Final Project Milestone One: Problem Identification and Statement : (Tobacco use and dependence in New Hampshire)

AssociationBetweenHouseholdandWorkplaceSmokingRestrictionsandAdolescentSmoking.pdf

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ORIGINAL CONTRIBUTION

Association Between Household and Workplace Smoking Restrictions and Adolescent Smoking Arthur J. Farkas, PhD Elizabeth A. Gilpin, MS Martha M. White, MS John P. Pierce, PhD

S INCE THE HEALTH RISKS OF SMOK- ing became generally known following the release of the 1964 surgeon general’s report,1 adult

smoking prevalence in the United States has declined steadily.2,3 Not only has adult cessation increased,2-4 but initia- tion of smoking by adults became rare by 1980,5 when the age of initiation of regular smoking had shifted from early adulthood to the midteenage years or younger.6,7 Beginning in the early 1970s, youth smoking also began to decline. However, in the mid-1980s, the de- cline was arrested, and during the early 1990s, adolescent smoking increased rapidly.7-11 Although there is some in- dication that adolescent smoking de- clined slightly from 1996 to 1998,11 the magnitude of the increase in the 1990s alarmed many public health profes- sionals and focused attention on pub- lic policy to reduce adolescent smok- ing. Recent prevention efforts during the 1990s have emphasized school pro- grams, media campaigns, and enforce- ment of laws restricting the sale of ciga- rettes to youth.

In 1991, we suggested that smoking restrictions in the workplace might be an important public health strategy for reducing smoking in young adults.12

Hill and Borland13 reported that about

a third of adult Australian smokers stated that they first started smoking regularly at work. Workplace smoking restrictions can reduce the opportu- nity to smoke, and thereby interrupt establishment of nicotine addiction. A number of studies have shown that workplace smoking restrictions are associated with increased ces- sation14-18 and reduced cigarette con- sumption.14,16-26

It is important to determine whether policies restricting smoking in the workplace might be effective in reduc- ing smoking among adolescents who

Author Affiliations: Cancer Prevention and Control Program, Cancer Center, University of California, San Diego. Corresponding Author and Reprints: Arthur J. Far- kas, PhD, Cancer Prevention and Control Program, Cancer Center, University of California, 9500 Gilman Dr, La Jolla, CA 92093-0645 (e-mail: afarkas @ucsd.edu).

Context Recent marked increases in adolescent smoking indicate a need for new pre- vention approaches. Whether workplace and home smoking restrictions play a role in such prevention is unknown.

Objective To assess the association between workplace and home smoking restric- tions and adolescent smoking.

Design, Setting, and Subjects Data were analyzed from 2 large national population- based surveys, the Current Population Surveys of 1992-1993 and 1995-1996, which included 17 185 adolescents aged 15 to 17 years.

Main Outcome Measures Smoking status of the adolescents surveyed, com- pared by presence of home and workplace smoking restrictions.

Results After adjusting for demographics and other smokers in the household, ado- lescents who lived in smoke-free households were 74% (95% confidence interval [CI], 62%-88%) as likely to be smokers as adolescents who lived in households with no smoking restrictions. Similarly, adolescents who worked in smoke-free workplaces were 68% (95% CI, 51%-90%) as likely to be smokers as adolescents who worked in a workplace with no smoking restrictions. Adolescent smokers were 1.80 (95% CI, 1.23-2.65) times more likely to be former smokers if they lived in smoke-free homes. The most marked relationship of home smoking restrictions to current adolescent smoking occurred in households where all other members were never-smokers. Cur- rent smoking prevalence among adolescents in homes without smoking restrictions approached that among adolescents in homes with a current smoker but with smoking restrictions.

Conclusions Parents with minor children should be encouraged to adopt smoke- free homes. Smoke-free workplaces can also augment smoking prevention. These find- ings emphasize the importance of tobacco control strategies aimed at the entire popu- lation rather than at youth alone. JAMA. 2000;284:717-722 www.jama.com

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work. Although few young adoles- cents are employed, by midadoles- cence many have part-time jobs. While there is evidence of an association be- tween home smoking restrictions and adult smoking behavior,27-29 there is little information about their poten- tial impact on adolescents. Assuming such an association, public policy that encourages parents to voluntarily adopt home smoking restrictions might prove useful for prevention of adolescent smoking. Two studies showed less smoking experimentation among elementary school students living in households that restricted smok- ing30,31; 1 of these studies31 also exam- ined middle school students and found a similar effect. Only 1 study has ex- amined home smoking restrictions in relationship to smoking among high school students; it also included middle school students and analyzed current regular smoking instead of experimen- tation, but no significant relationship was demonstrated.32

The objective of this study was to ex- amine whether household and work- place smoking restrictions are associ- ated with lower rates of adolescent smoking. We used data from popula- tion-based surveys conducted in the 1990s that asked questions about smok- ing and included adolescents 15 to 17 years of age. Thus, we explore the re- lationship of smoking restrictions to current or former smoking at the time of the interview.

METHODS Data Sources

We combined data from 6 monthly Cur- rent Population Surveys (CPSs) con- ducted in 1992-1993 and 1995-1996 that contained a special Tobacco Use Supple- ment.33 The CPSs are conducted con- tinuously by the US Census Bureau for labor force monitoring; they cover the ci- vilian, noninstitutionalized population aged 15 years or older.34 The CPS is a probability sample based on a stratified sampling scheme of clusters of house- holds, and typically surveys about 56000 households containing approximately 110 000 persons each month. The labor

force interviews are conducted with an adult household member who re- sponds for all eligible household mem- bers. In contrast, the special Tobacco Use Supplement was individually adminis- tered to each household member aged 15 years or older. Response rates for the CPS Labor Force Core Questionnaire were over 93% for the 6 monthly surveys, while the self-response rates for the To- bacco Use Supplement were over 84%. About a quarter of the interviews were conducted in person with the remain- der conducted by telephone. We re- stricted the main analyses to the 17 185 teenaged self-respondents who were 15 to 17 years of age when surveyed.

Measures Smoking Status. Tobacco Use Supple- ment respondents were asked, “Have you smoked at least 100 cigarettes in your entire life?” Those responding “no” were classified as never-smokers, while those responding “yes” were clas- sified as smokers. Smokers were asked, “Do you now smoke cigarettes every day, some days, or not at all?” Respondents who answered “every day” or “some days” were classified as current smok- ers while those who answered “not at all” were considered former smokers.

Household Smokers. Adolescent re- spondents were divided into 3 groups, depending on the presence of current, former, and never-smokers aged 15 years or older in the household. For this purpose, the smoking status of the other household members was used even if obtained by proxy report. Adolescents in the first group lived with never- smokers only; adolescents in the sec- ond group lived with at least 1 former smoker but no current smokers; and adolescents in the third group lived with at least 1 current smoker.

Home Smoking Restrictions. To de- termine the level of household smok- ing restrictions, respondents were asked, “Which statement best describes the rules about smoking in your home?” Re- sponse choices were: (1) no one is al- lowed to smoke anywhere, (2) smok- ing is allowed in some places or at some times, or (3) smoking is permitted any-

where. These responses were desig- nated as smoke-free, partial ban, and no smoking restrictions, respectively.

Workplace Smoking Restrictions. Employment status and workplace smoking restrictions were used to as- sign each adolescent respondent to one of 5 categories. The workplace policy questions were asked only of adoles- cents who worked in either the public or private sectors and worked indoors but not in someone’s home. Indoor work- ers were asked, “Which of these best de- scribes your place of work’s smoking policy for indoor public or common ar- eas such as lobbies, rest rooms, and lunch rooms?” and “Which of these best de- scribes your place of work’s smoking policy for work areas?” Response choices for both questions were: (1) not al- lowed in any (public/work) areas, (2) al- lowed in some (public/work) areas, and (3) allowed in all (public/work) areas. Those who answered that smoking was “not allowed in any public areas” and “not allowed in any work areas” were classified as working in smoke-free work- places. Those who only answered that smoking was “not allowed in any work areas” were classified as working under a work-area ban. The remaining indoor workers were classified as working un- der a partial work-area ban. Depending on employment status, the remaining adolescents were classified as either other workers (mostly outdoor workers or workers in someone’s home) or non- workers.

School Enrollment and Hours Worked. School enrollment was ascer- tained by proxy or self-response for per- sons 16 to 24 years of age. In 1992-1993 the survey asked, “Last week was ( . . . ) attending or enrolled in a high school, college or university?” and for those 15 years or older employed in the previous week, “How many hours did ( . . . ) work last week at all jobs?” In 1995-1996, the questions changed slightly: “Last week, was ( . . . ) enrolled in a high school, col- lege or university?” and “How many hours per week did ( . . . ) usually work at the main job?” and “How many hours per week did ( . . . ) usually work at other (job/jobs)?”

IMPACT OF RESTRICTIONS ON ADOLESCENT SMOKING

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Statistical Methods The public-use data files for the 6 sur- veys included a weighting variable for self-respondents that ensures esti- mates from the combined sample for each year (ie, 1992-1993, 1995-1996) are representative of the 1990 US popu- lation by sex, age, race/ethnicity, and region. Besides adjusting for demo- graphic differences in nonresponse, the weights also take into account the sam- pling design.

x2 Procedures were used to assess dif- ferences among percentages (Yates- adjusted for 2 3 2 tables, and Mantel- Haenszel when a graded response was expected). A result was considered sig- nificant for these tests if P,.01.

Logistic regression analyses included variables for age and school enrollment, sex, ethnicity, survey year, the smoking status of other household members, household smoking restrictions, and workplace smoking restrictions as inde- pendent variables in 2 analyses with dif- ferent dependent variables: (1) ever- smoking and (2) in a nested analysis, ces- sation. For all percentages and odds ratios, 95% confidence intervals (CIs) were computed. Variance estimates were inflated by a factor of 1.29 (design effect) to account for the deviation of the sample design from a simple random sample of the US population.34

RESULTS Changes in Smoking Restrictions Over Time

There were 1813 current and 386 former smokers, which we grouped as ever- smokers. The total number of never- smokers was 14986. TABLE 1 shows that the percentage (95% CI) of adolescents (15-17 years old), who lived in smoke- free households increased significantly from 47.8% (±1.1%) in 1992-1993 to 55.0% (±1.3%) in 1995-1996. This was true regardless of the smoking status of other household members, but adoles- cents living with current smokers were less likely to live in smoke-free homes at either time. While the percentage of adolescents who worked outside the home increased from 22.8% (±0.9%) to 27.2% (±1.2%) from 1992-1993 to 1995-

1996, the percentage of adolescent in- door workers in smoke-free work- places increased from 22.7% (±1.9%) to 40.0% (±2.4%). The mean (SD) for hours worked during the previous week by em- ployed adolescents was 16.0 (9.6), which indicates that most adolescents were part- time workers.

Smoking Restrictions and Being a Smoker TABLE 2 shows the likelihood that an adolescent was a smoker according to age and school enrollment, household com- position, and level of smoking restric- tions. While most of the 16- and 17-year- olds were enrolled in school, 4.2% (95%

Table 1. Adolescents Who Report Smoke-Free Households and Workplaces*

Variable

1992-1993 1995-1996

No. of Respondents

% (95% Confidence

Interval) No. of

Respondents

% (95% Confidence

Interval)

Report smoke-free household Overall 10 083 47.8 (±1.1) 7102 55.0 (±1.3)

Type of household Never-smokers only 3484 70.5 (±1.7) 2720 75.4 (±1.8)

Former but no current smokers

2593 64.5 (±2.1) 1720 73.7 (±2.4)

$1 current smoker 4006 16.6 (±1.3) 2662 22.6 (±1.8)

Work outside the home for pay 10 083 22.8 (±0.9) 7102 27.2 (±1.2)

Report working in a smoke-free workplace†

2398 22.7 (±1.9) 2019 40.0 (±2.4)

*The percentages are weighted. P,.001 for all comparisons. †Restricted to adolescents who work indoors and outside the home.

Table 2. Lifetime Ever-Smoker Status Among US Adolescents in Association With Home and Work Smoking Restrictions*

Variable

No. of Respondents (N = 17 185)

% Ever-Smokers (±95% Confidence

Interval)

Odds Ratio (95% Confidence

Interval) P

Value

School enrollment status and age, y Enrolled/15 5473 8.0 (±0.8) 1.0

Enrolled/16 5785 11.7 (±0.9) 1.46 (1.22-1.74) ,.001

Not enrolled/16 253 33.1 (±6.6) 6.89 (4.63-10.25) ,.001

Enrolled/17 5142 14.7 (±1.1) 1.94 (1.63-2.32) ,.001

Not enrolled/17 532 41.4 (±4.8) 9.09 (6.84-12.07) ,.001

Household composition Never-smokers only 6204 6.4 (±0.7) 1.0

Former and never-smokers 4313 10.8 (±1.1) 1.66 (1.37-2.01) ,.001

$1 current smoker 6668 20.4 (±1.1) 3.00 (2.51-3.58) ,.001

Household smoking restrictions None 4549 19.3 (±1.3) 1.0

Partial 3880 14.9 (±1.3) 0.99 (0.84-1.16) .86

Smoke-free 8756 8.8 (±0.7) 0.74 (0.62-0.88) ,.001

Employment and workplace smoking restrictions

Indoor work and partial work-area ban

1500 19.1 (±2.3) 1.0

Indoor work and work-area ban

648 17.0 (±3.3) 0.80 (0.56-1.12) .13

Indoor work and smoke-free workplace

1328 14.0 (±2.1) 0.68 (0.51-0.90) .002

Other workers† 941 17.8 (±2.8) 0.97 (0.72-1.32) .83

Not working 12 768 11.6 (±0.6) 0.77 (0.63-0.95) .004

*The percentages are weighted. Odds ratios were adjusted for demographics (sex, race/ethnicity, survey year) and other variables in the analyses.

†Defined as mostly outdoor workers or workers in someone’s home.

IMPACT OF RESTRICTIONS ON ADOLESCENT SMOKING

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CI, ± 0.7%) of the 16-year-olds and 9.4% (95% CI,±1.0%) of the 17-year-olds had dropped out. The odds ratios were ad- justed for demographics (sex, race/ ethnicity, survey year) not shown and the remaining variables in the analysis. Older adolescents were more likely to be smok- ers than younger adolescents and drop outs were particularly likely to be smok- ers. Adolescents living with current

smokers were 3 times as likely to be smokers than those living with never- smokers, but those living with at least 1 former smoker (and no current smok- ers) were only about 1.66 (95% CI, 1.37- 2.01) times more likely to be smokers. Adolescents living in smoke-free homes were 0.74 (95% CI, 0.62-0.88) times as likely to be smokers as those living in homes with no smoking restrictions; par- tial bans had no significant effects on ado- lescents not smoking. In addition, ado- lescents who worked indoors in a smoke- free workplace were 0.68 (95% CI, 0.51- 0.90) times as likely to be smokers than those who worked indoors with a par- tial work-area ban. Nonworking adoles- cents were 0.77 (95% CI, 0.63-0.95) times as likely to be smokers as indoor workers with a partial work-area ban.

Adolescents who live in smoke-free homes are half as likely to be smokers as those living in homes with no restric- tions, regardless of their school enroll- ment status (FIGURE 1). Further, ado- lescents enrolled in school who work in smoke-free workplaces are signifi- cantly less likely to be smokers than other workers and those working under a par- tial indoor ban (FIGURE 2), but work- place restrictions appear to have little ef- fect on dropouts.

Cessation and Smoking Restrictions TABLE 3 shows the likelihood that an adolescent smoker was in cessation when interviewed according to age and school enrollment, household composition, and levels of smoking restrictions. Again, the odds ratios are adjusted for other demo- graphics and the remaining variables in the analysis. The likelihood of cessa- tion was 1.60 (95% CI, 1.09-2.33) times higher for adolescents living with a former smoker (but no current smok- ers) compared with those living with a current smoker, but adolescents living with only never-smokers did not show significantly increased cessation.

Adolescents living in smoke-free households were 1.80 (95% CI, 1.23- 2.65) times more likely to be in cessa- tion than those living in households with no restrictions on smoking. Par-

tial smoking restrictions were not sig- nificantly associated with cessation. Un- like ever-smoking, cessation was not significantly related to workplace smok- ing restrictions.

Household Composition, Home Smoking Restrictions, and Adolescent Smoking Prevalence Adolescents living with a current smoker had the highest smoking preva- lence (FIGURE 3). Prevalence was about the same for adolescents living with a current smoker under either a partial smoking ban or in a smoke-free home, but was lower compared with those with no household smoking restric- tions (P = .02). In households with a former smoker (but no current smok- ers), there was no significant relation- ship between smoking restrictions and prevalence (P = .09). When adoles- cents lived only with never-smokers, however, the level of home smoking re- striction was highly associated with prevalence (P,.001). Note that preva- lence for the group with no home smok- ing restrictions was only slightly higher than prevalence in households with at least 1 former smoker, and it ap- proached the level for adolescents liv- ing with a current smoker in house- holds with only a partial restriction.

COMMENT The results from these national sur- veys strongly suggest that smoke-free workplaces and homes are associated with significantly lower rates of ado- lescent smoking. Further, even after ad- justment for the presence of smokers in the household and school enroll- ment, smoke-free homes have a greater association with lower rates of smok- ing prevalence than smoke-free work- places. In addition, smoke-free homes were associated with an increased like- lihood of smoking cessation in adoles- cent smokers. Complete rather than partial bans on smoking in the home and in the workplace produced the most significant associations.

Because only about 25% of adoles- cents are employed, smoke-free homes should affect adolescent smoking more

Figure 1. Percentage and 95% Confidence Limit of Ever-Smokers Among Adolescents Aged 16 to 17 Years as a Function of the Level of Household Smoking Restrictions and School Enrollment (n = 11 712)

Household Smoking Restriction

% E

ve r-

S m

o ke

Enrolled in School Not Enrolled in School

Smoke-Free (n = 5932)

Partial Ban (n = 2638)

No Ban (n = 3142)

Data based on the Current Population Survey on Tobacco Use for 1992-1993 and 1995-1996.

Figure 2. Percentage and 95% Confidence Limit of Ever-Smokers Among Adolescents Aged 16 to 17 Years as a Function of Employment and Workplace Smoking Restrictions and School Enrollment (n = 11 712)

Employment and Workplace Smoking Restrictions

% E

ve r-

S m

o ke

Enrolled in School Not Enrolled in School

Not Working

(n = 7913)

Other Workers (n = 645)

Partial Indoor Work-

Area Ban (n = 1346)

Indoor Work-

Area Ban (n = 597)

Indoor Smoke-

Free (n = 1211)

Data based on the Current Population Survey on Tobacco Use for 1992-1993 and 1995-1996. Other workers defined as mostly outdoor workers or work- ers in someone’s home.

IMPACT OF RESTRICTIONS ON ADOLESCENT SMOKING

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than smoke-free workplaces. Al- though a smoke-free workplace was as- sociated with a significantly reduced likelihood of an adolescent becoming a smoker, it may not completely counter the influence of the increased income a job provides. Adolescents with more spending money, either from employ- ment or other sources, are more likely to smoke, and smoke more on average than adolescents with less discretion- ary spending money.35

It is well-known that adolescents of parents who smoke are more likely to be- come smokers.36-39 Our results were ad- justed for the smoking status of other household members, generally the par- ents. We previously showed that ado- lescents whose parents had quit smok- ing were only about two thirds as likely to be smokers as those with a parent who still smoked.40 Further, adolescent smok- ers whose parents had quit were twice as likely to be former smokers when sur- veyed than those with a parent who still smoked. Finally, the earlier in the ado- lescent’s life that parents quit, the lower the risk of their adolescent smoking. Adult smokers (18 years or older) who lived or worked under smoke-free con- ditions were more likely to be actively trying to quit and were more likely to be in cessation for at least 6 months when surveyed than were those reporting no home or workplace smoking restric- tions.28 Thus, smoke-free homes and workplaces may also have an indirect ef- fect on adolescent smoking by encour- aging parental cessation.

Adoption of a smoke-free home policy sends a message to family members that smoking is not condoned, while the lack of such a policy may send the opposite message. Adolescents who lived in households without a complete ban where all of the other members were never-smokers were nearly as likely to be current smokers as adolescents who lived in households with a current smoker and at least partial household smoking restrictions. Public health policy should continue to educate the population concerning the dangers of secondhand smoke and stress that adopting smoke-free homes is some-

thing concrete that parents can do to in- fluence their children not to smoke.

Tobacco control efforts should also continue to encourage smoke-free workplace ordinances throughout the United States. Besides protecting non- smokers from secondhand smoke and encouraging smoking cessation among adults, smoke-free workplaces may be an important strategy for reducing the percentage of adolescents who be- come smokers. Adolescents who ex- periment with smoking and spend a sig- nificant amount of their time at work where smoking is prohibited may not be as likely to progress to established smoking. However, longitudinal stud- ies are needed to establish this link.

There are some limitations to the pre- sent study. It is not longitudinal. Thus, the results, while suggestive of impor- tant associations, are not definitive. Smoking status is by self-report, and it is not validated by biochemical assay; however, studies of adolescents have

shown that there is stability of self- reported substance use and that ques- tionnaires provide reliable data.41 Sec-

Figure 3. Current Smoking Prevalence and 95% Confidence Limit Among Adolescents Aged 15 to 17 Years as a Function of Exposure to Smokers in the Household and the Level of Household Smoking Restrictions (N = 17 185)

Smoking Status of Other Household Members

% C

u rr

en t

S m

o ke

≥1 Current Smoker

(n = 4549)

≥1 Former Smoker

(n = 3880)

Never-Smokers Only

(n = 8756)

No Ban Partial Ban Smoke-Free

Data based on the Current Population Survey on To- bacco Use for 1992-1993 and 1995-1996.

Table 3. Cessation Among US Adolescents in Association With Home and Work Smoking Restrictions*

Variable

No. of Ever-Smokers

(n = 2199)

% Former Smokers (±95%

Confidence Interval)

Odds Ratio (95% Confidence

Interval) P

Value

School enrollment status and age, y Enrolled/15 458 21.7 (±4.3) 1.0

Enrolled/16 677 19.1 (±3.4) 0.89 (0.59-1.35) .53

Not enrolled/16 89 13.4 (±8.0) 0.58 (0.24-1.40) .16

Enrolled/17 747 18.3 (±3.1) 0.80 (0.53-1.21) .22

Not enrolled/17 228 13.0 (±5.0) 0.63 (0.34-1.16) .08

Household composition $1 current smoker 1357 15.2 (±2.2) 1.0

Former and never-smokers 446 26.8 (±4.7) 1.60 (1.09-2.33) .005

Never-smokers only 396 19.6 (±4.5) 1.13 (0.75-1.69) .51

Household smoking restrictions None 868 13.6 (±2.6) 1.0

Partial 578 16.4 (±3.4) 1.15 (0.77-1.71) .44

Smoke-free 753 25.3 (±3.5) 1.80 (1.23-2.65) ,.001

Employment and workplace smoking restrictions

Indoor work and partial work-area ban

271 14.1 (±4.7) 1.0

Indoor work and work-area ban

113 14.9 (±7.5) 1.18 (0.50-2.79) .66

Indoor work and smoke-free workplace

179 20.1 (±6.7) 1.58 (0.81-3.06) .12

Other workers† 158 20.4 (±7.1) 1.71 (0.85-3.45) .09

Not working 1478 19.0 (±2.3) 1.46 (0.89-2.41) .09

*The percentages are weighted. Odds ratios were adjusted for demographics (sex, race/ethnicity, survey year) and the other variables in the analyses.

†Defined as mostly outdoor workers or workers in someone’s home.

IMPACT OF RESTRICTIONS ON ADOLESCENT SMOKING

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ond, telephone surveys of adolescents often produce lower smoking preva- lence estimates than school surveys.7 The CPS measure of smoking (at least 100 cigarettes in one’s lifetime) may be less sensitive to underreporting. Adoles- cents who have smoked a fair amount are probably less inclined to try to hide it from parents (they likely already know) or to be embarrassed about it with the interviewer. Finally, there is the issue of reporting discrepancy regarding home smoking restrictions by adolescents com- pared with household adults. House- hold adults also were asked about house- hold smoking restrictions, and the

agreement among parents and adoles- cents was high (81%). When there was a household consensus, about the same percentage of adults reported more restrictive smoking policies (9%) as less restrictive policies (10%) when com- pared with the adolescent. Perceived policy is probably more important than actual policy set by household adults; if adolescents think there are smoking restrictions, it is likely that they will act accordingly.

In summary, our findings suggest an important role for smoke-free homes and workplaces in reducing adoles- cent smoking. More importantly, they

stress the importance of targeting to- bacco control interventions to the en- tire population for primary preven- tion rather than emphasizing special programs aimed only at adolescents. As the prevalence trends in the mid- 1960s and early 1970s for adults and adolescents indicate, it is likely that an- other downturn in adolescent smok- ing would follow a significant further decline in adult smoking.

Funding/Support: Preparation of this article was sup- ported by grant CA 72092 to the Cancer Prevention Research Unit from the National Institutes of Health and by grant 6PT-5002 from the University of California, Oak- land, Tobacco-Related Disease Research Program.

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IMPACT OF RESTRICTIONS ON ADOLESCENT SMOKING

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