or cocaine use.

The continuing relationship between cigarette use and other risky behaviors also has implications for public health efforts. Most prevention programs have historically focused on single issues rather than targeting and identifying co-occurring behaviors [37]. Throughout the 1990s, there was an overall shift toward less risk-taking among youth; however, the percentage of adolescents who had engaged in more than five risky behaviors did not decrease during this time period, suggesting that “single issue” prevention efforts may fail to target those youth who are most at risk [12], [38], [39]. This is similar to the findings in adults, wherein adult heavy smokers, as compared with light smokers, are also more likely to report heavy alcohol use, to be overweight or obese, and to undertake less exercise [40]. Identifying multiple related risky behaviors in the adolescent population, and focusing on multiple-issue prevention programs, may help prevent the continuance of these patterns. Our findings suggest that adolescents may benefit from multi-faceted prevention programs that target smoking as well as other risky behaviors.

This study has several limitations. Because this study relied on self-report data, we cannot assess the validity of responses. Also, the YRBS surveys only adolescents enrolled in school, thus these findings may not generalize to adolescents in general because the risk behavior profile of adolescents not enrolled in school may be different. Also, we did not control for the effect of each of the risky behaviors on each other, such as alcohol use on sexual activity. Lastly, the YRBS does not include measures that would help elucidate causal factors for risky behaviors. Therefore we cannot easily identify why the relationship between these behaviors has changed over time. Future research might focus on how the association between smoking and other risky behaviors has changed among different gender and racial/ethnic cohorts or on populations who engage in both smoking and other risky behaviors, both to further understand the relationships between these behaviors and to better target prevention efforts and smoking intervention strategies.

Clinicians should recognize that current adolescent smokers are even more likely to engage in risky sexual behavior, risky alcohol-related behaviors, and to not wear a bicycle helmet than were adolescents in the early nineties. There is a strong need to screen for other risky behaviors when exploring smoking status. Furthermore, prevention efforts may need to be partnered with efforts to target STD and HIV-related behaviors, as well as with alcohol use prevention in order to reach adolescents of greatest risk. Our findings suggest that current prevention programs may not effectively reach adolescents who have continued to engage in multiple risky behaviors. As the prevalence of certain behaviors decreases, adolescents who continue to engage in these behaviors may be more risky in general. An appreciation of these findings may improve prevention and intervention programs and help guide our understanding of how tobacco control policies may have affected the risk profile of the average American adolescent smoker.

Back to Article Outline

Acknowledgment 

This work was funded by grant R03-HS014418-01 from the Agency for Health Care Research and Quality and by an Alpha Omega Alpha Student Research Fellowship.

Back to Article Outline

References 

1. Substance Abuse and Mental Health Services Administration. Results from the 2002 National Survey on Drug Use and Health: National Findings . Rockville, MD: Department of Health and Human Services; 2003; Office of Applied Studies, NHSDA Series H-22, DHHS Publication No. SMA 03-3836
   • View In Article
2. Centers for Disease Control and Prevention . Cigarette use among high school students—United States, 1991–2003 . MMWR . 2004;53(23):499–502
   • View In Article
3. Grunbaum JA , Kann L , Kinchen S , et al.   Youth risk behavior surveillance—United States, 2003 . MMWR Surveill Summ . 2004;53:1–96
   • View In Article
4. Siegel M , Biener L , Rigotti NA . The effect of local tobacco sales laws on adolescent smoking initiation . Prev Med . 1999;29:334–342
   • View In Article
   • MEDLINE
   • CrossRef
5. Jason LA , Berk M , Schnopp-Wyatt DL , Talbot B . Effects of enforcement of youth access laws on smoking prevalence . Am J Community Psychol . 1999;27:143–160
   • View In Article
   • MEDLINE
   • CrossRef
6. Luke DA , Stamatakis KA , Brownson RC . State youth-access tobacco control policies and youth smoking behavior in the United States . Am J Prev Med . 2000;19:180–187
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (186 KB)
   • CrossRef
7. Farrelly MC , Healton CG , Davis KC , et al.   Getting to the truth (evaluating national tobacco countermarketing campaigns) . Am J Public Health . 2002;92:901–907
   • View In Article
   • MEDLINE
   • CrossRef
8. Pesa J . The association between smoking and unhealthy behaviors among a national sample of Mexican-American adolescents . J Sch Health . 1998;68:376–380
   • View In Article
   • MEDLINE
   • CrossRef
9. Everett SA , Giovino GA , Warren CW , et al.   Other substance use among high school students who use tobacco . J Adolesc Health . 1998;23:289–296
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (169 KB)
   • CrossRef
10. Neumark-Sztainer D , Story M , Dixon LB , Murray DM . Adolescents engaging in unhealthy weight control behaviors (are they at risk for other health-compromising behaviors?) . Am J Public Health . 1998;88:952–955
    • View In Article
    • MEDLINE
    • CrossRef
11. Valois RF , Oeltmann JE , Waller J , Hussey JR . Relationship between number of sexual intercourse partners and selected health risk behaviors among public high school adolescents . J Adolesc Health . 1999;25:328–335
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (178 KB)
    • CrossRef
12. Lindberg L , Boggess S , Williams S . Multiple Threats (The Co-Occurence of Teen Health Risk Behaviors (HHS-100-95-0021)) . Trends in the Well-Being of America’s Children and Youth . Washington, DC: The Urban Institute; 1999;
    • View In Article
13. Everett SA , Malarcher AM , Sharp DJ , et al.   Relationship between cigarette, smokeless tobacco, and cigar use, and other health risk behaviors among U.S. high school students . J Sch Health . 2000;70:234–240
    • View In Article
    • MEDLINE
    • CrossRef
14. Orpinas PK , Basen-Engquist K , Grunbaum JA , Parcel GS . The co-morbidity of violence-related behaviors with health-risk behaviors in a population of high school students . J Adolesc Health . 1995;16:216–225
    • View In Article
    • Abstract
    • Full-Text PDF (711 KB)
    • CrossRef
15. Donovan JE , Jessor R , Costa FM . Syndrome of problem behavior in adolescence (a replication) . J Consult Clin Psychol . 1998;56:762–765
    • View In Article
    • MEDLINE
    • CrossRef
16. Donovan JE , Jessor R . Structure of problem behavior in adolescence and young adulthood . J Consult Clin Psychol . 1985;53:890–904
    • View In Article
    • MEDLINE
    • CrossRef
17. Jessor R . Risk behavior in adolescence (a psychosocial framework for understanding and action) . J Adolesc Health . 1991;12:597–605
    • View In Article
    • Full-Text PDF (1163 KB)
    • CrossRef
18. Martin CA , Kelly TH , Rayens MK , et al.   Sensation seeking, puberty, and nicotine, alcohol, and marijuana use in adolescence . J Am Acad Child Adolesc Psychiatry . 2002;41:1495–1502
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (130 KB)
    • CrossRef
19. Kandel DB , Yamaguchi K , Chen K . Stages of progression in drug involvement from adolescence to adulthood (further evidence for the gateway theory) . J Stud Alcohol . 1992;53:447–457
    • View In Article
    • MEDLINE
20. Kandel D , Yamaguchi K . From beer to crack (developmental patterns of drug involvement) . Am J Public Health . 1993;83:851–855
    • View In Article
    • MEDLINE
    • CrossRef
21. Ritchey PN , Reid GS , Hasse LA . The relative influence of smoking on drinking and drinking on smoking among high school students in a rural tobacco-growing county . J Adolesc Health . 2001;29:386–394
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (134 KB)
    • CrossRef
22. Chen X , Unger JB , Palmer P , et al.   Prior cigarette smoking initiation predicting current alcohol use (evidence for a gateway drug effect among California adolescents from eleven ethnic groups) . Addict Behav . 2002;27:799–817
    • View In Article
    • MEDLINE
    • CrossRef
23. Brener N , Kann L , McManus T , et al.   Reliability of the 1999 youth risk behavior survey questionnaire . J Adolesc Health . 2002;31:336
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (72 KB)
    • CrossRef
24. Brener ND , Collins JL , Kann L , et al.   Reliability of the Youth Risk Behavior Survey Questionnaire . Am J Epidemiol . 1995;141:575–580
    • View In Article
    • MEDLINE
25. Centers for Disease Control and Prevention (CDC) . YRBSS National Youth Risk Behavior Survey, Trends in the Prevalence of Alcohol Use . Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2003;
    • View In Article
26. Lowry R , Holtzman D , Truman BI , et al.   Substance use and HIV-related sexual behaviors among US high school students (are they related?) . Am J Public Health . 1994;84:1116–1120
    • View In Article
    • MEDLINE
    • CrossRef
27. Scal P , Ireland M , Borowsky IW . Smoking among American adolescents (a risk and protective factor analysis) . J Community Health . 2003;28:79–97
    • View In Article
    • MEDLINE
    • CrossRef
28. Robinson KL , Telljohann SK , Price JH . Predictors of sixth graders engaging in sexual intercourse . J Sch Health . 1999;69:369–375
    • View In Article
    • MEDLINE
    • CrossRef
29. Centers for Disease Control and Prevention . Trends in sexual risk behaviors among high school students—United States, 1991–2001 . MMWR . 2002;51:856–859
    • View In Article
30. Centers for Disease Control and Prevention (CDC) . Tracking the Hidden Epidemics, Trends in STDs in the United States 2000 . Atlanta, GA: US Department of Health and Human Services, CDC; 2000;
    • View In Article
31. Ventura SJ , Freedman MA . Teenage childbearing in the United States, 1960–1997 . Am J Prev Med . 2000;19:18–25
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (332 KB)
    • CrossRef
32. Schroeder SA . Tobacco control in the wake of the 1998 Master Settlement Agreement . N Engl J Med . 2004;350:293–301
    • View In Article
    • CrossRef
33. Wasserman J , Manning WG , Newhouse JP , Winkler JD . The effects of excise taxes and regulations on cigarette smoking . J Health Econ . 1991;10:43–64
    • View In Article
    • MEDLINE
    • CrossRef
34. Dalton MA , Tickle JJ , Sargent JD , et al.   The incidence and context of tobacco use in popular movies from 1988 to 1997 . Prev Med . 2002;34:516–523
    • View In Article
    • MEDLINE
    • CrossRef
35. Centers for Disease Control and Prevention (CDC) . YRBSS National Youth Risk Behavior Survey, Trends in the Prevalence of Marijuana, Cocaine, and other Illicit Drug Use . Atlanta, GA: US Department of Health and Human Services, CDC; 2003;
    • View In Article
36. National Institute on Drug Abuse (NIDA) . High School and Youth Trends . Bethesda, MD: National Institute of Drug Abuse, National Institutes of Health; 2003;
    • View In Article
37. Catalano RF , Berglund MA , Ryan JA , et al.   Positive Youth Development in the United States (Research Findings on Evaluations of Positive Youth Development Programs) . Seattle, WA: United States Department of Health and Human Services; 1998;
    • View In Article
38. Brener ND , Collins JL . Co-occurrence of health-risk behaviors among adolescents in the United States . J Adolesc Health . 1998;22:209–213
    • View In Article
    • Abstract
    • Full-Text PDF (365 KB)
    • CrossRef
39. Boggess S , Lindberg LD , Porter L . Changes in Risk Taking among High School Students 1991–1997 (HHS-100-95-0021) . Trends in the Well-Being of America’s Children and Youth . Washington, DC: The Urban Institute; 1999;
    • View In Article
40. Wilson D , Taylor A , Roberts L . Can we target smoking groups more effectively? A study of male and female heavy smokers . Prev Med . 1995;24:363–368
    • View In Article
    • MEDLINE
    • CrossRef