Do paediatricians provide brief intervention for adolescents who smoke?

AIMS: This study aimed to describe the self-reported practice of paediatricians in brief interventions for adolescents who smoke. We also aimed to compare practice with confidence, skills and knowledge of brief intervention and nicotine replacement therapy after a targeted training programme. METHODS: Medical staff at The Children's Hospital at Westmead completed a questionnaire of clinical practice and confidence in brief intervention for smoking cessation. Data were analysed comparing self-reported practice with confidence, skill and knowledge of brief interventions, based on Fiore's 5A's approach (Ask about smoking at every opportunity, Assess willingness to quit, Advise patients to quit smoking, Assist quit attempts and Arrange follow up). RESULTS: Fifty-seven clinicians completed questionnaires, 55 (96%) recognised the importance of asking adolescents about smoking. Thirty-one (54%) identified adolescent smokers all or most of the time, increasing to 50 (88%) if their presenting condition was associated with smoking. Twenty-five (44%) clinicians assessed the stage of change, 33 (58%) advised the adolescent to quit smoking, nine (16%) assisted quit attempts and 10 (17.5%) arranged follow up. Clinicians more confident in brief intervention skills, motivational interviewing and relapse prevention were more likely to use the 5A's (P<0.05). Training increased clinician's confidence in brief intervention skills and knowledge of nicotine replacement therapy (P<0.01); however, there was no statistically significant change in clinical practice 1 month post training. CONCLUSION: Training paediatricians in brief intervention skills, motivational interviewing and relapse prevention can increase the use of 5A's brief intervention in clinical practice, potentially increasing quit attempts in adolescents who smoke.     

Use of nicotine replacement therapy in adolescent smokers and nonsmokers

BACKGROUND: Assessing whether and how adolescents use nicotine replacement therapy (NRT) will be important given recent recommendations to make NRT more accessible by lowering its price, increasing its distribution, and advising health care professionals to suggest its use for smoking cessation. OBJECTIVES: To report the prevalence, ease of access, and reasons for NRT use and describe inappropriate use in adolescent smokers and nonsmokers. DESIGN: Cross-sectional survey of 4078 high school students during the school term of 1998. SETTING: City schools in Memphis, Tenn. MAIN OUTCOME MEASURES: Community-based self-reported prevalence of NRT use and characteristics of those using NRT. RESULTS: Approximately 5% of adolescents reported trying or using nicotine gum or patches. Females were less likely than males and African Americans were less likely than others to use NRT. For African American smokers, NRT use was highest at lower smoking levels, while other smokers showed the opposite pattern. Almost 40% of former smokers reported using NRT to try to quit smoking; however, 75% of current smokers endorsed using NRT for reasons other than trying to quit smoking. Other inappropriate use of NRT was reported; 18% of NRT users reported themselves as never smokers. More than 50% of students reported that it would be easy for them to get NRT. CONCLUSIONS: Nicotine replacement therapy is used by adolescent smokers and nonsmokers, is easily accessible, and is used for reasons other than trying to quit smoking. Efforts are needed to discourage NRT use in nonsmoking youth and to encourage appropriate use of NRT in young smokers to maximize its potential for successful cessation.     

Delivery of smoking prevention and cessation services to adolescents

OBJECTIVES: To describe the delivery of smoking prevention and cessation screening and counseling practices to adolescents and to examine the effect of physician specialty, sex, practice characteristics, and familiarity with preventive care guidelines on the delivery of smoking cessation counseling services. METHODS: Cross-sectional self-reported survey of pediatricians and family physicians in 3 New York metropolitan statistical areas who had seen 1 or more adolescents for well care within the past 6 months. RESULTS: Of 564 eligible physicians, 371 (66%) responded. Physicians reported asking most adolescents about smoking (91%) but were less likely to ask about peer smoking use (41%) or smokeless tobacco use (32%). Similarly, they reported assessing motivation to quit for 81% of smokers, but less often helped set quit dates (34%) or scheduled follow-up visits (28%). Family physicians were more likely to provide more effective smoking cessation interactions than pediatricians (mean smoking counseling performance score, 61 vs. 53; P<.001). Family physicians were also more likely to be familiar with National Cancer Institute guidelines than pediatricians (48% vs. 27%; P<.001). Female physicians reported having spent more time with their last adolescent patient (mean, 26 vs 21 minutes; P<.001) and more often spent time alone with adolescent patients (85% vs. 76% of visits; P<.001) than did male physicians. In multivariate modeling, specialty, familiarity with National Cancer Institute guidelines, time spent, and confidentiality factors were associated with better smoking counseling performance. CONCLUSION: Familiarity with smoking cessation guidelines and physician's specialty and practice style with adolescents are associated with better delivery of tobacco cessation counseling to adolescents.     

The role of smoking-cessation-specific parenting in adolescent smoking-specific cognitions and readiness to quit

BACKGROUND: An instrument assessing smoking-cessation-specific parenting was developed and tested in relation to a) the pros of smoking and quitting and self-efficacy to resist smoking, and b) adolescent readiness to quit. METHODS: Cross-sectional survey data from 998 Dutch adolescents who smoked regularly were used to perform structural equation analyses. RESULTS: Adolescents who perceived relatively few advantages of smoking and many benefits of quitting reported a high readiness to quit. Self-efficacy was not related to readiness to quit. Smoking-cessation-specific parenting was both directly related to a high readiness to quit, and indirectly through the perceived pros of quitting. Also, if one or both parents were smokers, adolescents reported experiencing less smoking-cessation-specific parenting and a lower readiness to quit. However, in general, differences in paths were not found between adolescents with two parents who did not smoke and adolescents with one or two parents who smoked. CONCLUSIONS: Given that anti-smoking socialisation has not yet been operationalised in terms of smoking-cessation-specific parenting, the present results will warrant further research into smoking-cessation-specific parenting in relation to adolescent smoking cessation. Further, parental smoking should not discourage parents from engaging in smoking-cessation-specific parenting as its relations with smoking cognitions and readiness to quit were highly similar in both the group with two parents who did not smoke and the group with one or two parents who smoked.     

Smoking cessation in adolescents: the role of nicotine dependence, stress, and coping methods

OBJECTIVES: To compare perceived reasons for continued smoking and withdrawal symptoms between current smokers and quitters in an inner-city adolescent population. To examine the relationship of nicotine dependence, stress, and coping methods between smokers and quitters and, using the Transtheoretical Model of Change, among adjacent smoking cessation stages. DESIGN: A cross-sectional study using a self-administered questionnaire. PARTICIPANTS: The study comprised 354 clinic patients between the ages of 12 and 21 years who reported past or present smoking. MAIN OUTCOME MEASURES: Demographic characteristics, smoking status, perceived reasons for continued smoking, attempts to quit, and withdrawal symptoms, as well as standardized scales assessing nicotine dependence, stress, and coping methods. RESULTS: The overall prevalence of smoking in this population was 26%. Smokers were significantly more likely to report smoking more cigarettes per day as well as higher levels of physical addiction (P<.01), greater levels of perceived stress (P<.02), and less use of cognitive coping methods (P<.02) than quitters (P<.005). However, comparison of consecutive stages revealed a significant difference only between precontemplation and contemplation in cognitive coping methods (P<.01). Three of 20 withdrawal symptoms (cravings, difficulty dealing with stress, and anger) were reported more frequently among current smokers who had attempted to quit in the last 6 months than among former smokers (P<.01). CONCLUSION: Interventions for inner-city adolescents who smoke should be designed to target those with the highest levels of nicotine dependence, stress, and decreased use of cognitive coping methods because they are the least likely to quit on their own, rather than developing stage-specific models.     

Prevention of tobacco use in adolescents: review of current findings and implications for healthcare providers

This paper reviews recent research on adolescent smoking initiation and youth tobacco prevention and control strategies. Gender, ethnicity, family factors, and genetics are associated with smoking initiation and adolescent tobacco use. Evidence indicates that comprehensive tobacco control programs are an effective strategy for reducing adolescent smoking, and even modest gains from prevention and cessation efforts could lead to substantial reductions in the morbidity and mortality costs of smoking. Clinicians have an important role in prevention and treatment of tobacco use in adolescents, and the rate of delivery of clinical preventive services in this area should be increased. Consequently, clinicians working with adolescents should be familiar with established guidelines regarding tobacco use prevention and treatment and use general outpatient office visits as an important opportunity to prevent tobacco use.     

An Integrative Review of Adolescent Smoking Cessation Using the Transtheoretical Model of Change

IntroductionThe purpose of this literature review is to report the effectiveness of trials using the Transtheoretical Model of Change for achieving smoking cessation among adolescents.MethodAn integrative literature review was performed. Two reviewers searched the Internet for randomized, controlled trials or observational studies of adolescent smoking cessation trials reported between 1999 and June 2009 that used the Transtheoretical Model of Change.ResultsSix randomized controlled trials remained after all inclusion and exclusion criteria were met. Each study was reviewed qualitatively and odds ratio and quit rates were calculated. Four studies demonstrated an odds ratio of greater than 1.0, and in four studies significantly better quit rates were found in the intervention arm versus the control arm at the endpoint evaluation.DiscussionEvidence exists for the effectiveness of stage-based interventions in promoting smoking cessation in adolescents.     

Tobacco addiction in young people: the paediatrician's role

Smoking is the leading cause of preventable deaths worldwide. Both first- and second-hand tobacco smoking are a major cause of morbidity in children. Smoking has both a health and an economic impact. Whilst there has been legislation in the UK that has impacted tobacco use, there remain about 88,000 children who start smoking each year in the UK. There is an increasing focus to treat tobacco addiction as a disease, and the dependency is more likely to start in the adolescent years. The paediatrician has an important role in systematically identifying smokers and offering highly cost-effective treatments to smokers in order to improve the chances of quitting and thus reduce the consequences that come along with smoking. This article discusses the importance of recognizing nicotine addiction, the increasing use of electronic cigarettes, the benefits of nicotine replacement therapy and behavioural support in smoking cessation in the paediatric population. We explore the WHO Framework Convention of Tobacco Control and the relevance of it to the paediatrician's role.     

Counseling smoking parents of young children: comparison of pediatricians and family physicians

BACKGROUND: Secondhand smoke is a major cause of morbidity in young children, and exposure to smoking parents is the principal source. Physician visits for young children present an opportunity to effect behavioral change among smoking parents. OBJECTIVE: To survey pediatricians and family physicians in their knowledge and practice of smoking cessation counseling with parents. DESIGN: Cross-sectional mail survey. SETTING: Urban California. PARTICIPANTS: Pediatricians and family physicians in urban areas of California, younger than 65 years, practicing in an ambulatory setting, and randomly selected from the American Medical Association Physician Masterfile. MAIN OUTCOME MEASURES: Reported frequency of asking about tobacco use, using cessation counseling techniques with smokers, and perceived barriers to providing cessation services. RESULTS: Of the 1000 mailed surveys, 899 were eligible and 499 (56% response rate) were returned and completed. A higher proportion of pediatricians compared with family physicians were women (44% vs 29%; P<.01) and nonwhite (44% vs 32%; P =.01). Family physicians compared with pediatricians were more likely to report referring a parent to a smoking cessation program (41% vs 30%), giving pamphlets on smoking cessation (40% vs 28%), asking for a quit date (41% vs 18%), scheduling a follow-up visit to discuss quitting (27% vs 5%), and recommending nicotine replacement therapy (41% vs 13%) (for each comparison, P<.001). Pediatricians were more likely to report recording in the medical record smoking by a parent as a problem for the child (65% vs 48%; P<.001), but a higher proportion of pediatricians perceived that parents would ignore the advice (39% vs 24%; P<.001) and lacked interest in quitting smoking (45% vs 27%; P<.001). Pediatricians were more likely to agree that they lacked smoking cessation counseling skills (26% vs 7%; P<.001). Multivariate models showed that pediatricians were less likely to report performing 5 of 14 smoking cessation techniques in at least 50% of smoking parents. CONCLUSIONS: Pediatricians appear to lack training to implement smoking cessation counseling with smoking parents. Physicians in private practice are less likely to counsel smoking parents. Educational interventions for pediatricians are needed to decrease secondhand smoke exposure for young children.     

Maternal tobacco smoking, nicotine replacement and neurobehavioural development

Abstract The adverse effects of prenatal cigarette smoke exposure on human reproductive outcomes are a major scientific and public health concern. In the United States, approximately 25% of women of childbearing age currently smoke cigarettes, and only a small percentage of these individuals quit after learning of their pregnancy. Women interested in smoking cessation during pregnancy have a number of options, including behavioural and pharmacological aids, but nicotine replacement therapy (NRT) is by far the most common approach. While NRT avoids exposure to the myriad compounds present in tobacco smoke, nicotine itself causes damage to the developing nervous system. The purpose of this article is to review the detrimental effects of developmental tobacco smoke exposure on short- and long-term outcomes with particular emphasis on neurobehavioural consequences. In conclusion based on the clear, adverse effects of nicotine on brain development observed in human and animal studies, we suggest that safer alternatives for smoking cessation in pregnancy are badly needed.     

Characteristics of smoker adolescents seeking smoking cessation services]

In France, the prevalence of tobacco consumption is 31% for teenagers between 15 and 19 years old. Nevertheless, few French studies have been published on the characteristics of young smokers seeking smoking cessation services. The development of smoking cessation centres in France since 1999 was associated to the setting up of a e-transfer system in order to evaluate the adequacy between these services and the needs of smokers. OBJECTIVE: To analyse the characteristics of smokers aged less than 19 years registered in the smoking cessation services national database. METHODS: A cross-sectional population-based study has been conducted in the smoking cessation services participating in the national database. The study population included 321 young smokers attending the smoking cessation centres during the period 2001-2005. RESULTS: The 321 smokers (mean age 16.6 years) were mostly girls (56.4%). A background of depression was declared by 19% of young smokers and an abnormal result was found for the hospital anxiety depression-screening test among 34% of the population for the anxiety scale and 6% for the depression scale. Mean daily tobacco consumption was 15.3 cigarettes per day and heavy nicotine dependence was found for 24.1% of the population. A nicotine replacement therapy was prescribed for every smoker. CONCLUSION: Nicotine dependence was heavy for 24.1% of the 321 young smokers seeking smoking cessation services. More than 1/3 had an abnormal result for the hospital anxiety depression-screening test. Tailored interventions for smoking cessation should be available for adolescent's smokers, especially school-based services.     

Risk and protective factors for nicotine dependence in adolescence

Background:  We investigated the role of psychosocial and proximal contextual factors on nicotine dependence in adolescence. Methods:  Data on a multiethnic cohort of 6th to 10th graders from the Chicago public schools were obtained from four household interviews conducted with adolescents over two years and one interview with mothers. Structural equation models were estimated on 660 youths who had smoked cigarettes by the first interview. Results:  Pleasant initial sensitivity to tobacco use, parental nicotine dependence (ND), adolescent ND and extensiveness of smoking at the initial interview had the strongest total effects on adolescent ND two years later. Perceived peer smoking and adolescent conduct problems were of lesser importance. Parental ND directly impacted adolescent ND two years later and had indirect effects through pleasant initial sensitivity and initial extensiveness of smoking. Parental depression affected initial adolescent dependence and depression but adolescent depression had no effect on ND. The model had greater explanatory power for males than females due partly to the stronger effect of conduct problems on dependence for males than females. Conclusions:  The findings underscore the importance of the initial drug experience and familial factors on adolescent nicotine dependence and highlight the factors to be the focus of efforts targeted toward preventing ND among adolescents.     

Nicotine patch therapy in 101 adolescent smokers: efficacy, withdrawal symptom relief, and carbon monoxide and plasma cotinine levels

OBJECTIVES: To determine the efficacy of nicotine patch therapy in adolescents who want to stop smoking and to assess biochemical markers of smoking and nicotine intake. DESIGN: Nonrandomized, open-label trial using a 15 mg/16 h patch. SETTING: Two midwestern cities. SUBJECTS: One hundred one adolescents aged 13 through 17 years smoking at least 10 cigarettes per day (cpd). INTERVENTION: Six weeks of nicotine patch therapy and follow-up visits at 12 weeks and 6 months. MAIN OUTCOME MEASURES: Self-reported smoking abstinence verified by expired-air carbon monoxide (CO) level of no more than 8 ppm, nicotine withdrawal symptoms, and plasma cotinine level. RESULTS: Forty-one participants were female (mean [+/- SD] age, 16.5 [+/- 1.1] years). Median baseline smoking rate was 20.0 cpd (range, 10-40 cpd). Biochemically confirmed point prevalence smoking abstinence was 10.9% (11/101) at 6 weeks and 5.0% (5/101) at 6 months. The mean (+/- SD) plasma cotinine level at baseline was 1510.9 +/- 732.7 nmol/L; for nonsmoking subjects at weeks 3 and 6, 607.8 +/- 386.2 and 710.0 +/- 772.5 nmol/L, respectively. Plasma cotinine levels were correlated with CO levels at baseline (r = 0.27; P = .006), week 3 (r = 0.34; P = .004), and week 6 (r = 0.26; P = .03) and with mean cigarettes smoked per day during weeks 3 (r = 0.24; P = .04) and 6 (r = 0.30; P = .02). Mean smoking rates decreased significantly during the study, an effect that lessened at 12 weeks and 6 months. CONCLUSIONS: Nicotine patch therapy plus minimal behavioral intervention does not appear to be effective for treatment of adolescent smokers. Plasma cotinine and CO levels appear to be valid measures of smoking rates during the cessation process, but not at baseline. Smoking rates were reduced throughout the study. Additional pharmacological and behavioral treatments should be considered in adolescent smokers.     

Protecting children and adolescents against the risks of vaping

Youth vaping presents significant risks for the health and safety of Canadian children and adolescents. This statement provides background information about vaping, vaping products, and related devices, discusses the short- and long-term harms known to be associated with their use, and offers prevention and cessation strategies for youth who vape or are at risk for starting. Youth vaping is associated with increased risk for tobacco and other substance use, mental health problems, pulmonary and cardiovascular disease, and unintentional injuries. Vaping should not be used as a smoking cessation tool for youth, due to lack of effectiveness and evidence of harm. Many preventive and treatment strategies used for tobacco cessation, including behavioural and pharmacological options, can be adapted to help youth quit vaping. Recommendations for community stakeholders and policy makers are included.     

Characteristics of African American teenage smokers who request cessation treatment: implications for addressing health disparities

BACKGROUND: Ethnoracial disparities in both tobacco-related mortality and treatment outcome for smoking cessation have been reported among adults, but there is a dearth of information on ethnoracial differences among adolescent smokers. OBJECTIVE: To compare smoking-related characteristics in African American and non-African American teenaged applicants for a smoking cessation trial.Participants, Design, and SETTING: Four hundred thirty-two teenaged smokers (mean [SD] age, 15.6 [1.5] years; 61.8%, female; 31.9%, African American) responded via telephone to various media advertisements. Self-reported sociodemographic, smoking-related, and clinical data were obtained to determine preeligibility for trial participation. MAIN OUTCOME MEASURES: The number of cigarettes smoked per day, Fagerstr?m Test for Nicotine Dependence (FTND) score, motivation to quit, self-reported health problems, and medication use. RESULTS: Compared with non-African Americans, African Americans had lower FTND scores (mean [SD] score, 5.31 [2.24] vs 6.18 [2.18]; P<.01), and smoked fewer cigarettes per day (mean [SD] number of cigarettes, 12.6 [8.3] vs 15.4 [7.5] cigarettes/d; P<.04). The FTND scores were similar in both groups when adjusted for the number of cigarettes smoked per day. African American and non-African American teenagers reported similar motivation to quit (mean [SD] score, 8.64 [1.68] vs 8.53 [1.59], respectively). No difference was found in frequency of physical health problems (eg, asthma), diagnosed psychiatric conditions, or prescribed psychiatric medication although fewer African American teenaged smokers took medication for physical problems (21.2% vs 36.7%). CONCLUSIONS: Cessation treatment interventions designed for African American youths should include lower FTND-defined levels, or the use of other instruments that do not focus on the number of cigarettes smoked per day. Our findings also highlight the importance of ethnocultural issues in treatment research that aims to address health disparities.     

Intervening With Smoking Parents of Inpatients to Reduce Exposure: The INSPIRE Randomized Controlled Trial

BackgroundHospitalized children have high rates of tobacco smoke exposure; parents who smoke may be receptive to interventions during their child's hospitalization.ObjectiveWe tested the efficacy of a smoking cessation intervention for parents of hospitalized children.MethodsWe conducted a randomized, single-blind clinical trial from 12/14-5/18 at the Children's Hospital Colorado. Hospitalized children who had a parent who smoked tobacco were eligible. Intervention: Intervention participants received motivational interviewing sessions, 2 weeks of nicotine replacement therapy; both groups received referral to the Quitline Consenting parents completed a questionnaire; urine was collected from the child for measurement of cotinine. Our primary outcome was: 1) increase in reporting “no one is allowed to smoke anywhere” in the home (smoke-free home rule). Additional outcomes included: 2) change in child's cotinine from baseline to 1 year, and 3) parental quitting at 1 year. Data were analyzed using Chi-square and t tests for bivariable data, and multivariable logistic and linear regression.ResultsOf 1641 eligible families approached, 252 were randomized (15%); 149 families had follow-up data at 12 months (59%). In the adjusted analysis, there was no difference between the groups in smoke free home rules, or child cotinine level; in an intention-to-treat analysis, 15% in the intervention group versus 8% of controls reported quit (p=0.07).ConclusionsA smoking cessation intervention can be delivered to parents of hospitalized children. While hospitalization provides an opportunity to help parents quit smoking, more efficient and effective engagement strategies are needed to optimize tobacco control success.     

Measuring the loss of autonomy over nicotine use in adolescents: the DANDY (Development and Assessment of Nicotine Dependence in Youths) study

CONTEXT: There is no validated, theory-based tool for assessing the onset of nicotine dependence. However, the use of all addictive substances can result in a loss of autonomy. We propose that nicotine dependence begins when autonomy is lost, ie, when the sequelae of tobacco use, either physical or psychological, present a barrier to quitting. OBJECTIVES: To test the autonomy theory of nicotine dependence, and to evaluate the Hooked on Nicotine Checklist (HONC) as a measure of the loss of autonomy over tobacco use. DESIGN: The psychometric performance and concept validity of the HONC were evaluated in a 30-month prospective longitudinal study of the natural history of tobacco use in a cohort of 679 seventh-grade students. RESULTS: As hypothesized, endorsement of a single item on the HONC was associated with a failed attempt at smoking cessation (odds ratio [OR], 29; 95% confidence interval [CI], 13-65), continued smoking until the end of follow-up (OR, 44; 95% CI, 17-114), and daily smoking (OR, 58; 95% CI, 24-142). Scores on the HONC correlated with the maximum amount smoked (r = 0.65; P<.001) and the maximum frequency of smoking (r = 0.79; P<.001). Internal reliability was 0.94. A 1-factor solution explained 66% of the total variance. CONCLUSIONS: The data support the autonomy theory that dependence begins with the loss of autonomy. The autonomy theory represents a potentially useful alternative to current concepts of nicotine dependence for adolescents, and the HONC appears to measure lost autonomy in adolescents. Construct validity was demonstrated by its utility in predicting failed cessation and the progression of tobacco use. In addition, the psychometric properties were excellent.     

Identification of adolescent tobacco users in a pediatric practice

CONTEXT: Though prevention of adolescent tobacco use is a major public health goal, there is little information on the ability of pediatricians to identify adolescents experimenting with tobacco and regular tobacco users. OBJECTIVES: To pilot use of a short questionnaire and analysis of urinary cotinine level to identify adolescent smokers in a pediatric practice, and to determine characteristics of tobacco users. SETTING: Suburban pediatric practice. METHOD: Consecutive high school students completed a short questionnaire and urine cotinine assessment. Three groups were defined: smokers (urine cotinine level >100 ng/mL), experimenters (smoked within the last year; urine continine level 相似文献   

Predictors of change on the smoking uptake continuum among adolescents

CONTEXT: Understanding how advertising and other risk and demographic factors affect adolescent susceptibility to smoking would allow for the development of more effective youth-targeted tobacco prevention and cessation programs and policies. OBJECTIVE: To examine the effect of various demographic and risk factors on different stages of smoking among adolescents. DESIGN: A nationally representative cross-sectional survey, The Robert Wood Johnson Foundation's Survey of Tobacco Price Sensitivity, Behavior, and Attitudes Among Teenagers and Young Adults. SUBJECTS: The Robert Wood Johnson Foundation's Survey of Tobacco Price Sensitivity, Behavior, and Attitudes Among Teenagers and Young Adults included 17,287 adolescent respondents (aged, 13-19 years) in 1996. MAIN OUTCOME MEASURES: Stage of susceptibility and correlates of progression toward regular smoking. RESULTS: Of all never [corrected] smoking adolescents, 32% were susceptible smokers (have never smoked, but might) with younger adolescents almost 3 times more likely than older adolescents to be susceptible. Female subjects were 50% [corrected] more likely than male subjects to be susceptible. In addition to exposure to others' smoking, owning or willingness to own tobacco promotional items, having a favorite cigarette advertisement, skipping school, poor school performance, and lack of attendance in religious activities were associated with progression along the uptake continuum. CONCLUSIONS: Improved understanding of the tobacco use trajectories of adolescents and the risk factors associated with progression will help clinicians and tobacco control advocates create effective youth-targeted interventions and policies. Findings suggest that physicians and other health care providers should redouble their efforts to ask preadolescents and young adults about smoking or the likelihood of their smoking. Nonsmokers should also be advised about the addictive nature of tobacco products and the resulting loss of control that accompanies addiction.