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Tobacco use is a learned and socially mediated behavior. Experimenting with tobacco is attractive to children and youths because of associations they learn to make between tobacco use and the kind of social identity they wish to establish. Repeated and ubiquitous messages reinforcing the positive attributes of tobacco use give youths the impression that tobacco use is pervasive, normative in many social contexts, and socially acceptable among people they aspire to be like. Youths are led to believe that tobacco consumption is a social norm among attractive, vital, successful people who seek to express their individuality, who enjoy life, and who are socially secure. Several factors are involved in maintaining this impression among youths and in fostering tobacco use as a social norm at a time when public health messages are calling attention to the serious health risks associated with tobacco consumption. These factors will be highlighted in this chapter, and attention will also be called to a growing, largely local, movement calling for the exercise of greater social responsibility in the reduction of environmental cues that reinforce tobacco use in public spaces frequented by children and youths. At issue is an ecology of representations, ideas, images, cues, and the like, that foster tobacco use as normative behavior.

THE FUNCTION OF SOCIAL NORMS

The term "norms" has a broad range of meaning, with very specific connotations applied in the social sciences. In general, however, and for the purposes of discussion in this report, social norms are at once descriptive, that is, normative in a statistical sense denoting majority approval, and prescrip-



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Page 71 Tobacco use is a learned and socially mediated behavior. Experimenting with tobacco is attractive to children and youths because of associations they learn to make between tobacco use and the kind of social identity they wish to establish. Repeated and ubiquitous messages reinforcing the positive attributes of tobacco use give youths the impression that tobacco use is pervasive, normative in many social contexts, and socially acceptable among people they aspire to be like. Youths are led to believe that tobacco consumption is a social norm among attractive, vital, successful people who seek to express their individuality, who enjoy life, and who are socially secure. Several factors are involved in maintaining this impression among youths and in fostering tobacco use as a social norm at a time when public health messages are calling attention to the serious health risks associated with tobacco consumption. These factors will be highlighted in this chapter, and attention will also be called to a growing, largely local, movement calling for the exercise of greater social responsibility in the reduction of environmental cues that reinforce tobacco use in public spaces frequented by children and youths. At issue is an ecology of representations, ideas, images, cues, and the like, that foster tobacco use as normative behavior. THE FUNCTION OF SOCIAL NORMS The term "norms" has a broad range of meaning, with very specific connotations applied in the social sciences. In general, however, and for the purposes of discussion in this report, social norms are at once descriptive, that is, normative in a statistical sense denoting majority approval, and prescrip-

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Page 72 tive, that is, guidelines for acceptable behavior associated with sociocultural  values. Norms are maintained both by social reinforcements and social sanctions. A social learning analysis of tobacco use takes into account the different types of social reinforcement that coincide with the development of tobacco use from experimentation to initiation to maintenance of regular use. Experimentation typically occurs under conditions of peer reinforcement; usually the initial inhalation of smoke is aversive but eventually the youth develops a tolerance to it. In other words, the adolescent "learns" in a peer context that tobacco use is an acceptable or desirable behavior, despite initial negative physiological reactions. Continued use produces pharmacologic reinforcement to sustain the behavior independent of social reinforcement. The behavior then occurs in different situations, where new learning takes place. The young smoker discriminates between situations in which smoking is socially acceptable or unacceptable. At the same time, various environmental or situational cues, such as an ashtray, or an empty cigarette pack, or a party, not only can suggest acceptability but can also stimulate physiological responses that reinforce the addiction to nicotine.1 Hence, whereas the addictive power of nicotine drives a person to use tobacco regularly and to maintain that regular use, it is the power of these perceived social norms that persuades children and youths to experiment with and initiate use of tobacco. The development of these perceived norms among children and youths is influenced by pervasive images and messages of everyday life. These messages come from  numerous sources: friends, peers, family, school, the workplace, church, films, magazines, radio and television, billboards, electronic media, advertisements, sports events, arts performances, and so on. These messages typically have a prescriptive influence on social norms; in other words, in addition to characterizing what members of society do, they suggest to people what they should do. As standards set by a society or social group, norms define the boundaries of behavior; they dictate etiquette, protocol, and a sense of what is normal, natural, expected, and acceptable in given contexts. Because the norms of society are in large part prescribed through public sources, they are subject to the influence of interest groups that seek to legitimize an agenda and to engineer behavior. Social groups are influenced by, but do not passively accept, prescribed norms. They mark their identity by selectively adopting and appropriating behaviors and images that take on meaning in opposition to behaviors and images adopted by other groups. Markers of group identity and conventions of group membership are not fixed, but rather change over time. Images associated with tobacco use are not stable, if not reinforced. For adolescents, norms are particularly complex, for two reasons. First, adolescence is a transitional period "shaped by prior development in childhood and the future requirements of adulthood, as well as by current expectations and opportunities."2 Second, adolescence itself is a complex developmental period,

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Page 73 marked by physiological, emotional, and psychological changes. Adolescentsare establishing their sense of self and redefining themselves socially in the contexts of family, peers, school, the workplace, and the local community.3 Parents and peers contribute in different ways to the development of adolescents' values. Adolescents tend to hold values similar to those of their parents regarding education, religion, and work, but are more similar to their peers in aspects of adolescent culture, such as music and appearance.4 Peers find security, identity, and a sense of wellness by constructing peer groups and group norms dictating valued behaviors.5 These behaviors have more potency if they are also perceived as normative for adults, yet not acceptable for children.6 If an adolescent perceives a specific behavior, such as drinking alcohol or using tobacco, to be normative in the peer group, he or she might adopt the behavior in order to belong to the group or to feel relaxed when with the group. In developing peer norms, adolescents look to the greater social environment for concepts of adult identity, particularly in the behavior of leaders, heroes, and film stars, and in the media. Messages, especially repeated messages. that associate behaviors with maturity, peer approval, and independence tend to be the most influential. An overabundance of such messages in relation to a given behavior can result in a youth's misperception of how pervasive the behavior actually is. Misperception of the pervasiveness of tobacco use can be a powerful influence on behavior. What are the current norms regarding tobacco use? How do social norms influence, or make children and youths susceptible to adopting, tobacco use? How can actions by parents, social groups, and communities set and reinforce social norms and thereby prevent the initiation of tobacco use by children and youths? THE EMERGING TOBACCO-FREE NORM The Decline of Tobacco Use A useful scientific descriptor of the pervasiveness of behaviors is statistical trend data, which describe patterns of behavior with information obtained in an objective manner through surveys. A review of trend data on tobacco use reveals that currently the norm for three-quarters of the population in the United States is non-use of tobacco. The survey data describe the overall decrease in smoking prevalence in the general population from 40% in 1965 to 26% from 1990 to 1992.7 In the military, prevalence of any smoking decreased from 51% in 1980 to 35% in 1992; the prevalence of heavy smoking (one or more packs per day) decreased from 34% in 1980 to 18% in 1992.8 Among high school seniors, the prevalence of daily smoking was 29% in 1976, 21% in 1980, 17% in 1992, and 19% in 1993.9 Youths and adults alike want to quit using tobacco. A 1993 national Gallup

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Page 74 poll reported that 76% of adult smokers have tried to quit smoking. Despite past failures, 73% believe that they will be nonsmokers within 5 years, and 30% were trying to quit at the time of the survey.10 Similarly, in a 1994 USA Today/CNN Gallup poll, 70% of smokers expressed interest in quitting; 48% had tried to do so but failed. About the same percentage (76%) of adolescent girls (smokers and ex-smokers) in the Teen Lifestyle Study had attempted to quit.11 Two large national surveys of teens also reveal that youths want to and try to quit. The 1989 TAPS (Teenage Attitudes and Practices Survey) data show that 74% of 12-through 18-year-old smokers had seriously thought about quitting; 64% had tried at some time to stop smoking and 49% had tried during the preceding 6 months (figure 3-1).12 The Monitoring the Future Project data show that nearly half of smokers who were seniors in high school between 1976 and 1989 wanted to quit, and about 40% had tried unsuccessfully to do so.13 As discussed above, social norms vary among groups, and the trend data describe a variety of tobacco use patterns in different groups identified by gender, ethnicity, and socioeconomic status. Knowing what the trends are for specific groups is important in determining what the social norms are perceived to be, and what factors may reinforce tobacco use, so that counter-strategies can be developed and implemented. For example, important racial/ethnic differences in cigarette smoking have become apparent among high school seniors during the FIGURE 3-1  Sources: Nichter, Mark, Mimi Nichter, C. Ritenbaugh, and N. Buckovic. The Teen Lifestyle Project: Preliminary Report. Tucson: University of Arizona. 1994 (unpublished); and SmithKline Beecham. Gallup Report: A National Survey of Americans Who Smoke. New York, 1993.

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Page 75 life of the Monitoring the Future Project. In the late 1970s three student ethnic groups—non-Hispanic whites, African Americans, and Hispanics—had fairly similar smoking rates; all three mirrored the general decline in adult smoking from  1977 to 1981.  Since 1981, however, a considerable divergence has emerged: smoking rates have declined very little for non-Hispanic white and Hispanic youths, but the rates for African-American youths have continued to decline steadily. As a result, in 1992, the smoking rates for African-American students were about one-fifth to one-third of those for white students; specifically, for African-American high school seniors, the prevalence of daily cigarette smoking reported is 4%, whereas for non-Hispanic whites it is 21%.14 Currently, there is no explanation for this difference. Data from the Monitoring the Future Project also reveal a striking difference between levels of education and amount of cigarettes smoked daily. For example, smoking half a pack or more a day is nearly three times as prevalent among the noncollege-bound youths (19% versus 7%) and these differences persist after high school.15 What little information is available on the smoking habits of American-Indian groups shows large regional and tribal variations. For instance, one study found tobacco use to be very high among girls, and daily cigarette smoking higher among girls than among boys, after the seventh grade. Daily cigarette smoking rose from 8.9% for girls and 8.1 % for boys in junior high to 17.8% and 15.0%, respectively, for high school students. Elsewhere rates of about 20% were reported for regular smoking among American-Indian youths, and the rates seem to be increasing.16 It is clear that the use of smokeless tobacco by young American Indians and Alaskan Natives, boys and girls, is higher than by any other ethnic group. In studies of communities, weekly use of smokeless tobacco by boys was 43% and by girls 34%.17 Furthermore, a study found rates of occasional use of smokeless tobacco by American Indians to be astonishingly high among the very young: 74% of girls and 90% of boys who reported weekly use of smokeless tobacco began using it before the age of 10.18 Other studies have documented that American-Indian children may initiate smokeless tobacco use before kindergarten.19 What are the reasons behind this diversity in tobacco use among the various age, gender, and ethnic groups? Why are some members of the population more susceptible to becoming addicted to this health risk? No clear answers have emerged. Several studies have shown that perceptions of vulnerability vary with ethnicity and that African-American and Hispanic adolescents feel more susceptible than their white peers to a variety of health outcomes, including cancer. AIDS, and pregnancy.20 One study found that differences in perceived vulnerability are a function of knowledge.21 Youths acquire knowledge through many cultural social systems, systems that also can convey erroneous impressions of the trends in tobacco use, as described in the section below. The military services historically have reinforced a pro-tobacco norm, and

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Page 76 had a smoking prevalence about 10% higher than that in the general population. Cigarettes have traditionally been cheaper in commissaries and post exchanges than in retail outlets, and cigarettes were distributed free to the troops during wartime. A high prevalence of tobacco use continued after World War II, and in 1980 was 51% for military men. (This finding was followed by a Department of Defense (DoD) memorandum requesting that an intensive antismoking campaign be carried out at all levels of DoD.)22 Studies by the Naval Health Research Center found that young men between the ages of 18 and 24 entering the Navy in 1986 smoked at the same rate (28%) as civilians of that age group, but that one year later the same group of naval recruits had a smoking rate of 41%.23 The reasons given for the smoking initiation were "curiosity" and "friends smoking." The researchers conclude that social factors may have a fairly strong influence on smoking behavior of new Navy personnel, especially given that the Navy encourages cohesiveness and uniformity. Fortunately, in the past few years, the prescribed norm for the military has been a tobacco-free environment, and research studies have shown that prevention interventions can be successful in reducing the percentage of recruits who take up smoking. The Social Unacceptability of Tobacco Use The social unacceptability of tobacco use throughout society in the United States is anchored in changing attitudes toward health and personal responsibility: The contemporary place of the cigarette in American life is a distant shout from its accepted position in the 1950s. Despite the opposition of the tobacco industry, the public health campaigns of the past three decades have brought about a remarkable change in attitudes and meanings toward smoking. The health movement has produced a cultural shift in the meaning of health and patterns of living that would have seemed impossible 30 years ago.24 The emergent tobacco-free norm reflects two distinct links between personal responsibility and health. First and least controversial is the idea that it is socially, and perhaps morally, irresponsible to expose nonsmokers to the risks of disease associated with environmental tobacco smoke (ETS). In the wake of the 1993 report of the Environmental Protection Agency confirming the harmful effects of ETS, public support for laws and policies guaranteeing smoke-free environments is now nearly universal among nonsmokers, and even very high among smokers. In a recent Gallup poll of smokers, 42% of smokers said that nonsmokers' rights in public places should supersede smokers' rights.25 In a national poll of U.S. voters, 72% of voters believe that second-hand smoke can give nonsmokers cancer and other serious diseases, and 64% favored banning smoking in all public places, such as restaurants, stores, and government buildings.26 The apparently high level of compliance with public smoking restrictions

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Page 77 reflects a widespread acceptance of both the norm favoring smoke-free environments and of its legitimacy. Indeed a norm of civility—obligating a smoker to request permission of nonsmokers to light up and enabling companions and social hosts to deny permission—has taken root throughout society.27 The second concept about health and personal responsibility underlying the emerging tobacco-free norms is that exposing one's own health to the risk of diseases, including tobacco-related diseases, is itself socially unacceptable. This attitude reflects a marked shift from the traditional libertarian intuition that tobacco use (or other personal risk-taking) is ''no one else's business." It now seems that tobacco use, just as other health-related behaviors, is seen as "everyone's business" because the costs of tobacco-related disease are borne by the whole society.28 In general, the public seems to have accepted the idea that unhealthy personal choices are of public concern. This attitude is associated with widespread acceptance of the legitimacy of public policies aimed at discouraging people from using tobacco, particularly through taxes that require tobacco users to absorb the social costs of their unhealthy choices. Thus, the emerging tobacco-free norm has two underlying values. First, no one should be exposed to tobacco smoke, because it puts everyone exposed to it at risk; therefore the environment should be smoke-free. People who smoke should do so only in environments that protect others from exposure, for example, in areas with separate ventilation systems. Second, because the aggregate effects of tobacco-related health consequences affect everyone, society as a whole has an interest in discouraging tobacco use and in supporting the efforts of people who are trying to stop using tobacco. This means instilling and supporting the idea that to stop using tobacco is "the right thing to do." TOBACCO USE AS PERCEIVED BY CHILDREN AND YOUTHS Increasingly, through a variety of channels, the message is being conveyed that tobacco is not used by the majority of people and that it is not socially acceptable. The public health values underlying this tobacco-free norm are steadily growing stronger and are being articulated more emphatically. Nevertheless, youths do not perceive the norm to be tobacco-free; rather, they commonly overestimate the percentage of their peers and adults who use tobacco. The Perception of Tobacco Use In an interview study of 895 urban children and youths, the respondents greatly overestimated the prevalence of adult and peer smoking. The mean estimate for adult smoking was 66% at a time when 30% of adults were cigarette smokers. Estimates of peer smoking were about double the real figure by students in high school and higher by students in grade school.29  Other studies

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Page 78 show similar results. Findings from  the 3-year (1990-1992) Teen Lifestyle Project reveal that, although only 5% of adolescent girls in a Tucson sample smoked regularly and another 20% smoked only occasionally or only at parties, 31% of their peers thought that 51-75% of girls at their school smoked and another 10% thought that 75-90% smoked. The estimates about percentages of boys who smoke were similar, as they were for adult men and women. For example, 28% thought that 51-75% of women were smokers and 15% thought that 75-90% were smokers.30 A study of over 200 adolescents in Michigan found that youths' perceptions of the prevalence of smoking were "highly inaccurate": 79% of the youths thought that over half of all adults smoke and 68% thought that over half of all teens smoke.31 Adolescents who smoke overestimate smoking prevalence by a greater margin than do nonsmokers. A study of 5,351 sixth to twelfth graders from a midwestern and a southwestern community found that adolescents who smoked estimated significantly higher numbers of smokers than did adolescents who did not smoke (table 3-1). For example, middle school students who smoke estimated that 48.9% of boys smoke, whereas nonsmokers estimated that 27.2% of boys smoke, a difference of 21.7%.  Smokers estimated that 66.8%  of men smoke, whereas nonsmokers estimated 56.5%.32 Similarly, a study of 5,610 students from the Los Angeles area found that students in the eighth and ninth grades greatly overestimate the number of adolescents and adults who smoke regularly. Adolescent smokers who were regular smokers made the greatest TABLE 3-1 Estimates by youths of the percentage of boys, girls, men, and women who smoke   Middle school students High school students   Boys Girls Men Women Boys Girls Men Women Midwest Sample                 Nonsmokers 27.2 21.3 56.5 50.9 38.3 34.5 50.8 47.6 Smokers 48.9 41.8 66.8 58.1 50.6 44.7 60.1 54.2 Smoker-nonsmoker difference 21.7c 20.5c 10.3c 7.2c 12.3c 10.2c 9.3c 6.6c Southwest Sample                 Nonsmokers 34.4 26.6 60.6 55.2 44.7 43.0 59.6 56.1 Smokers 49.0 47.1 68.7 64.3 48.6 48.0 63.5 57.5 Smokers-nonsmoker difference 14.6c 20.5c 8.1a 9.1b 3.9 5.0a 3.9 1.4 ap < .05; bp < .01; cp < .001. Source: Sherman. Steven J., Clark C. Presson, Laurie Chassin, Eric Corty. and Richard Olshavsky. "The False Consensus Effect in Estimates of Smoking Prevalence: Underlying Mechanisms." Personality and Social Psychology Bulletin 9:2 (1983): 201.

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Page 79 overestimates. Whereas in fact 9% and 12% of eighth and ninth graders, respectively, were regular smokers, students who were regular smokers estimated that 55% smoke regularly. Whereas 33% of adults were smokers at that time (1981 Los Angeles data), the students who were regular smokers estimated the figure to be 66-70% (figure 3-2). Interestingly, nonsmokers underestimated the percentage of adolescents who have ever tried smoking, whereas regular smokers FIGURE 3-2  Fact: 12% of 9th graders are regular smokers. Perception: 9th graders who are regular smokers estimate that 55% of their peers are also regular smokers. Source: Adapted from Sussman, S., C. W. Dent, J. Mestel-Rauch, et al. "Adolescent Nonsmokers, Triers, and Regular Smokers' Estimates of Cigarette Smoking Prevalence: When Do Overestimations Occur and by Whom?" Journal of Applied Psychology 18(7) (1988): 542-543.

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Page 80 overestimated the percentage by 6-9%. In addition, the study found that inflated estimates, relative to the adolescent's stage of smoking development, were significantly associated with future onset of smoking. The researchers concluded that "the provision of accurate norms regarding regular smoking by adolescents and adults might be extremely beneficial to prevention efforts."33 In fact, overestimating smoking prevalence is one of the strongest predictors of smoking initiation.34 Spreading a False Impression: The Ubiquitous Pro-Tobacco Message The misperception of youths that the large majority of peers and adults use tobacco may well derive from the near-constant exposure youths experience to pro-tobacco messages and images, which make tobacco use seem common. (See chapter 4 on advertising for a full discussion.) Pro-tobacco messages are ubiquitous in the American environment. Children walking home from schools see billboards in their neighborhoods promoting tobacco products (figure 3-3). Children themselves become walking billboards by wearing t-shirts, caps, and other clothing items that display tobacco logos. Children watch film and sports stars smoke and chew tobacco products. They read magazines with ads that either FIGURE 3-3  The young children who will ride this bus to and from school will likely be exposed to a number of tobacco advertisements along the way. Source: Courtesy of John Slade.

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Page 81 directly or indirectly promote tobacco products. They eat in restaurants that permit tobacco use. They frequent and linger in shopping malls where tobacco use is permitted. Many even attend schools where smoking is permitted on the grounds and where teachers smoke even if the students are prohibited from smoking. Youths attend cultural events, such as music concerts, and sporting events, such as rodeos and car racing, either sponsored by the tobacco industry or where billboards, scoreboards, or contestants display tobacco logos. Furthermore, tobacco products are displayed in many stores frequented by youths and are easily purchased by youths. As a result, children learn early and erroneously that tobacco use is widespread and acceptable, especially as an adult behavior. The primary concept conveyed by the multitude of pro-tobacco messages is that there are benefits to using tobacco. The repetition of these messages reinforces the perception of benefits, and that perception influences youths, making them susceptible to tobacco use. The importance of the perceived benefits of smoking as a predictor of susceptibility to smoking was examined in a study of teen smoking in California. That study defined "susceptibility" as "the absence of a determined decision not to smoke in the future."35 In surveys conducted in 1990 and 1992, adolescents were asked if they believed that smoking helps people when they are bored, helps them relax, helps people feel more comfortable at parties and in other social situations, and helps them keep their weight down. The findings were as follows: 1. In each year, over 40% of adolescents felt that smoking helped people socialize; over 30% felt that it helped people relax. The benefit least endorsed by teenagers related to weight control, with percentages at about 16%. 2. In each year, only one-third of adolescents did not perceive that smoking provided any of these benefits. 3. One-quarter of adolescents reported one benefit of smoking. 30% reported two or three benefits, and 12% reported four or five benefits. 4. Adolescents who were 12-13 years old were just as likely to perceive benefits of smoking as those who were 16-17 years old. This result suggests that the belief that smoking has utility is established before the adolescent years.36 The belief that there are benefits to smoking was a major predictor of both susceptibility and smoking in the last month in the 1990 and 1992 surveys. The univariate statistics from the 1992 survey indicate that, of those who did not perceive any of these benefits, 24% were susceptible to smoking; of those who perceived one benefit, 38% were susceptible to smoking; of those who perceived two benefits, 41% were susceptible; and of those who perceived three or more benefits, 57% were susceptible. In cross-sectional analyses of the 1992 survey data, the proportion of susceptible youth who experimented with cigarettes rose dramatically with age (14% of 12-year-olds versus 90% of 19-year-olds) compared to experimentation among those not susceptible (5% of 12-year-olds ver-

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Page 92 youths. Sports stars are heroes and role models for youths. The arena of sports offers three distinct opportunities to promote a tobacco-free norm. First, one's physiologic performance while participating sports is diminished by tobacco use. By recognizing that participation in sports can be a receptive learning moment for an adolescent, peers, parents, and coaches could have an important influence on a youth who is active in sports. Second, many youths imitate the behavior of sports stars, including the use of spitting tobacco and cigarettes. In 1993, professional baseball minor-league teams adopted a total ban on smoking or chewing by all players, coaches, and umpires anywhere in the ballparks. Third, two-thirds of major-league stadiums have voluntarily eliminated smoking from their seating areas; 18 stadiums have eliminated tobacco advertising. At least half of the 50 states restrict smoking in gymnasiums and arenas as part of their clean indoor air legislation.86 A Current Population Survey survey of youths asked if they thought that smoking should be allowed in indoor sporting events; 65% replied "not at all," and 28.6% replied "to allow in some areas."87 Community and Youth Organizations One of the highest rates of tobacco use is among youths who have dropped out of high school; they are of course the least likely group to be reached through school programs. It might be possible to reach some of these youths through their communities, that is, through organizations or events sponsored by community groups. Youths who remain in school may be likely to participate in organizations for youths. Thus, community groups and youth organizations provide an important means of promoting the tobacco-free norm to youths at all risk levels and of providing alternative behaviors to tobacco use through organizational activities that allow youths to have a sense of belonging and to be relaxed among their peers. Organizations can also provide opportunities for youths to become active in promoting the tobacco-free norm to their peers. Organizations have begun to recognize their potential for preventing tobacco use by children and youths and a number of them have begun to affiliate in order to enhance their resources and effect. For example, a national alliance of organizations that serve youths or have youth memberships, the Coalition for America's Children, was founded in 1991 "to promote health, education, safety, and security for all American children" by increasing public awareness of children's issues through member organizations and by providing materials and technical assistance to member organizations. In 1993-1994, the Coalition adopted prevention of tobacco use by children as a major issue. The Institute of Medicine collaborated with the Coalition to conduct a survey of the Coalition's member organizations to determine their level of involvement in tobacco control issues and the level of interest in becoming more involved. The results indicate that while there is some interest and activity in tobacco issues, organizations that serve children are not fully aware of the seriousness of the issues. For example,

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Page 93 66% of the responding organizations have a formal policy on tobacco use that is enforced; an effort is made to prevent the use of tobacco by staff in 47% of the organizations and by the general public in 28%; however, only a few provide assistance for tobacco cessation. Sixty-three percent of the respondents felt that tobacco use by children was less important than other issues in which their organizations were involved; another 34% felt the issue was of about the same importance. (Note that staff size, minimal funds, and specificity of mission may be factors influencing their thinking and activities.) Nevertheless, 81% indicated that they would be very likely or somewhat likely to distribute information on tobacco issues to members, and 77% indicated that they would be very likely or somewhat likely to incorporate tobacco into their health materials. According to 68% of the respondents, public awareness in their community of the issues surrounding children's use of tobacco is less than that for other children's issues; 45% feel that there is little or no media coverage devoted to this topic. The Join Together Project, funded by the Robert Wood Johnson Foundation, is a national resource for information and technical assistance to coalitions of community organizations that combat tobacco, alcohol, and other drug abuse. In 1993 Join Together surveyed 12,000 collaborative agencies nationwide, soliciting information on how their coalitions are organized and what they do.88 Of the 5,475 responding agencies, 2,196 are lead agencies or sponsoring agencies of coalitions or organizations. Of this subset, 23% (779) reported having extensive programs on tobacco prevention, and some were considering expanding their activities. Most of those agencies are attempting to reach high-risk populations, such as pregnant teens, juvenile offenders, and dropouts, as well as the general youth populations. They focus on the community environment as opposed to needs of individuals, and on system-wide change rather than on specific areas. Among the policy barriers most frequently identified by the agencies was the need to break down barriers that exist between organizations and governments. The community coalitions are broad-based collections of public and private agencies and many volunteers, and most have either equal participation by professionals, government officials, and lay people or are led mostly by lay people. Local police and schools are represented in a high percentage of the coalitions; however, participation should be broadened in two respects. Local recreation departments, where youths may spend time after school and on weekends, are active in less than one-third of all substance abuse coalitions. The mass media were reported to be active in less than one-half (41%) of the community coalitions, even though they can be influential in helping set the tone for a community's approach to substance abuse. ADVOCACY FOR A TOBACCO-FREE NORM Many organizations and coalitions have taken on advocacy roles, promoting a tobacco-free norm. For example, some religions have begun to

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Page 94 unite in their efforts to prevent tobacco use by youths. The Interreligious Coalition on Smoking OR Health represents 15 religious organizations. In supporting tobacco control initiatives, the coalition holds that there is "an obligation to preserve the quality of human life" and "a moral obligation to protect the vulnerable, such as the young."89 Similarly, the Union of American Hebrew Congregations adopted a resolution in 1987 to promote tobacco control. The resolution includes implementing tobacco education for youths and enacting smoke-free policies in public places.90 Churches and church-affiliated activities and organizations are important norm-setting sources of influence on children and youths. Coalitions have also been established through government-supported tobacco control initiatives. State and local coalitions support policy change on a large-scale basis by involving communities. Staffed by state and local government health officials, these coalitions are composed of a spectrum of organizations and individuals concerned with tobacco control. Examples are regional coalitions such as the Rocky Mountain Tobacco-Free Challenge, the Tobacco-Free Heartland Coalition, and the National Cancer Institute's American Stop Smoking Intervention Project (ASSIST). ASSIST, which is conducted in partnership with the American Cancer Society, provides funding to 17 states to support community-based tobacco control interventions. The $150 million project, to be implemented from  1993 to 1998, aims to reduce tobacco use through policy interventions and media advocacy mobilized by statewide and local coalitions. Youths are a priority prevention group in the ASSIST effort. The 17 states are Colorado, Indiana, Maine, Massachusetts, Michigan, Minnesota, Missouri, New Jersey, New Mexico, New York, North Carolina, Rhode Island, South Carolina, Virginia, Washington, West Virginia, and Wisconsin. A state-initiated and state-supported program resulted from California's Proposition 99. In 1988, California voters approved Proposition 99, an excise tax on tobacco products that earmarked 20% of the revenue to support tobacco control efforts. Enabling legislation provided funding of approximately $14 million in 1990-1991 and $79 million in 1991-1992. As a major component of the tobacco control program, the state health department funds 61 local coalitions supported by local health departments, 10 regional coalitions staffed by administrative agencies, and 4 ethnic networks.91 Other combined local and national efforts are being implemented by voluntary health organizations and by health and health professionals' organizations. For example, tobacco control is an important issue for the American Heart Association, the American Cancer Association, and the American Lung Association. These organizations, which traditionally have focused on public education and research, are increasingly pursuing public policy initiatives to tobacco control. Health and health professionals' organizations, at national, state, and local levels are drawing on their memberships to support policy efforts. These include organizations such as the American Medical Association, American Public Health Association, American Medical Women's Association, American Acad-

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Page 95 emy of Family Physicians, American Dental Association, American Association of Occupational Health Nurses, and Doctors Ought to Care (DOC). The American Medical Association (AMA) took a major step into the realm of tobacco control advocacy when it sponsored the Tobacco Use in America Conference in 1989, which brought together tobacco control advocates and members of Congress. The 100 invited conference participants formed workgroups around major tobacco control policy issue areas and developed recommendations.92 In 1993, the AMA sponsored a second conference, again promoting collaboration among legislators and advocates and producing a series of recommendations. Special tobacco editions of the Journal of the American Medical Association are important sources of research and draw media attention to tobacco issues. The AMA serves as the administrative agency for the $10 million Robert Wood Johnson Foundation SmokeLess States program. This program will support statewide coalitions to reduce tobacco uptake and use and increase public awareness of the role of tobacco control policy in health care reform. Supporting organizations are not frontline advocacy groups themselves, but support the efforts and coordinate advocacy groups. At the national level, the Advocacy Institute's Smoking Control Advocacy Resource Center (SCARC) plays a unique role by bringing together disparate parts of the tobacco control movement. Its electronic communications network, SCARCNet, provides advocates with timely, concise strategic resources and offers them the opportunity to confer about strategic questions and share advocacy successes and failures. Over 400 U.S.-based advocates representing all areas of tobacco control have joined the network, and hundreds more receive periodic mailings updating them on tobacco control strategies. Other organizations have taken frontline positions as advocates of tobacco control, for example ANR, ASH, and GASP. Foundations and others have also increased funding for advocacy activities. The Robert Wood Johnson Foundation (RWJ) now plays the leading foundation role in supporting these efforts. RWJ funded the Tobacco Policy Research Project in 1991, which brought together committees of researchers and experts in tobacco control policy to assess research needs; the committee reports were published as a supplement to the journal Tobacco Control. Following this project, RWJ launched a 4-year, $5 million program to support policy-related research. Most recently, RWJ launched its SmokeLess States initiative, a 4-year, $10 million program to support up to 18 statewide coalitions. Grantees will implement comprehensive tobacco control programs including education, treatment, and policy initiatives. All tobacco control policies, either directly or indirectly, affect youths. To that extent, the range of groups described above all address issues concerning youths. For many, however, their youth-focused activities are not primary. A few groups do focus on youths in particular, including the following. Stop Teenage Addiction to Tobacco (STAT) focuses primarily on the issue of tobacco and youth. STAT advocates directly for policy changes at the federal, state, and

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Page 96 local levels  In 1989 STAT began hosting an annual conference focused on advocacy activities around youth tobacco use; at the 1993 conference, attendees included approximately 100 youths who participated in a separate youth track. Through a 3-year, $1 million grant from the Robert Wood Johnson Foundation, STAT also funds four youth-involved local initiatives to reduce youth tobacco use prevalence. Smokefree Educational Services (SES), a relatively small-scale organization with an all-volunteer staff, has scored many policy victories in New York City. SES works with hundreds of youths on youth-focused advocacy efforts and disseminates information on its efforts and other important issues to over 13,000 advocates nationally through its newsletter. The North Bay Health Resources Center's STAMP (Stop Tobacco Access for Minors Project), funded through Proposition 99, distributes signs to stores regarding youth access in a 6-county (approximately 40-city) region of Northern California. Across the nation, youths themselves are becoming involved and carrying the issue forward. Involving youths in working on tobacco control efforts has been a way to empower them and to increase youth awareness of tobacco issues. For example, the Gold Country, a 13-county region in California, has active youth coalitions in each county and holds an annual youth summit that provides advocacy training. Additionally, many statewide and local coalitions such as those established for ASSIST and California have youth representatives. Youths are involved in all phases of advocacy, including documenting the problem in the community, developing strategies for addressing the problem, and presenting their ideas to the community, media, and policymakers. Youths who have been willing to speak out for their own concerns have inspired respect for their cause. For example, testimony before the city council by teens from San Jose STAT proved important in convincing the San Jose City Council to implement a vending machine ban.93 While youths have been central in these efforts, until recently they have only been part of organizations run and funded by adults, and their numbers are small compared to SADD and other anti-drug efforts. At the 1993 annual STAT conference, a group of 20-30 youths from across the country decided that it was time to establish an organization created and run by youths. They formed their own organization—Students Coalition Against Tobacco (SCAT)—which aims to establish nationwide chapters that will focus on peer education as well as advocacy efforts. SCAT's young chairperson has expressed the need for youth involvement as follows: The next step must be to create school based clubs, following the model of SADD, that will advocate for social change on the level where the problem is originating. We must empower young people to work within their domain—the school system. These teens can conduct peer educational programs and work to enhance comprehensive health educational programs. The mere presence and advertisement of such a group will bring an awareness to students of the issues. Young people know where the problems lie and upon mobilization can enact

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Page 97 change more rapidly than any organization acting on behalf of young people. It will be the job of these young people to target their peers for a smoke-free lifestyle before the industry ... can get to them.94 In summary, there has been an initiation of community activity supporting tobacco control policies. The efforts of community organizations, coalitions, and advocacy groups have been successful in establishing hundreds of ordinances that seek to improve the public health through a tobacco-free norm. In the process, the public has become somewhat more aware of the problems of tobacco and more supportive of tobacco control efforts. Those activities are an important beginning because they demonstrate that the public will support tobacco control measures and that youths are responsive to helping set the tobacco control agenda. However, the efforts to date are not sufficient in themselves to counter the pro-tobacco messages in our culture and to correct the misperception of the level of tobacco use. Community organizations and coalitions are potentially the most effective means of accomplishing those objectives, but they need support to broaden their bases. REINFORCING THE TOBACCO-FREE NORM: CONCLUSIONS AND RECOMMENDATIONS We must not become complacent about the downward trend of smoking prevalence during the past two decades. To the contrary, the public should be concerned about the fact that prevalence has leveled off and that there was a slight increase in youth smoking in 1993. Renewed efforts are required to once again start the downward trend and to prevent youths from ever initiating tobacco use. The forces influencing tobacco use originate well beyond a youth's immediate personal environment of family and peers; youths encounter pro-tobacco messages everywhere and repeatedly in the social environment. Therefore, countermeasures should be actively undertaken to promote a tobacco-free norm. The Committee recommends that: 1. Public education programs and messages should be increased and implemented on a continuous basis to (a) inform the public about the hazards of tobacco use and of environmental tobacco smoke and (b) promote a tobacco-free environment. In particular, mass media campaigns, including paid counter-tobacco advertisements, should be intensified to reverse the image appeal of pro-tobacco messages, especially those that appeal to children and youths. 2. Tobacco-free policies should be adopted and enforced in all public locations, especially in those that cater to or are frequented by children and youths, including all educational institutions, sports arenas, cultural facilities, shopping malls, fast-food restaurants, and transit systems.

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Page 98 3. All levels of government should adopt tobacco-free policies in public buildings. The Department of Defense should continue its aggressive efforts to adopt tobacco-free policies in all military services. 4. All workplaces should adopt tobacco-free policies. 5. All organizations involved with youths should adopt tobacco-free policies that apply to all persons attending or participating in all events sponsored by the organizations, and should actively promote a tobacco-free norm. 6. Parents should clearly and unequivocally express disapproval of tobacco use to their children, and, if smokers themselves, should quit smoking. To advance understanding of how best to promote a tobacco-free social norm, the Committee recommends that the following research approaches be undertaken: 7. Research should be conducted to determine the factors influencing the substantial decline in tobacco use by African-American youths, with particular attention to the role of social norms. 8. Youths should be involved in the development of research questions and approaches and in designing and evaluating health messages and programs. REFERENCES 1. U.S. Department of Health, Education, and Welfare. Smoking and Health. A Report of the Surgeon General, 1979. DHEW  Pub. No. (PHS) 79-50066. Rockville, MD: Office on Smoking and Health. 16-5, 6. 2. Crocket, Lisa J., and Anne C. Petersen. ''Adolescent Development: Health Risks and Opportunities for Health Promotion." In Millstein, Susan, Anne C. Petersen, and Elena O. Nightingale, eds. Promoting the Health of Adolescents: New Directions for the Twenty-first Century. New York: Oxford University Press, 1993. 13. 3. Hurrelmann, Klaus. "Adolescents as Productive Processors of Reality: Methodological Perspectives." In Hurrelmann, K., and U. Engel, eds. The Social World of Adolescents: International Perspectives. Berlin: Walter de Gruyter, 1989. 4. Kandel, D. B. "Processes of Peer Influences in Adolescence." In Silbereisen, R. K., K. Eyferth, and G. Rudinger, eds. Development as Action in Context.. Berlin: Springer-Verlag, 1986. 203-227; Lerner, R., M. Karson, M. Meisels, and J. R. Knapp. "Actual and Perceived Attitudes of Late Adolescents: The Phenomenon of the Generation Gap." Journal of Genetic Psychology 126 (1975): 197-207. 5. Leventhal, Howard, and Patricia Keeshan. "Promoting Healthy Alternatives to Substance Abuse." In Millstein, Susan, Anne C. Petersen, and Elena O. Nightingale, eds. Promoting the Health of Adolescents: New Directions for the Twenty-first Century. New York: Oxford University Press, 1993. 260-284. 6. Jessor, Richard, and S. L. Jessor. Problem Behavior and Psychosocial Development: A Longitudinal Study of Youth. New York: Academic Press, 1977. 7. Centers for Disease Control. "Cigarette Smoking Among Adults-United States, 1992." Morbidity and Mortality Weekly Report 43:19 (20 May 1994): 342-346.

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Page 99 8. Bray, Robert M., L. A. Kroutil, J. W. Luckey, S. C. Wheeless, V. G. Iannacchione. D. W. Anderson, M. E. Marsden, and G. H. Dunteman. Highlights: 1992 Worldwide Survey of Substance Abuse and Health Behaviors Among Military Personnel. RTI/5154/06-17FR. Research Triangle Institute, December 1992. 45. 9. Johnston, Lloyd, P. O'Malley, and J. Bachman. "Monitoring the Future Study." Press release. The University of Michigan, Ann Arbor. January 27, 1994. 10. SmithKline Beecham. Gallup Report: A National Survey of Americans Who Smoke. New York, 1993. 11. Manning, Anita. "Poll Shows More Back Smoking Ban." USA Today (16 Mar. 1994): Dl; and Nichter, Mark, Mimi Nichter, C. Ritenbaugh, and N. Vuckovic. "The Teen Lifestyle Project: Preliminary Report, 1994." University of Arizona, Dept. of Anthropology. Unpublished data. 12. Allen, Karen, A. Moss, G. A. Giovino, D. R. Shopland, and J. P. Pierce. "Teenage Tobacco Use: Data Estimates From the Teenage Attitudes and Practices Survey, United States, 1989." Advance Data 224 (I Feb. 1993): 9. 13. Centers for Disease Control and Prevention. Preventing Tobacco Use Among Young People. A Report of the Surgeon General, 1994. S/N 017-001-004901-0. Washington, DC: U.S. Department of Health and Human Services, 1994. 78. 14. Johnston, Lloyd D., P. M. O'Malley, and J. G. Bachman. National Survey Results on Drug Use from Monitoring the Future Study, 1975-1992; Vol. II. NIH Pub. No. 93-3598.  Washington, DC: National Institute on Drug Abuse, 1993. 15-17. 15. Ibid., 15. 16. Schinke, Steven P., Robert F. Shilling, Lewayne D. Gilchrist, Marianne R. Ashby, and E. Kitajima. "Native Youth and Smokeless Tobacco: Prevalence Rates, Gender Differences, and Descriptive Characteristics." NCI Monograph 8: Smokeless Tobacco Use in the United States. NIH Pub. No. 89-3055. (1989): 39-42. 17. Schinke, Steven P., Robert F. Schilling, Lewayne D. Gilchrist, Marianne R. Ashby, and Eiji Kitajima. "Pacific Northwest Native American Youth and Smokeless Tobacco Use." International Journal of Addiction 22:9 (1987): 881-884; Bruerd, B. "Smokeless Tobacco Use Among Native American School Children." Public Health Reports 105:2 (1990): 196-201. 18. Schinke et al., 1989. 19. Centers for Disease Control. "Smokeless Tobacco Use in Rural Alaska." Morbidity and Mortality Weekly Report 36:10 (20 Mar. 1987): 140-143. 20. Eisen, M., G. L. Zellman, and A. L. McAlister. "A Health Belief Model Approach to Adolescents' Fertility Control: Some Pilot Program Findings." Health Education Quarterly 12:2 (1985): 185-210; Michielutte, R., and R. A. Diseker. "Children's Perception of Cancer in Comparison to Other Chronic Illnesses." Journal of Chronic Diseases 35:11 (1982): 843-852; and Price, James H., S. M. Desmond, M. Wallace, D. Smith, and P. M. Stewart. "Differences in Black and White Adolescents' Perceptions about Cancer." Journal of School Health 58:2 (1988): 66-70. 21. DiClemente, Ralph, Cherrie Boyer, and Edward Morales. "Minorities and AIDS: Knowledge, Attitudes, and Misconceptions Among Black and Latino Adolescents." American Journal of Public Health 78:1 (1988): 55-57. 22. Bray, Robert M., L. A. Kroutil, J. W. Luckey, S. C. Wheeless, V. G. Iannacchione. D. W. Anderson, M.E. Marsden, and G. H. Dunteman. 1992 World Survey of Substance Abuse and Health Behaviors Among Military Personnel. RTI /5154/06-16FR Research Triangle Institute, December 1992. 6-2, 6-3. 23. Cronan, Terry A., Terry L. Conway, and Suzanne L. Kaszas. "Starting to Smoke in the Navy: When, Where, and Why?" Social Science and Medicine 33:12 (1991): 1349-1353. 24. Gusfield, Joseph R. "The Social Symbolism of Smoking and Health." In Rabin, Robert L., and Stephen D. Sugarman, eds. Smoking Policy: Law, Politics, and Culture. New York: Oxford University Press, 1993. 67. 25. SmithKline Beecham.

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Page 100 26. Marttila & Kiley, Inc. Highlights From an American Cancer Society Survey of U.S. Voter Attitudes Toward Cigarette Smoking. Boston, MA: Marttila & Kiley, Inc., 9 Sept. 1993. 25-26. 27. Kagan, Robert A., and Jerome H. Skolnick. "Banning Smoking: Compliance Without Enforcement." In Rabin, Robert L., and Stephen D. Sugarman. eds. Smoking Policy: Law, Politics, and Culture. New York: Oxford University Press, 1993. 83. 28. Bonnie, Richard J. "The Efficacy of Law as a Paternalistic Instrument." In Melton, Gary, ed. Nebraska Symposium on Human Motivation, 1985. Lincoln: University of Nebraska, 1986: 131-211. 29. Leventhal, Howard, Kathleen Glynn, and Raymond Fleming. "Is the Smoking Decision an 'Informed Choice'? Effect of Smoking Risk Factors on Smoking Beliefs." Journal of the American Medical Association 257:24 (1987): 3373-3376. 30. Nichter, Mark, Mimi Nichter, C. Ritenbaugh, and N. Vuckovic. The Teen Lifestyle Project: Preliminary Report, 1994. (Unpublished.) 31. Tuakli, Nadu, M. A. Smith, and C. Heaton. "Smoking in Adolescence: Methods for Health Education and Smoking Cessation." Journal of Family Practice 31:4 (1990): 369-374. 32. Sherman, Steven J., Clark C. Presson, Laurie Chassin, Eric Corty, and Richard Olshavsky. "The False Consensus Effect in Estimates of Smoking Prevalence: Underlying Mechanisms." Personality and Social Psychology Bulletin 9:2 (1983): 197-207. 33. Sussman, Steve, Clyde W. Dent, Jill Mestel-Rauch, C. Anderson Johnson, William B. Hansen, and Brian R. Flay. "Adolescent Nonsmokers, Triers, and Regular Smokers' Estimates of Cigarette Smoking Prevalence: When Do Overestimations Occur and by Whom?" Journal of Applied Social Psychology 18:7 (1988): 537-551. 34. Chassin, Laurie, Clark C. Presson, Steven J. Sherman, Eric Corty, and Richard W. Olshavsky. "Predicting the Onset of Cigarette Smoking in Adolescents: A Longitudinal Study." Journal of Applied Social Psychology 14:3 (1984): 224-243; Collins, Linda M., Steve Sussman, Jill Mestel Rauch, Clyde W. Dent, C. Anderson Johnson, William B. Hansen, and Brian R. Flay. "Psychosocial Predictors of Young Adolescent Cigarette Smoking: A Sixteen-Month, Three-Wave Longitudinal Study." Journal of Applied Social Psychology 17:6 (1987): 554-573. 35. Pierce, John P., A. Farkas, N. Evans, C. Berry, W. Choi, B. Rosbrook, M. Johnson, and D. G. Bal. Tobacco Use in California 1992. A Focus on Preventing Uptake in Adolescents. Sacramento, California: Department of Health Services, 1993. 43. 36. Ibid. See tables B-6, B-7. 37. Ibid., 48. 38. Nichter et al. 39. Pierce, John P., Lora Lee, and Elizabeth Gilpin. "Smoking Initiation by Adolescent Girls, 1944 Through 1988." Journal of the American Medical Association 271:8 (1994): 608-611. 40. Robinson, Robert G., Michael Pertschuk, and Charyn Sutton. "Smoking and African Americans." In Samuels, Robert G., Michael Pertschuk, and Charyn Sutton, eds. Improving the Health of the Poor: Strategies for Prevention. Menlo Park, CA: Henry J. Kaiser Family Foundation, May 1992. 157. 41. Lewit, Eugene M., Douglas Coate, and Michael Grossman. "The Effects of Government Regulation on Teenage Smoking." Journal of Law and Economics 24:3 (1981): 545-573. 42. Centers for Disease Control and Prevention. Preventing Tobacco Use, 188. 43. Flay, Brian R. "Mass Media Linkages with School-Based Programs for Drug Abuse Prevention." Journal of School Health 56:9 (1986): 402-406; Leventhal, Howard, and Paul D. Cleary. "The Smoking Problem: A Review of the Research and Theory in Behavioral Risk Modification." Psychological Bulletin 88:2 (1980): 370-405; and Warner, K. E., and H. A. Murt. "Impact of the Antismoking Campaign on Smoking Prevalence: A Cohort Analysis." Journal of Public Health Policy 3:4 (1982): 374-390. 44. Sussman, Steve, Clyde W. Dent, Brian R. Flay, William B. Hansen, and C. Anderson Johnson. "Psychosocial Predictors of Cigarette Smoking Onset by White, Black, Hispanic, and Asian Adolescents in Southern California." Morbidity and Mortality Weekly Report 36:4 (1987): 1 IS-17S. 45. Hunter, Saundra, Janet B. Croft, Igor A. Vizelber, and Gerald S. Berenson. "Psychosocial

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