ORIGINAL RESEARCH
A Motivational Profile for Smoking Among Adolescents Amanda Gimenes Bonilha, PhD, Elisa Sebba Tosta de Souza, MD, Mayara Piani Sicchieri, BStat, Jorge Alberto Achcar, PhD, Jos´e Alexandre S. Crippa, MD, and Jos´e Baddini-Martinez, MD
Objectives: To characterize a motivational profile of reasons for smoking among teenagers. To investigate the influence of clinical and social elements on observed scores. Methods: High school students who smoked in the past month (n = 226; age, 16.4 ± 10 years; 46.5% male) answered a questionnaire during school time. The instrument included the University of S˜ao Paulo Reasons for Smoking Scale (USP-RSS), the Fagerstr¨om Test for Nicotine Dependence, and clinical and social information. The USP-RSS scores from 307 healthy adult smokers (67.5% male; age, 37.9 ± 11.2 years) were also used for comparisons. Results: Most of the adolescents (90.2%) exhibited low or very low levels of nicotine addiction (median Fagerstr¨om Test for Nicotine Dependence score 0, range 0 to 8). The mean scores of the USPRSS subscales were as follows: Addiction, 1.9 ± 1.1; Pleasure From Smoking, 3.0 ± 1.3; Tension Reduction, 2.4 ± 1.3; Stimulation, 1.9 ± 0.9; Automatism, 1.3 ± 0.6; Handling, 2.3 ± 1.1; Social Smoking, 1.9 ± 1.0; Weight Control, 1.4 ± 1.0; and Affiliative Attachment, 1.6 ± 0.9. In comparison with adults, teenagers exhibited lower scores for Addiction, Pleasure From Smoking, Tension Reduction, Automatism, Weight Control, and Affiliative Attachment and higher scores for Social Smoking (P < 0.05). Older age, past school failure, illicit drugs use, alcohol abuse, high levels of perceived stress, and the death of at least one parent were associated with high scores for all subscales. Conclusions: The USP-RSS subscales Addiction, Pleasure From Smoking, and Social Smoking were important factors for adolescent smoking. Comparisons with adult smokers stressed the importance of the component of Social Smoking. The identification of distinctive factors that drive teenagers to smoke might help in making decisions dealing with interventions aimed at smoking cessation and control. From the Internal Medicine Department (AGB, ESTS, JBM), Social Medicine Department (MPS, JAA), and Department of Neuroscience and Behavior (JASC), Medical School of Ribeir˜ao Preto, University of S˜ao Paulo, Ribeir˜ao Preto, S˜ao Paulo, Brazil. Received for publication October 26, 2012; accepted August 28, 2013. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (http://www .journaladdictionmedicine.com). The authors declare no conflicts of interest. Send correspondence and reprint requests to Jos´e Baddini-Martinez, MD, Internal Medicine Department, Medical School of Ribeir˜ao Preto, University of S˜ao Paulo, Avenida Bandeirantes 3900, CEP: 14048-900, Ribeir˜ao Preto, S˜ao Paulo, Brazil. Email: [email protected]. C 2013 American Society of Addiction Medicine Copyright ISSN: 1932-0620/13/0706-0439 DOI: 10.1097/01.ADM.0000434987.76599.c0
Key Words: adolescent behavior, health behavior, smoking, stress psychological, substance-related disorders (J Addict Med 2013;7: 439–446)
I
t is well known that most smokers start smoking during adolescence. The number of teenagers who smoke seems to be increasing in several countries throughout the world, mainly in developing countries (US Department of Health and Human Services, 2012). As a consequence, understanding the factors leading to smoking in adolescents is a matter that still deserves study. Although the psychoactive properties of nicotine are recognized as the most important contributor to tobacco addiction, several other factors are also involved with the development and continuation of smoking (Benowitz, 2010). These include social influences, psychological characteristics, and genetic profiles (Bierut et al., 2009; Cosci et al., 2011; Adachi-Mejia et al., 2012). Tobacco dependence can then be considered as a broad construct comprising several psychosocial facets. Motivations for smoking have been studied for decades in this context, and several motivational factors have been recognized, including the desire to maximize positive effects or to minimize negative affects (Ikard et al., 1969; Currie, 2004; S´anchez-Johnsen et al., 2006). In recent years, we have developed a new tool for evaluating smokers’ motivations (Souza et al., 2010). The University of S˜ao Paulo Reasons for Smoking Scale (USP-RSS) resulted from the incorporation of 9 questions from the 68item Wisconsin Inventory of Smoking Dependence Motives with 21 questions from the Modified Reasons for Smoking Scale (Berlin et al., 2003; Piper et al., 2004). Factor analysis resulted in a 21-question solution grouped into 9 subscales. The initial study showed that the USP-RSS provides a distinct framework of motivational factors for smoking, with satisfactory psychometric properties (Souza et al., 2010). Although several studies have been published in the literature, using distinct versions of Reasons for Smoking scales in various settings, we were not able to find any study that was conducted to analyze these features specifically in adolescents (Ikard et al., 1969; Berlin et al., 2003; Currie, 2004; S´anchezJohnsen et al., 2006; Souza et al., 2010). The objectives of this study were to characterize a motivational profile of reasons for smoking among teenagers by using the USP-RSS and to investigate the influence of certain clinical and social elements on the observed scores. The USP-RSS profile of teenagers who smoke was also compared with that of adults.
J Addict Med r Volume 7, Number 6, November/December 2013
Copyright © 2013 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
439
J Addict Med r Volume 7, Number 6, November/December 2013
Bonilha et al.
METHODS Study Sample and Survey Methods The present data are part of a larger research aimed to characterize risk factors associated with smoking among Brazilian adolescents. It was an observational study involving adolescent students of the secondary education system. Ten secondary schools of the city of Ribeir˜ao Preto, in the state of S˜ao Paulo, southeast Brazil, were selected by lottery to participate in the study. Six classes were randomly selected to be investigated in each school, 2 for every 1 of the 3 grade components of the Brazilian high school system. Students were invited to participate in the study and received a consent form to be signed by a parent or a guardian at home. A few days later, the students answered an anonymous, multiple-choice, selfadministered questionnaire during regular classes. The instrument was developed on the basis the questionnaire used in the Brazilian arm of the Global Youth Tobacco Surveillance study along with information concerning the Fagerstr¨om Test for Nicotine Dependence (FTND), the 10-item Perceived Stress Scale, and the 21 questions from the USP-RSS (Heatherton et al., 1991; Luft et al., 2007; Warren et al., 2008). The USP-RSS comprises 9 subscales, each one exhibiting an individual score ranging from 1 to 5 in a Likert scale (1, never; 2, seldom; 3, occasionally; 4, frequently; and 5, always). For the overall scale, the Cronbach α coefficient is 0.83 and all individual components exhibit high test-retest reliability (Souza et al., 2010). Each component reflects a distinct motivation for smoking: • Addiction: a roughly equivalent to the degree of physical dependence to tobacco, this factor basically evaluates cigarette withdrawal symptoms. • Pleasure From Smoking: assess smoking secondary to the search for pleasurable sensations. • Tension Reduction: assess smoking because of the search for attenuation of afflictive feelings. • Stimulation: assess smoking motivated by the search for better cognition and vigil. • Automatism: assess smoking without intention or awareness as consequence of conditioned behaviors. • Handling: assess smoking because of the search for tactile sensorimotor stimulation. • Social Smoking: assess smoking because of the feeling of facilitation of interpersonal relationships attributed to tobacco consumption. • Weight Control: reflects smoking moved by the fear of gaining weight. • Affiliative Attachment: reflects strong emotional ties to smoking and cigarettes. A total of 2044 questionnaires were distributed to the students, and data from 2014 subjects were suitable for analysis. Adolescents who smoked (AS) were defined as subjects who had consumed at least 1 cigarette in the past month. This definition of a smoker is the same as used in previous studies dealing with smoking prevalence in adolescents that were performed worldwide (Warren et al., 2008). This study focuses on data available for 226 participants classified as AS.
440
The USP-RSS scores of adult smokers used for comparisons were obtained from a sample of 307 volunteers, at least 19 years old (67.5% male; mean age, 37.9 ± 11.2 years). They were part of a study dealing with the validation of this scale that was previously published (Souza et al., 2010). These volunteers were regular smokers, without known physical or psychiatric comorbidities, and had answered a similar self-applied questionnaire, just before spontaneous blood donation, 3 years before. The mean number of cigarettes smoked per day for this group was 15.0 ± 9.1 units, and the mean FTND score was 3.7 ± 2.5.
Measures The following characteristics of the AS were evaluated in the study: • Religion: measured the subject’s belonging to or professing any type of religious conviction. • School failure: determined the presence of at least 1 episode of grade repetition throughout the subject’s school career. • Own income: provided information regarding the presence of regular paid activity or salary. • Alcohol consumption: measured the usual behavior of the volunteer concerning alcoholic beverages and classified the behavior into 1 of 3 categories: A, no intake; B, low or occasional intake; and C, heavy or regular intake. Students who used to get drunk sporadically or who used to drink at least once a week were included in the last class. • Illicit drug consumption: measured the customary behavior of the volunteer regarding the use of agents, such as pot, cocaine, crack, and similar substances. Adolescents who reported at least sporadic use of such products were included in the “yes” category. • Smoking parents/guardians: recorded information about the presence of current or past smoking history in at least 1 of the volunteer’s tutors. • Parents’ condition: reported on the type of familial structure and support available to the teenager and involved 3 categories: A, both parents are alive and living together; B, both parents are alive but living apart; and C, 1 or both parents are dead. • Smoking siblings/cousins: reported on the presence or absence of smokers among close relatives. • Smoking friends: reported on the presence or absence of smokers among close friends. • Perceived stress level: categorized as either high or low. High levels of stress were defined as a 10-item Perceived Stress Scale value equal to or greater than 17, the median of the scores for the whole 2014 original group. • Degree of nicotine addiction: classified on the basis of FTND scores as very low (0-2), low (3-4), moderate (5), high (6-7), and very high (8-10).
Data Analysis The influence of sociodemographic variables on the USP-RSS profiles of AS was investigated using the statistical multivariate method known as “profile analysis,” where the P values were obtained using Lambda and Wilks statistics (Johnson and Wichem, 1998). The same methodology was also C
2013 American Society of Addiction Medicine
Copyright © 2013 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
J Addict Med r Volume 7, Number 6, November/December 2013
used to compare the teenager profiles with previous obtained profiles for adult smokers. A longer explanation about “profile analysis” may be found as Supplemental Digital Content. The statistical analysis followed the following steps: 1. When it was characterized parallelism among the profiles (P > 0.05 for the parallel profile tests), the next step was to verify whether the profiles were coincident. It means that P values ≤0.05 in the coincident profile tests indicate absence of this hypothesis, that is to say, there is a significative difference among the analyzed categories of the USP-RSS profiles. 2. When it was characterized absence of parallelism among the profiles (P ≤ 0.05 for the parallel profile tests), the study was complemented by univariate comparisons of the individual responses in each domain using the Student t tests or standard analysis of variance followed by the Tukey tests. This approach was taken to give better characterization of significative differences for the USP-RSS domain in study among the categories. The present study was approved by the institutional ethics committee, by the local state educational board, and by the principal of each school.
RESULTS The sample consisted of 226 high school students with a mean age of 16.4 ± 10 (range, 14-19) years. There were 121 (53.5%) female students and 105 (46.5%) male students. Regular cigarette consumption was reported by 133 (58.9%) subjects, and sporadic consumption was informed by 93 (41.1%). Most of the subjects (185, 81.9%) smoked between 1 and 10 cigarettes in their smoking days. The median time of cigarette consumption for the group was 1 year (range 0 to 11 years). The FTND scores of AS ranged from 0 to 8, with a median value of 0. Most of the adolescents (90.2%) exhibited low or very low levels of nicotine addiction. The clinical and social features of the group are given in Table 1. The mean and standard deviations of the scores for USPRSS domains in the 226 AS were as follows: Addiction, 1.9 ± 1.1; Pleasure From Smoking, 3.0 ± 1.3; Tension Reduction, 2.4 ± 1.3; Stimulation, 1.9 ± 0.9; Automatism, 1.3 ± 0.6; Handling, 2.3 ± 1.1; Social Smoking, 1.9 ± 1.0; Weight Control, 1.4 ± 0.9; and Affiliative Attachment, 1.6 ± 0.9. Figures 1 and 2 illustrate the influence of distinct factors on the USP-RSS profiles of smoking adolescents. The profiles exhibited coincidence and parallelism in the analysis involving the variables of sex, own income, smoking siblings/cousins, and smoking friends (Fig. 1). Therefore, these variables did not significantly influence the USP-RSS profile in the adolescent group. The USP-RSS profiles showed parallelism and no coincidences in relation to the variables of age, school failure, alcohol consumption, illicit drug use, parents’ condition, and levels of stress (Figs. 1 and 2). These results indicate that USPRSS scores homogeneously increased with age, particularly in comparisons of the lowest- and the highest-age categories, and in participants with school failures. The USP-RSS scores were also consistently higher in participants with a history of illicit drug use. In addition, low or occasional alcohol consumption C
Smoking Among Adolescents
TABLE 1. Clinical and Social Features of 226 Participants Enrolled in the Study Characteristic Sex Female Male Age, yr ≤14 15 16 17 ≥18 Religion No Yes School failure No Yes Own income No Yes Alcohol consumption No Low or occasional Heavy or regular Illicit drug consumption No Yes Smoking parents/guardians† No Yes Parents’ condition‡ A B C Smoking siblings/cousins No Yes Smoking friends No Yes Stress level PSS-10 score ≥17 PSS-10 score
A Motivational Profile for Smoking Among Adolescents Amanda Gimenes Bonilha, PhD, Elisa Sebba Tosta de Souza, MD, Mayara Piani Sicchieri, BStat, Jorge Alberto Achcar, PhD, Jos´e Alexandre S. Crippa, MD, and Jos´e Baddini-Martinez, MD
Objectives: To characterize a motivational profile of reasons for smoking among teenagers. To investigate the influence of clinical and social elements on observed scores. Methods: High school students who smoked in the past month (n = 226; age, 16.4 ± 10 years; 46.5% male) answered a questionnaire during school time. The instrument included the University of S˜ao Paulo Reasons for Smoking Scale (USP-RSS), the Fagerstr¨om Test for Nicotine Dependence, and clinical and social information. The USP-RSS scores from 307 healthy adult smokers (67.5% male; age, 37.9 ± 11.2 years) were also used for comparisons. Results: Most of the adolescents (90.2%) exhibited low or very low levels of nicotine addiction (median Fagerstr¨om Test for Nicotine Dependence score 0, range 0 to 8). The mean scores of the USPRSS subscales were as follows: Addiction, 1.9 ± 1.1; Pleasure From Smoking, 3.0 ± 1.3; Tension Reduction, 2.4 ± 1.3; Stimulation, 1.9 ± 0.9; Automatism, 1.3 ± 0.6; Handling, 2.3 ± 1.1; Social Smoking, 1.9 ± 1.0; Weight Control, 1.4 ± 1.0; and Affiliative Attachment, 1.6 ± 0.9. In comparison with adults, teenagers exhibited lower scores for Addiction, Pleasure From Smoking, Tension Reduction, Automatism, Weight Control, and Affiliative Attachment and higher scores for Social Smoking (P < 0.05). Older age, past school failure, illicit drugs use, alcohol abuse, high levels of perceived stress, and the death of at least one parent were associated with high scores for all subscales. Conclusions: The USP-RSS subscales Addiction, Pleasure From Smoking, and Social Smoking were important factors for adolescent smoking. Comparisons with adult smokers stressed the importance of the component of Social Smoking. The identification of distinctive factors that drive teenagers to smoke might help in making decisions dealing with interventions aimed at smoking cessation and control. From the Internal Medicine Department (AGB, ESTS, JBM), Social Medicine Department (MPS, JAA), and Department of Neuroscience and Behavior (JASC), Medical School of Ribeir˜ao Preto, University of S˜ao Paulo, Ribeir˜ao Preto, S˜ao Paulo, Brazil. Received for publication October 26, 2012; accepted August 28, 2013. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (http://www .journaladdictionmedicine.com). The authors declare no conflicts of interest. Send correspondence and reprint requests to Jos´e Baddini-Martinez, MD, Internal Medicine Department, Medical School of Ribeir˜ao Preto, University of S˜ao Paulo, Avenida Bandeirantes 3900, CEP: 14048-900, Ribeir˜ao Preto, S˜ao Paulo, Brazil. Email: [email protected]. C 2013 American Society of Addiction Medicine Copyright ISSN: 1932-0620/13/0706-0439 DOI: 10.1097/01.ADM.0000434987.76599.c0
Key Words: adolescent behavior, health behavior, smoking, stress psychological, substance-related disorders (J Addict Med 2013;7: 439–446)
I
t is well known that most smokers start smoking during adolescence. The number of teenagers who smoke seems to be increasing in several countries throughout the world, mainly in developing countries (US Department of Health and Human Services, 2012). As a consequence, understanding the factors leading to smoking in adolescents is a matter that still deserves study. Although the psychoactive properties of nicotine are recognized as the most important contributor to tobacco addiction, several other factors are also involved with the development and continuation of smoking (Benowitz, 2010). These include social influences, psychological characteristics, and genetic profiles (Bierut et al., 2009; Cosci et al., 2011; Adachi-Mejia et al., 2012). Tobacco dependence can then be considered as a broad construct comprising several psychosocial facets. Motivations for smoking have been studied for decades in this context, and several motivational factors have been recognized, including the desire to maximize positive effects or to minimize negative affects (Ikard et al., 1969; Currie, 2004; S´anchez-Johnsen et al., 2006). In recent years, we have developed a new tool for evaluating smokers’ motivations (Souza et al., 2010). The University of S˜ao Paulo Reasons for Smoking Scale (USP-RSS) resulted from the incorporation of 9 questions from the 68item Wisconsin Inventory of Smoking Dependence Motives with 21 questions from the Modified Reasons for Smoking Scale (Berlin et al., 2003; Piper et al., 2004). Factor analysis resulted in a 21-question solution grouped into 9 subscales. The initial study showed that the USP-RSS provides a distinct framework of motivational factors for smoking, with satisfactory psychometric properties (Souza et al., 2010). Although several studies have been published in the literature, using distinct versions of Reasons for Smoking scales in various settings, we were not able to find any study that was conducted to analyze these features specifically in adolescents (Ikard et al., 1969; Berlin et al., 2003; Currie, 2004; S´anchezJohnsen et al., 2006; Souza et al., 2010). The objectives of this study were to characterize a motivational profile of reasons for smoking among teenagers by using the USP-RSS and to investigate the influence of certain clinical and social elements on the observed scores. The USP-RSS profile of teenagers who smoke was also compared with that of adults.
J Addict Med r Volume 7, Number 6, November/December 2013
Copyright © 2013 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
439
J Addict Med r Volume 7, Number 6, November/December 2013
Bonilha et al.
METHODS Study Sample and Survey Methods The present data are part of a larger research aimed to characterize risk factors associated with smoking among Brazilian adolescents. It was an observational study involving adolescent students of the secondary education system. Ten secondary schools of the city of Ribeir˜ao Preto, in the state of S˜ao Paulo, southeast Brazil, were selected by lottery to participate in the study. Six classes were randomly selected to be investigated in each school, 2 for every 1 of the 3 grade components of the Brazilian high school system. Students were invited to participate in the study and received a consent form to be signed by a parent or a guardian at home. A few days later, the students answered an anonymous, multiple-choice, selfadministered questionnaire during regular classes. The instrument was developed on the basis the questionnaire used in the Brazilian arm of the Global Youth Tobacco Surveillance study along with information concerning the Fagerstr¨om Test for Nicotine Dependence (FTND), the 10-item Perceived Stress Scale, and the 21 questions from the USP-RSS (Heatherton et al., 1991; Luft et al., 2007; Warren et al., 2008). The USP-RSS comprises 9 subscales, each one exhibiting an individual score ranging from 1 to 5 in a Likert scale (1, never; 2, seldom; 3, occasionally; 4, frequently; and 5, always). For the overall scale, the Cronbach α coefficient is 0.83 and all individual components exhibit high test-retest reliability (Souza et al., 2010). Each component reflects a distinct motivation for smoking: • Addiction: a roughly equivalent to the degree of physical dependence to tobacco, this factor basically evaluates cigarette withdrawal symptoms. • Pleasure From Smoking: assess smoking secondary to the search for pleasurable sensations. • Tension Reduction: assess smoking because of the search for attenuation of afflictive feelings. • Stimulation: assess smoking motivated by the search for better cognition and vigil. • Automatism: assess smoking without intention or awareness as consequence of conditioned behaviors. • Handling: assess smoking because of the search for tactile sensorimotor stimulation. • Social Smoking: assess smoking because of the feeling of facilitation of interpersonal relationships attributed to tobacco consumption. • Weight Control: reflects smoking moved by the fear of gaining weight. • Affiliative Attachment: reflects strong emotional ties to smoking and cigarettes. A total of 2044 questionnaires were distributed to the students, and data from 2014 subjects were suitable for analysis. Adolescents who smoked (AS) were defined as subjects who had consumed at least 1 cigarette in the past month. This definition of a smoker is the same as used in previous studies dealing with smoking prevalence in adolescents that were performed worldwide (Warren et al., 2008). This study focuses on data available for 226 participants classified as AS.
440
The USP-RSS scores of adult smokers used for comparisons were obtained from a sample of 307 volunteers, at least 19 years old (67.5% male; mean age, 37.9 ± 11.2 years). They were part of a study dealing with the validation of this scale that was previously published (Souza et al., 2010). These volunteers were regular smokers, without known physical or psychiatric comorbidities, and had answered a similar self-applied questionnaire, just before spontaneous blood donation, 3 years before. The mean number of cigarettes smoked per day for this group was 15.0 ± 9.1 units, and the mean FTND score was 3.7 ± 2.5.
Measures The following characteristics of the AS were evaluated in the study: • Religion: measured the subject’s belonging to or professing any type of religious conviction. • School failure: determined the presence of at least 1 episode of grade repetition throughout the subject’s school career. • Own income: provided information regarding the presence of regular paid activity or salary. • Alcohol consumption: measured the usual behavior of the volunteer concerning alcoholic beverages and classified the behavior into 1 of 3 categories: A, no intake; B, low or occasional intake; and C, heavy or regular intake. Students who used to get drunk sporadically or who used to drink at least once a week were included in the last class. • Illicit drug consumption: measured the customary behavior of the volunteer regarding the use of agents, such as pot, cocaine, crack, and similar substances. Adolescents who reported at least sporadic use of such products were included in the “yes” category. • Smoking parents/guardians: recorded information about the presence of current or past smoking history in at least 1 of the volunteer’s tutors. • Parents’ condition: reported on the type of familial structure and support available to the teenager and involved 3 categories: A, both parents are alive and living together; B, both parents are alive but living apart; and C, 1 or both parents are dead. • Smoking siblings/cousins: reported on the presence or absence of smokers among close relatives. • Smoking friends: reported on the presence or absence of smokers among close friends. • Perceived stress level: categorized as either high or low. High levels of stress were defined as a 10-item Perceived Stress Scale value equal to or greater than 17, the median of the scores for the whole 2014 original group. • Degree of nicotine addiction: classified on the basis of FTND scores as very low (0-2), low (3-4), moderate (5), high (6-7), and very high (8-10).
Data Analysis The influence of sociodemographic variables on the USP-RSS profiles of AS was investigated using the statistical multivariate method known as “profile analysis,” where the P values were obtained using Lambda and Wilks statistics (Johnson and Wichem, 1998). The same methodology was also C
2013 American Society of Addiction Medicine
Copyright © 2013 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
J Addict Med r Volume 7, Number 6, November/December 2013
used to compare the teenager profiles with previous obtained profiles for adult smokers. A longer explanation about “profile analysis” may be found as Supplemental Digital Content. The statistical analysis followed the following steps: 1. When it was characterized parallelism among the profiles (P > 0.05 for the parallel profile tests), the next step was to verify whether the profiles were coincident. It means that P values ≤0.05 in the coincident profile tests indicate absence of this hypothesis, that is to say, there is a significative difference among the analyzed categories of the USP-RSS profiles. 2. When it was characterized absence of parallelism among the profiles (P ≤ 0.05 for the parallel profile tests), the study was complemented by univariate comparisons of the individual responses in each domain using the Student t tests or standard analysis of variance followed by the Tukey tests. This approach was taken to give better characterization of significative differences for the USP-RSS domain in study among the categories. The present study was approved by the institutional ethics committee, by the local state educational board, and by the principal of each school.
RESULTS The sample consisted of 226 high school students with a mean age of 16.4 ± 10 (range, 14-19) years. There were 121 (53.5%) female students and 105 (46.5%) male students. Regular cigarette consumption was reported by 133 (58.9%) subjects, and sporadic consumption was informed by 93 (41.1%). Most of the subjects (185, 81.9%) smoked between 1 and 10 cigarettes in their smoking days. The median time of cigarette consumption for the group was 1 year (range 0 to 11 years). The FTND scores of AS ranged from 0 to 8, with a median value of 0. Most of the adolescents (90.2%) exhibited low or very low levels of nicotine addiction. The clinical and social features of the group are given in Table 1. The mean and standard deviations of the scores for USPRSS domains in the 226 AS were as follows: Addiction, 1.9 ± 1.1; Pleasure From Smoking, 3.0 ± 1.3; Tension Reduction, 2.4 ± 1.3; Stimulation, 1.9 ± 0.9; Automatism, 1.3 ± 0.6; Handling, 2.3 ± 1.1; Social Smoking, 1.9 ± 1.0; Weight Control, 1.4 ± 0.9; and Affiliative Attachment, 1.6 ± 0.9. Figures 1 and 2 illustrate the influence of distinct factors on the USP-RSS profiles of smoking adolescents. The profiles exhibited coincidence and parallelism in the analysis involving the variables of sex, own income, smoking siblings/cousins, and smoking friends (Fig. 1). Therefore, these variables did not significantly influence the USP-RSS profile in the adolescent group. The USP-RSS profiles showed parallelism and no coincidences in relation to the variables of age, school failure, alcohol consumption, illicit drug use, parents’ condition, and levels of stress (Figs. 1 and 2). These results indicate that USPRSS scores homogeneously increased with age, particularly in comparisons of the lowest- and the highest-age categories, and in participants with school failures. The USP-RSS scores were also consistently higher in participants with a history of illicit drug use. In addition, low or occasional alcohol consumption C
Smoking Among Adolescents
TABLE 1. Clinical and Social Features of 226 Participants Enrolled in the Study Characteristic Sex Female Male Age, yr ≤14 15 16 17 ≥18 Religion No Yes School failure No Yes Own income No Yes Alcohol consumption No Low or occasional Heavy or regular Illicit drug consumption No Yes Smoking parents/guardians† No Yes Parents’ condition‡ A B C Smoking siblings/cousins No Yes Smoking friends No Yes Stress level PSS-10 score ≥17 PSS-10 score
