Pediatric Annals

Preventing Regular Teenage Cigarette Smoking

William J Wong-McCarthy, PHD; Ellen R Gritz, PHD

Abstract

"The physician is shrinking from his duty if he does not do his utmost to discourage the smoking habit." These words conclude Roy Dawber's summary of the results of the 24-year epidemiological Framingham study with respect to cigarette smoking as a cardiovascular risk factor.1 The general public is overwhelmingly persuaded that cigarette smoking is unhealthful.2 This article will assume, therefore, that all but a miniscule number of physicians already believe cigarette smoking to be a health-threatening activity.

SMOKING INCIDENCE AMONG TEENAGERS

Nationwide surveys of the prevalence of adolescent (12 to 18 years old) smoking were conducted on a biannual basis by the Federal Government between 1968 and 1974 and then again in 1979.M Regular smoking is defined as smoking at least one cigarette a week and having smoked at least 100 cigarettes (five packs) previously.

Until 1975 the percentage of teenagers adopting the cigarette smoking habit increased for girls and increased or stayed at a relatively high level for boys.3 Between 1974 and 1979 the overall proportion of boys smoking regularly declined markedly 10.7% whereas the overall proportion of girls appeared to level out at a point slightly greater than that of boys, 12.7%. 3'5 More than 80% of all teenagers experiment with cigarettes at one time or another but only 20% to 30% are currently becoming regular smokers by age ]8.6,7 A very sizable fraction of our teenage population is obviously electing to expose itself to enhanced risk of cardiovascular disease, to greater likelihood of contracting cancer, and to other sources of death and injury arising from the use of cigarettes.

IMPORTANCE OF PREVENTING TEENAGE ADOPTION OF THE SMOKING HABIT

Discouraging teenagers from smoking is an urgent and difficult task. Merely delaying the onset of regular cigarette smoking reduces subsequent smoking-related morbidity and mortality significantly.8 The economic costs of cigarette smoking to society taken as a whole run to some $41 billion a year.9 Although it is estimated that 30 million adult Americans have given up cigarettes permanently, smoking cessation by adult smokers has been widely confirmed to be difficult and generally of short duration before relapse.10 Cigarette smoking is classified as a dependence disorder by behavioral scientists," and formally included in the diagnostic nomenclature of the American Psychiatric Association.12 Dependence on, or addiction to tobacco is thought to be due to nicotine, the primary alkaloid. The pharmacologie effects of nicotine are diverse, affecting both central and peripheral nervous systems and several organ systems. Nicotine acts directly via cholinergic stimulation and indirectly via the release of catecholamines.'3 Classified as a stimulant, nicotine exerts both stimulating and sedating effects upon mood (arousal), and is used by persons for this modulation effect, as well as for psychosocial reasons. Attempts at cessation of the smoking habit are accompanied by severe craving and withdrawal symptoms. Cessation is made difficult both by the element of physical and psychological addiction to nicotine, as well as the need to learn a new repertoire of non-cigarette related responses to daily events and Stressors (stimuli), on the order of 20 to 40 times per day for the average smoker.

Prevention of regular smoking in teenagers appears to be the most effective way to reduce the overall incidence of cigarette smoking. The family physician has an important role to play in discouraging teenagers from smoking. This article discusses the physician's role and how he or she can most effectively help the teenager to decide not to smoke.

Many physicians are probably baffled by teenagers' decisions to take up the smoking habit. Why do young people expose themselves to the nausea of initial smoking and persist in using a known…

"The physician is shrinking from his duty if he does not do his utmost to discourage the smoking habit." These words conclude Roy Dawber's summary of the results of the 24-year epidemiological Framingham study with respect to cigarette smoking as a cardiovascular risk factor.1 The general public is overwhelmingly persuaded that cigarette smoking is unhealthful.2 This article will assume, therefore, that all but a miniscule number of physicians already believe cigarette smoking to be a health-threatening activity.

SMOKING INCIDENCE AMONG TEENAGERS

Nationwide surveys of the prevalence of adolescent (12 to 18 years old) smoking were conducted on a biannual basis by the Federal Government between 1968 and 1974 and then again in 1979.M Regular smoking is defined as smoking at least one cigarette a week and having smoked at least 100 cigarettes (five packs) previously.

Until 1975 the percentage of teenagers adopting the cigarette smoking habit increased for girls and increased or stayed at a relatively high level for boys.3 Between 1974 and 1979 the overall proportion of boys smoking regularly declined markedly 10.7% whereas the overall proportion of girls appeared to level out at a point slightly greater than that of boys, 12.7%. 3'5 More than 80% of all teenagers experiment with cigarettes at one time or another but only 20% to 30% are currently becoming regular smokers by age ]8.6,7 A very sizable fraction of our teenage population is obviously electing to expose itself to enhanced risk of cardiovascular disease, to greater likelihood of contracting cancer, and to other sources of death and injury arising from the use of cigarettes.

IMPORTANCE OF PREVENTING TEENAGE ADOPTION OF THE SMOKING HABIT

Discouraging teenagers from smoking is an urgent and difficult task. Merely delaying the onset of regular cigarette smoking reduces subsequent smoking-related morbidity and mortality significantly.8 The economic costs of cigarette smoking to society taken as a whole run to some $41 billion a year.9 Although it is estimated that 30 million adult Americans have given up cigarettes permanently, smoking cessation by adult smokers has been widely confirmed to be difficult and generally of short duration before relapse.10 Cigarette smoking is classified as a dependence disorder by behavioral scientists," and formally included in the diagnostic nomenclature of the American Psychiatric Association.12 Dependence on, or addiction to tobacco is thought to be due to nicotine, the primary alkaloid. The pharmacologie effects of nicotine are diverse, affecting both central and peripheral nervous systems and several organ systems. Nicotine acts directly via cholinergic stimulation and indirectly via the release of catecholamines.'3 Classified as a stimulant, nicotine exerts both stimulating and sedating effects upon mood (arousal), and is used by persons for this modulation effect, as well as for psychosocial reasons. Attempts at cessation of the smoking habit are accompanied by severe craving and withdrawal symptoms. Cessation is made difficult both by the element of physical and psychological addiction to nicotine, as well as the need to learn a new repertoire of non-cigarette related responses to daily events and Stressors (stimuli), on the order of 20 to 40 times per day for the average smoker.

Prevention of regular smoking in teenagers appears to be the most effective way to reduce the overall incidence of cigarette smoking. The family physician has an important role to play in discouraging teenagers from smoking. This article discusses the physician's role and how he or she can most effectively help the teenager to decide not to smoke.

Many physicians are probably baffled by teenagers' decisions to take up the smoking habit. Why do young people expose themselves to the nausea of initial smoking and persist in using a known carcinogen when there appear to be no advantages to the use of cigarettes? It is cognitively easy to attribute teenage smoking onset to uninformed and irrational decision making. Basic research into the causes and correlates of smoking onset, however, has shown that teenagers who start smoking are informed14'15 and are prepared to explain at least in general terms, why they smoke. Clinical interventions must take these facts into account if they are to be effective in discouraging teenagers from adopting the cigarette smoking habit.

What are the facts? What should the family health provider know that will help him or her to construct an effective anti-smoking message? Nearly 20 years of extensive research have suggested a number of major influences on the adolescent's decision to smoke regularly but no comprehensive explanation for adolescent smoking currently exists. We have proposed two correlational models that include these major influences and that help to explain adoption of the smoking habit by teenagers.16'17 These models are too detailed to present here. They include such influences on adolescent smoking as: biological background, demographic background, valued personality characteristics, personal goals, smoking models, pro-smoking messages, anti-smoking messages, and personality impressions of typical smokers of particular brands of cigarettes. The model (Figure 1) we include here is derived from our earlier models but includes only those influences on adolescent smoking that relate to social status. The evidence so far suggests that adolescents' need for social status is the single strongest influence in their decision to smoke. The circles designate the factors that we believe from our reading of the literature to be the social status related factors of greatest importance in explaining adolescent cigarette smoking. The "x" associated with each factor is a particular measure (usually questionnaire scales) that are used to assess the importance of the factor for explaining teenage smoking.

The model assumes that teenagers are attracted to cigarette smoking as an important means of projecting an image of a full-fledged competent member of society. Reviews have consistently shown that teenage smokers are more likely than teenage nonsmokers to imitate the behavior of adults, try to appear older than they are, emulate respected (often older) peers and demand greater autonomy.6,18,19 These behavioral characteristics of teenage smokers may be described as aspects of a syndrome of "accelerated maturity."20

CHARACTERISTICS OF TEENAGERS WHO USE TOBACCO REGULARLY

If the antecedents of regular teenage smoking are to be reliably identified, prospective studies with repeated, annual measures of subjects' attitudes and smoking behavior are required. Unfortunately, almost all studies of teenage smoking have been limited to same-year comparisons of subjects varying in age rather than multiple-year studies where each subject's answers can be compared with answers that the same subject gave in earlier years. Results of studies involving same-year comparisons of subjects varying in age, however, can be suggestive of the true causes of smoking. Some of the most reliable results of such studies are given below. The characteristics distinguishing smokers from nonsmokers which are listed here are drawn from national survey data1 as well as from a sizable number of smaller scale research projects.

FIGURE 1CORRELATIONAL MODEL OF MAJOR STATUS-RELATED INFLUENCES ON ADOLESCENT CIGARETTE SMOKING

FIGURE 1

CORRELATIONAL MODEL OF MAJOR STATUS-RELATED INFLUENCES ON ADOLESCENT CIGARETTE SMOKING

Relative to nonsmokers, teenage smokers:

1. More frequently hold jobs while in school.

2. Have lower grades and lower academic aspirations.

3. Come more from single parent families.

4. More often have parents or siblings who smoke.

5. More often have friends who smoke.

Teenage smokers are also:

6. More likely to come from lower income families.

7. More likely to engage in delinquent behavior.

8. More likely to use other drugs such as hard liquor, beer and marijuana.

A THEORETICAL EXPLANATION

The following explanation of why some young people adopt the smoking habit was developed in order to make sense of the varied empirical findings reported above.

The overwhelming predominance of teenagers among all newly recruited regular smokers suggested that there was something uniquely characteristic about adolescent development that magnified the attractiveness of cigarette smoking.1,6

Probably the most important feature of early adolescent development is the development of an autonomous self-concept. Prior to adolescence the individual's identity is tied primarily to that of his or her family. The adolescent enteringjunior high school, however, typically moves from a close-to-home elementary school to a larger, farther-from-home school.21'" The greater heterogeneity of values, favorite activities, language, and socioeconomic background in the secondary school provides the developing adolescent with much broader opportunities for observing and trying out different conceptions of self. Empirical data do, in fact, show that entry to junior high school marks a major increase in the individual's need to develop an autonomous self image.23

Early adolescents are very self-conscious and very concerned about the discrepancy between their ideal selfimage and their real self-image.24 They will consciously try to change their real self-image to more greatly approximate their ideal self-image. The personality traits of toughness, friendliness, confidence, attractiveness and enthusiasm that are popularly attributed to cigarette smokers25 could be sufficiently alluring to persuade adolescents to adopt the smoking habit. The use of cigarette smoking in an attempt to improve one's self image could help to explain why most adult smokers started their habit during their adolescent years.6

What ideal self image an adolescent might choose would depend on background factors such as gender, age, health, socioeconomic class and ethnicity. In the school setting, academic achievement and athletic achievement are primary means of reducing the distance between one's ideal self image and one's real self image. Low socioeconomic status and a minority ethnic status often make high academic or athletic achievement difficult, thereby eliminating two primary means by which teenagers can improve their real self image.

For those adolescents performing well in school, a major component of their status is simply seniority in the system. For the significant minority who are failing courses, being kept back a year or who leave high school prior to graduation, however, a premium is placed on status that can be achieved primarily through voluntary peer group associations. In a period when social skills are just developing, such teenagers find themselves feeling a critical need for social skills that will make them appear sufficiently attractive to warrant their inclusion in significant peer groups. Academically marginal students will be particularly concerned about acquiring or maintaining relatively high social status to compensate for their low academic status. It is reasonable to assume that such adolescents would be very interested in knowing better how to project an image of themselves as adroit, fluent, authoritative and as persons with whom people could build a mutually beneficial solid relationship.

We contend that such adolescents are likely to view the smoking of cigarettes as an excellent, easily-mastered vehicle for the projection of an enhanced social image. The adoption of the smoking habit can be viewed as a way of enlarging a person's repertoire of possible communicative behaviors, a fact that would be disproportionately appealing to tbe status-sensitive sociolinguistically naive adolescent. In a communicative setting, the smoker - as opposed to the same person not smoking - is likely to be viewed as more at ease and more socially adept because the smoker has an entire repertoire of well-practiced, sequenced motor commands that constitute the act of smoking a cigarette.

College-bound adolescents are less likely to smoke for several reasons, including the fact that they are less likely to have had parents who smoked and because they are more likely to come from families of higher-than-average income. These reasons aside, college-bound adolescents are less likely to smoke because, by implicitly agreeing to remain in the autonomy-restricting role of student for the foreseeable future, they do no have the same incentive as the non-college-bound to use cigarette smoking to jockey for social status. During their extended adolescence, college-bound men and women pick up the social skills that render superfluous the perceived social advantages of smoking. This may help explain why they do not take up regular smoking in as great n u moer s as do their academically less-invested age- ma tes.26,27

The above scenario is a plausible explanation for why particular adolescents adopt the cigarette smoking habit. Longitudinal research is currently underway to test these hypotheses.28

PRESSURES TO SMOKE

The typical adolescent will accord great respect and credibility to an anti-smoking message presented by his or her family physician. Unfortunately, the impact of a 10minute anti-smoking message once a year from a physician pales in comparison to the impact of the daily barrage of pro-smoking messages that the typical teenager sees and hears.

Adult models who smoke, older peers who smoke, the pro-smoking predominance of media portrayals of smoking and cigarette advertising have all been identified as being powerful influences on teenagers' decisions to smoke. Recently, there has been an upsurge of adolescent use of smokeless tobacco (snuff and chewing tobacco) as well, prompted by vigorous sports-related commercial promotion; this is another way to introduce teenagers to potential tobacco dependence and health problems.29 The impact of peer and family influences have been discussed above. The impact of cigarette advertising is discussed below in some detail because it tends to be underestimated.

Total cigarette advertising in the United States is currently estimated at approximately one billion dollars.30 Teenagers read newspapers, news magazines, general interest magazines, and sports magazines, and they are frequently exposed to outdoor advertising. These media are inundated with cigarette ads; for example, four of the top 10 newspaper advertisers and four of the top 1 5 magazine advertisers are tobacco companies. Almost one out of every two billboards showing a nationally advertised product has a cigarette advertisement on it.31 We sampled the three most recent issues of nine selected magazines (e.g., Time, Sports Illustrated, Popular Science, and Psychology Today). Our informal survey showed that nearly one ad in six was a cigarette ad. The proportion of cigarette ads to all ads ranged from a low of 7.2% for Glamour magazine to a high of 29.1% for Psychology Today. By any measure, cigarette advertising is an undeniably common potential source of information and influence in the lives of American teenagers.

There are many reasons for expecting that cigarette advertising would influence teenagers to adopt the smoking habit. One reason is that theme advertising, while ostensibly peopled by adult (over 25 years old) models, often portrays its models as engaged in activities and dressed in clothes that are suitable only for adolescents. Secondly, the sheer ubiquitousness of cigarette advertising - in magazines, in newspapers, in sports arenas and in billboard displays - encourages the teenager to think of smoking as a more popular habit than it actually is.3,4 A third reason is that advertising campaigns capitalize on already existing myths about the social benefits of smoking. These are benefits that are disproportionately appealing to adolescents. A recent FTC review25 of cigarette advertising stated: "...the dominant themes of cigarette advertising are that smoking is associated with youthful vigor, good health, good looks, and personal, social and professional acceptance and success..." These putative benefits of smoking happen to coincide with issues that teenagers have volunteered are of greatest concern to them, namely dating, academic achievement, peer relationships, and future success.32

PRESSURES NOT TO SMOKE

Cigarette smoking appears to be a behavior appropriate to a particular lifestyle. Parents, teachers and other adult authorities usually discourage the adolescent from adopting the independent, drug-involving lifestyle that is so often associated with cigarette smoking. Particular arguments against cigarette smoking seem to have had less effect on deterring adolescents from adopting the smoking habit than the concerted effort of adult society to discourage the lifestyle associated with cigarette smoking. Such concerted efforts are reflected in society's establishing appropriate legislation to discourage cigarette smoking.

Vellar has reported that, in Sweden, the combination of strict laws governing the use of tobacco, high federal excise taxes and governmental campaigns to discourage smoking has been successful in discouraging continued increases in the incidence of cigarette smoking among Swedes." Warner and others have noted similar success in the U.S. in discouraging continued increases in smoking through large scale anti-smoking information campaigns.34,35

There is evidence that a wholesale change of societal attitude toward cigarette smoking and smokers is already having an effect on well-informed segments of the population.36,37 The recent declines in reported smoking by teenage boys and the leveling off of increases in smoking by teenage girls have been attributed to the emergence of new anti-smoking norms. If this interpretation is accurate, then one can expect further declines in smoking in the future.

EFFECTIVENESS OF PREVENTION PROGRAMS

Programs designed to discourage young people from adopting the cigarette smoking habit have generally shown little success. Thompson surveyed all reports of anti-smoking health education programs published between 1960 and 1976.38 She found that school-wide anti-smoking campaigns, youth-to-youth programs and research on the effectiveness of different teaching methods at best produced significant improvement only in the students' attitudes toward smoking. These programs did not produce improvement in behavior.10,39,40 More recent reviews, however, have noted that recent decreases in public tolerance of smoking behavior have made it more likely that combinations of formerly ineffective prevention and cessation strategies would now be effective.10

Preliminary reports of current research programs that use an innovative, multi-method, psychosocial approach have been reporting significantly lower rates of smoking onset for their treatment groups.40^44 These school-based programs include a number of common features adapted from the seminal work of Evans et al including a focus on immediate rather than long term health consequences of smoking and including the training of the adolescent subjects to resist the pressures of pro-smoking social influences.45

RECOMMENDED STRATEGIES FOR DISCOURAGING ADOLESCENTS FROM SMOKING

The literature on smoking prevention and our personal experience suggest a number of steps that the physician may take to optimize the effectiveness of his/her antismoking message. The recommendations include:

* Only cursorily mention the long range health consequences of smoking - adolescents already know about the cardiovascular and cancer risks that cigarette smoking entails and, in any case, are considerably more motivated by concern for the more immediate consequences of smoking. These include changes in heart rate, blood pressure, and carbon monoxide concentration in the blood as well as minor respiratory symptoms.

* Discuss the immediate physiological consequences of cigarette smoking in some detail to alert or remind the adolescent that one doesn't have to wait 20 years for cigarette smoking to have a measurable, negative impact on body functioning.

* Mention alternatives to smoking for establishing a self-image that appears tough, independent, mature or sophisticated. These might include activities such as establishing a weight-lifting regimen, jogging and dancing, joining a Boys' Club or Girls' Club, or doing volunteer work for a hospital or a political or religious group.

* Mention the negative cosmetic effects of smoking - earlier wrinkling of skin, yellow stains on teeth and fingers, tobacco odor on clothes and breath.

* Mention the increasing ostracism of smokers by nonsmokers, informally and legally mandated, at places of work and in public gatherings in enclosed spaces.

* Mention the increasing evidence that second-hand smoke is injurious to the health of nonsmokers who are regularly exposed to smoke.46

* Acknowledge that many adults once believed that important social benefits were associated with smoking but also point out that the vast majority of adult smokers would now quit smoking if they could.

* Arm the cooperative adolescent with arguments for dealing with peer pressure to smoke cigarettes, using the topics and arguments used by Evans et al.39 One such argument would be that, by not smoking, a teenager demonstrates independence and nonconformity, traits normally prized by youth.

* Request posters and pamphlets from local voluntary health agencies (e.g., American Cancer Society, American Heart Association and American Lung Association) to put out in the waiting room. Suggest to patients that they pick up copies of such pamphlets on their way out.

These prevention strategies will help to reinforce adolescents' increasingly prevalent perception of cigarette smoking as a violation of popular norms. Such perceptions should lead to a decline in adolescent smoking onset.

REFERENCES

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2. Poll finds growing belief that disease is linked to smoking. Los Angeles Times Friday. September 4, 1981, p 4.

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7. Palmer AB: Some variables contributing to the onset of cigarette smoking among junior high school students. Soc Sci Med 4:359-366, 1970.

8. O'Rourke TW, Stone DB: A prospective study of trends in youth smoking. Journal of Drug Education 1:49-61. 1971.

9. Luce BR, Schweitzer SO: The economic costs of smoking-induced illness, in Jarvik ME. Cullen JW, Gritz ER, et al (eds): Research on Smoking Behavior. NIDA Monograph 17, US Dept of Health, Education, and Welfare publication No. (ADM) 78-581. Public Health Service, Government Printing Office, 1977.

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12. Diagnostic and Statistical Manual of Mental Disorders III. Washington, American Psychiatric Association, 1980.

13. Voile RL, Koelle GB: Ganglionic stimulating and blocking agents, in Goodman LS, Gilman A (eds): The Pharmacological Basis of Therapeutics, ed 5. New York. MacMillan Publishing Co Inc. 1975, pp 565-574.

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15. Williams CL: Primary prevention of cancer beginning in childhood. Prev Med 9:275-280, 1980.

16. Wong- McCarthy WJ: Adolescent cigarette smoking as a strategy for social skills enhancement. Presented at the Annual Meeting of the International Communication Association, Minneapolis, Minnesota, May, 1981.

17. Wong-McCarthy WJ, Gritz ER: Cigarette advertising effects on adolescent smoking. Grant proposal, UCLA Psychology Department, 1981.

18. Evans RI, Roselle RM, Mittelmark MB, et al: Deterring onset of smoking in children - Knowledge of immediate physiological effects and coping with peer pressure, media pressure, and parent modeling. Journal of Applied Social Psychology 8:126-135, 1978.

19. Kozlowski LT: Psychosocial influences on cigarette smoking, in Krasncgor NA (ed): The Behavioral Aspects of Smoking. NIDA Monograph 26, US Dept of Health, Education, and Welfare publication No. (ADM) 79-882, Public Health Service, Government Printing Office, 1979, pp 97-126.

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21. Looft WR: Egocentrism and social intervention in adolescence. Adolescence 6:485-495, 1971.

22. Kokenes B: Grade level differences in factors of seJf-esteem. Developmental Psychology 10:954-958. 1974.

23. Simmons RG, Rosenberg F, Rosenberg M: Disturbance in the self-image at adolescence. Am Sociol Rev 38:553-568, 1973.

24. Katz P, Zigler E: Self-image disparity: A developmental approach. J Pers Soc Psychol 5:186-195, 1967.

25. Staff Report on the Cigarette Advertising Investigation. Federal Trade Commission, May 1981.

26. Reeder LG: Sociocultural factors in the etiology of smoking behavior: An assessment, in Jarvik ME, Cullen JW, Gritz ER, et al (eds): Research on Smoking SeAavior.NIDA Monograph 17, US Dept of Health, Education, and Welfare publication No. (ADM) 78-581. Public Health Service, Government Printing Office, 1977, pp 186-201.

27. Green DE: Patterns of tobacco use in the United States, in Krasnegor NA (ed): Cigarette Smoking as a Dependence Process. NlDA Monograph 23, US Dept of Health, Education, and Welfare publication No. (ADM) 79800, Public Health Service, Government Printing Office, 1979.

28. Wong-McCarthy WJ, Feshbach S, Jarvik ME: Social communication functions of adolescent smoking. Grant proposal. Los Angeles, UCLA Psychology Department, 1979.

29. Gritz ER, Baer- Weiss V, Bcnowitz NL, et al: Plasma nicotine and confinine concentrations in habitual smokeless tobacco users. Clinical Pharmacol Ther 30:201-209, 1981.

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40. Evans RI, Rozelle RM, Maxwell SE, et al: Social modeling films to deter smoking in adolescents: Results of a three year field investigation. Journal of Appi Psychol 66:399-415. 1981.

41. Perry CL, Killen J, Slinkard LA, et al: Peer teaching and smoking preventions among junior high students. Adolescence 15:277-281, 1980.

42. McAlister AL, Perry CL, Killen J, et al: Pilot study of smoking, alcohol and drug abuse prevention. Am J Public Health 70:719-721, 1980.

43. Hurd PH, Johnson CA, Pechacek TF, et al: Prevention of cigarette smoking in seventh grade students. J Behav Med 3:15-27, 1980.

44. Botvin G, Eng A, Williams CL: Preventing the onset of cigarette smoking through life skills training. Prev Med 9:135- 143, 1980.

45. Evans RI: Smoking in children: Developing a social psychological strategy of deterrence. Prev Med 5:122-127, 1976.

46. White JR, Froeb HF: Small airways dysfunction in nonsmokers chronically exposed to tobacco smoke. N Engl J Med 302:720-723, 1980.

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