The association between home smoking restrictions and youth smoking behaviour: a review.

OBJECTIVE: To review the available evidence for home smoking restrictions as a useful tool in the prevention of youth smoking and to make recommendations for further research. METHODS: A PubMed search (1 January 1990 to 26 January 2010) identified studies involving youth ≤18 years using extensive criteria. In all, 17 studies relating home smoking restrictions to youth smoking behaviour were identified from titles, abstracts or the full text, as required. Two additional articles were identified by other means. KE, NS and EG reviewed the studies. Differences in interpretation were resolved by discussion, with EG making final decisions. RESULTS: Of the 19 studies, 16 (including the only 2 longitudinal studies) showed at least marginal evidence of an association of home smoking restrictions with reduced adolescent smoking behaviours. Associations were more numerous and stronger in homes without adult smokers, suggesting that even in such homes, lack of a smoke-free home may undermine the parental value of not smoking. Definitions of home smoking rules, adolescent smoking behaviour and treatment of parental smoking varied widely among studies. It is recommend that future research: (1) contrast smoke-free homes for everyone against all others, (2) included an interaction term for parental smoking and having a smoke-free home, or conduct separate analyses for homes with and without parental or other adults smokers and (3) examine early and later stages of the smoking uptake continuum. CONCLUSIONS: While the evidence is suggestive for an effect, further research is required to establish causality using longitudinal designs.

The effect of smoke-free homes on adult smoking behavior: a review.

INTRODUCTION: Smoke-free homes are known to reduce exposure to harmful secondhand smoke. Recent studies suggest that they may also positively affect smoking behavior among smokers themselves. METHODS: We review the literature on the effect of smoke-free homes on adult smoking behavior. The literature search included database (PubMed) and manual searches of related articles and reference lists for English-language studies published from 1 January 1990 to 16 November 2008. RESULTS: We identified 16 cross-sectional and 7 longitudinal studies of the population-level association of smoke-free homes with adult smoking behavior. Additional studies provided population estimates of trends in and correlates of smoke-free homes. Prevalence of smoke-free homes varies but has been increasing over time in the countries studied and was greater among smokers who were younger, of higher income or educational attainment, smoked fewer cigarettes per day, or lived with a nonsmoking adult or child. Both longitudinal and cross-sectional studies showed that smokers who had or who newly implemented a smoke-free home were significantly more likely to make a quit attempt and to be abstinent, after controlling for confounding factors. In longitudinal studies, those who continued to smoke had a modest, but significant, decrease in cigarette consumption at follow-up. DISCUSSION: There is strong and consistent population-level evidence that a smoke-free home is associated with increased smoking cessation and decreased cigarette consumption in adult smokers. As they not only reduce exposure to secondhand smoke but also increase cessation rates, promotion of smoke-free homes should be a key element in tobacco control programs.

Young adult smoking behavior: implications for future population health.

OBJECTIVE: To qualitatively project the future health burden of tobacco from present-day young adult smoking behavior. METHODS: Population surveys in California (2002) and nationally (1978-80, 2001-03). RESULTS: In 2002, 40% of California young adult smokers were nondaily smokers, 24% had quit at some time for >or=6 months, 45% said they smoked less now than previously, and 68% thought they would quit within 5 years. Interest in quitting was high, and most were actively engaged in the smoking cessation process. Young adult smoking behavior changed from 1978-80 to 2001-03. CONCLUSION: The future health burden from smoking will be less for the current generation of young adults.

Receptivity to tobacco advertising and promotions among young adolescents as a predictor of established smoking in young adulthood.

OBJECTIVES: We investigated whether receptivity to tobacco advertising and promotions during young adolescence predicts young adult smoking 6 years later. METHODS: Two longitudinal cohorts of adolescents drawn from the 1993 and 1996 versions of the California Tobacco Surveys were followed 3 and 6 years later. At baseline, adolescents were aged 12 to 15 years and were not established smokers. The outcome measure was established smoking at final follow-up. Receptivity to cigarette advertising and promotions was included in a multivariate logistic regression analysis along with demographic and other variables. RESULTS: The rate of established smoking at follow-up was significantly greater among members of the 1993 through 1999 cohort (21.0%) than among members of the 1996 through 2002 cohort (15.6%). However, in both cohorts, having a favorite cigarette advertisement and owning or being willing to use a tobacco promotional item showed nearly identical adjusted odds of future adult smoking (1.46 and 1.84, respectively). CONCLUSIONS: Despite the success of tobacco control efforts in reducing youth smoking, tobacco marketing remains a potent influence on whether young adolescents become established smokers in young adulthood (18-21 years of age).

The California Tobacco Control Program's effect on adult smokers: (1) Smoking cessation.

OBJECTIVES: To estimate national population trends in long-term smoking cessation by age group and to compare cessation rates in California (CA) with those of two comparison groups of states. SETTING: Retrospective smoking history of a population sample from the US: from CA, with a comprehensive tobacco-control programme since 1989 with the goal of denormalising tobacco use; from New York and New Jersey (NY & NJ), with similar high cigarette prices but no comprehensive programme; and from the tobacco-growing states (TGS), with low cigarette prices, no tobacco-control programme and social norms relatively supportive of tobacco use. PARTICIPANTS: Respondents to the Current Population Survey-Tobacco Use Supplements (1992-2002; n = 57 918 non-Hispanic white ever-smokers). MAIN OUTCOME MEASURES: The proportion of recent ever-smokers attaining long-term abstinence (quit > or = 1 year) and the successful-quit ratio (the proportion of all ever-smokers abstinent > or = 1 year). RESULTS: Nationally, long-term cessation rates increased by 25% from the 1980s to the 1990s, averaging 3.4% per year in the 1990s. Cessation increased for all age groups, and by > 40% (p<0.001) among smokers aged 20-34 years. For smokers aged < 50 years, higher cigarette prices were associated with higher quitting rates. For smokers aged < 35 years, quitting rates in CA were higher than in either comparison group (p<0.05). Half of the ever-smokers had quit smoking by age 44 years in CA, 47 years in NY & NJ, and by age 54 years in TGS. CONCLUSION: Successful smoking cessation increased by 25% during the 1990s in the US. Comprehensive tobacco-control programmes were associated with greater cessation success than were with high cigarette prices alone, although both effects were limited to younger adults.

The California Tobacco Control Program's effect on adult smokers: (2) Daily cigarette consumption levels.

OBJECTIVE: To investigate the association of the California Comprehensive Tobacco Control Program with self-reported population trends of cigarette consumption during 1992-2002. SETTING AND PARTICIPANTS: Participants were non-Hispanic white daily smokers (aged 20-64 years, n = 24 317) from the Tobacco Use Supplements to the Current Population Survey (1992-2002). We compared age-specific trends in consumption among daily smokers in three groups of states with differing tobacco control initiatives: California (CA; high cigarette price/comprehensive programme), New York and New Jersey (high cigarette price/no comprehensive programme), and tobacco-growing states (TGS; low cigarette price/no comprehensive programme). RESULTS: There was a general decline in cigarette consumption across all age groups in each category of states between 1992 and 2002, except the oldest age group in the TGS. The largest annual decline in the average number of cigarettes per day was observed among daily smokers in CA who were aged > or = 35 years (-0.41 cigarettes/day/year (95% CI -0.52 to -0.3)). This rate was significantly higher than the -0.22 cigarettes/day/year (95% CI -0.3 to -0.16; p<0.02) observed in same-age daily smokers from New York and New Jersey, and significantly higher than the rate in same-age daily smokers from the TGS (-0.15 cigarettes/day/year (95% CI -0.22 to -0.08; p<0.002)). There were no significant differences across state groups in the decline observed in daily smokers aged 20-34 years. In 2002, only 12% of daily smokers in CA smoked more than a pack per day, which was significantly lower than the 17% in New York and New Jersey, which again was significantly lower than the 25% in the TGS. CONCLUSIONS: The California Tobacco Control Program was associated with significant declines in cigarette consumption among daily smokers aged > or = 35 years of age, which in turn should lead to declines in tobacco-related health effects. The decline in consumption among young adult smokers was a national trend.

The California Tobacco Control Program's effect on adult smokers: (3) Similar effects for African Americans across states.

OBJECTIVE: To compare trends in African-American (AA) and non-Hispanic white (NHW) smoking between states categorised as having three different levels of tobacco control practice in the 1990s. SETTING AND PARTICIPANTS: Analysis of 1992-3 to 2001-2 Tobacco Use Supplements to the Current Population Survey for differences in adult (20-64 years) daily smoking prevalence for AAs and NHWs across states: California (CA; high cigarette price/comprehensive programme), New York (NY) and New Jersey (NJ; high cigarette price/no comprehensive programme), and tobacco growing states (TGS; low cigarette price/no comprehensive programme). RESULTS: From 1992-3 to 2001-2, there were large declines in AA smoking across states (2.7-3.8% decrease/year, adjusted for age, income, education, gender; p<0.05). Adjusted NHW smoking prevalence declined significantly only in CA. AA prevalence declined significantly and did not differ across state groups. In all years, in all state groups, adjusted prevalence was either not significantly different or was lower for AAs than for NHWs. More recent cohorts of AAs appeared to have taken up smoking at lower rates than older cohorts. CONCLUSION: There were uniformly large declines in AA smoking from 1992-3 to 2001-2 across states, independent of type of tobacco control strategy. Further research is needed into factors associated with smoking declines among AAs.

Validation of the WHI brief physical activity questionnaire among women diagnosed with breast cancer.

OBJECTIVE: To investigate the psychometric properties of the physical activity (PA) measure of the Women's Health Initiative (WHI). METHODS: Women diagnosed with breast cancer and enrolled in the Women's Healthy Eating and Living Study (average age 55 years) wore an accelerometer for 1 week and completed the 7-day Physical Activity Recall (PAR) and brief WHI measure. RESULTS: Both self-reports correlated 0.73 with the accelerometer and had 100% sensitivity for meeting the current PA guideline, but specificity was significantly higher for the PAR. CONCLUSIONS: The WHI measure had comparable validity, sensitivity, and measurement bias compared to the widely accepted PAR.

Population effectiveness of pharmaceutical aids for smoking cessation: what is associated with increased success?

Although nicotine replacement therapy (NRT) has shown efficacy in randomized controlled trials, population effectiveness has appeared to diminish after it became available over the counter. The present study examined the population effectiveness of bupropion. It also examined whether population effectiveness of pharmaceutical-aid use in general (NRT, bupropion, or both) might be influenced by environmental factors: Having a smoke-free home (possible indication of motivation to quit) or no other smoker in the household. Data from the large population-based cross-sectional 1999 and 2002 California Tobacco Surveys were combined to improve statistical power for subgroup analyses of duration of abstinence following the most recent quit attempt in the past year. Moderate-to-heavy daily smokers (at least 15 cigarettes/day) a year prior to the survey (N = 2,640) were the main focus. A Cox proportional-hazards analysis suggested that bupropion was effective, perhaps even in the longer term. Further analyses identified significant interactions on abstinence duration between having a smoke-free home and any pharmaceutical-aid use (NRT, bupropion, or both), and between having a smoke-free home and no other smoker in the household. Although pharmaceutical aids may have had a slight short-term benefit if the home was not smoke free, they appeared particularly effective if the home was smoke free, both in the short and longer term. The California population experience supports the policy that programs subsidizing pharmaceutical aids to help smokers quit (particularly bupropion, if appropriate) should target highly motivated smokers who have already taken a behavioral action, such as implementing a smoke-free home.

Trends in smoking among Hispanic women in California: Relationship to English language use.

BACKGROUND: Research has shown that Hispanic women who speak mostly English have higher smoking rates than those who speak mostly another language. It is unknown how differences in smoking by English language use among adult Hispanic women in California have changed in recent years. METHODS: We compared current daily (100 or more cigarettes in lifetime, now smokes daily) and current nondaily (100 or more cigarettes in lifetime, now smokes some days) smoking prevalence for adult Hispanic women by English language use at home from population-based, random-digit-dialed California Tobacco Surveys in 1996 (n = 1406, 74% response rate [RR]); 1999 (n = 1379, 69% RR), and 2002 (n = 2912, 64% RR). RESULTS: Current smoking prevalence was at least twice as high among those who speak mostly English compared to those who speak mostly another language in every survey year (1996: 14.7% vs 6.1%; 1999: 14.6% vs 6.1%; 2002: 11.7% vs 4.9%) with the ratio staying constant (2.4:1). There was a decline in current nondaily smoking among those who speak mostly English by 2002 (1996 and 1999 prevalence: approximately 6%, 2002: approximately 4%), but no declines in current daily smoking for either language-use group. CONCLUSIONS: There has been no reduction in the English-language-use gap in smoking among Hispanic women in California. There has been a significant decline in current nondaily smoking prevalence among women who speak mostly English, but no significant reduction in current daily smoking for either language-use group. It appears that not much progress has been made in California in reducing daily smoking prevalence among Hispanic women at the population level. Smoking prevention and cessation efforts among Hispanic women remain a priority.

What contributed to the major decline in per capita cigarette consumption during California's comprehensive tobacco control programme?

OBJECTIVES: California experienced a notable decline in per capita cigarette consumption during its comprehensive tobacco control programme. This study examines what proportion of the decline occurred from: (1) fewer ever smokers in the population, (2) more ever smokers quitting, and (3) current smokers smoking less. DESIGN, SUBJECTS: Per capita cigarette consumption computed from cigarette sales and from adult respondents to the large, cross-sectional, population-based California Tobacco Surveys of 1990 (n = 24,296), 1996 (n = 18,616) and 2002 (n = 20,525) were examined for similar trends. MAIN OUTCOME MEASURE: Changes (period 1: 1990-1996; period 2: 1996-2002) in per capita cigarette consumption from self-reported survey data were partitioned for the entire population and for demographic subgroups into the three components mentioned above. RESULTS: In periods 1 and 2, most of the decline in per capita cigarette consumption for the population as a whole was from current smokers smoking less followed by a reduction in ever smokers. The decline from smokers smoking less was particularly evident among young adults (18-29 years) in period 1. While the portion of the decline due to quitting in the entire population in period 1 was negligible, in period 2 it accounted for 22% of the total per capita decline. The decline from quitting in period 2 was mostly observed among women. CONCLUSIONS: Rather than near-term benefits from smokers quitting, population health benefits from reduced per capita cigarette consumption will likely occur over the longer term from fewer people becoming ever smokers, and more less-addicted smokers eventually quitting successfully.

Comparative validation of the IPAQ and the 7-Day PAR among women diagnosed with breast cancer.

BACKGROUND: The criterion-related validity and measurement bias of the long form of the International Physical Activity Questionnaire (IPAQ) was compared to the 7-Day Physical Activity Recall (PAR). METHODS: Participants were women who have been diagnosed with breast cancer and enrolled in the ongoing Women's Healthy Eating and Living Study. Women (N = 159, average age 57 years) wore an accelerometer for one week and then completed the IPAQ or the PAR. RESULTS: The validity correlation of the PAR was significantly higher (p < 0.001) than the IPAQ (0.73 vs. 0.33, respectively). The PAR and IPAQ overestimated total physical activity by 13% vs. 247%, respectively. The PAR had better sensitivity (p = 0.14) and specificity (p < .01) than the IPAQ (100% vs. 71% and 84% vs. 59%, respectively) in predicting attainment of the ACSM physical activity guideline. CONCLUSION: The PAR was superior to the IPAQ in terms of validity, measurement bias, and screening statistics.

Responsiveness of homocysteine concentrations to food and supplemental folate intakes in smokers and never-smokers enrolled in a diet intervention trial.

We investigated circulating homocysteine concentrations in relation to smoking, folate intake (from food and supplements), serum folate concentrations, and other dietary variables. The present study is part of a parent trial assessing the effects of increasing vegetable, fruit, and fiber intakes and reducing the percentage of energy obtained from fat on breast cancer recurrence in 3,088 women previously diagnosed with breast cancer. Of the 121 smokers enrolled in the parent trial, 85 were available at baseline for the present study and were randomly matched to 85 never-smokers on baseline folate intake, age, and intervention status. Follow-up data were available on 53 smokers (22 intervention and 31 comparison) and 56 never-smokers (24 intervention and 32 comparison). No significant differences in circulating homocysteine and folate concentrations were observed between smokers and never-smokers at baseline. For smokers, significant decreases in circulating homocysteine and significant increases in folate concentrations (p < .05) from baseline to 12 months were observed in the comparison group. For never-smokers, significant decreases in circulating homocysteine and significant increases in folate concentrations were observed in the intervention and comparison groups (p < .05). In the multivariate analysis, changes in serum folate concentration and supplemental folic acid were significantly associated with change in plasma homocysteine concentrations (p < .05). These findings show that increasing supplemental folic acid can reduce homocysteine concentrations, which may have implications for lowering cardiovascular disease risk for smokers and never-smokers.

Cigarette promotional offers: who takes advantage?

BACKGROUND: Promotional offers on cigarettes (e.g., dollar-off, multipack discounts) composed the largest share of tobacco industry marketing expenditures, totaling $8.9 billion, or 72% of the total budget in 2002. Internal industry documents indicate that young adults, potential quitters, and other price-sensitive groups are the targets of these marketing tactics. How effective they are in actually reaching these groups in the general population of smokers has not yet been investigated. METHODS: Data were from 4618 current smokers responding to the large, random-digit-dialed population-based 2002 California Tobacco Survey. The characteristics were identified of smokers who reported that they used these offers "every time I see one." RESULTS: Thirty-five percent of smokers used promotional offers every time they saw one. Multivariate analyses identified young adults, women, African Americans, those with higher daily cigarette consumption, and those worried about cigarette costs as more likely to use promotional offers at every opportunity. Smokers most committed to quitting were no more likely to use promotional offers than those with no intention to quit. Cigarette brand was highly correlated with age and race/ethnicity, and therefore was not included in the multivariate analysis. Those who smoked menthol cigarettes and Camels, more often young adults and African Americans, were much more likely than those of other brands to use promotional offers. CONCLUSIONS: With the exception of smokers intending to quit, cigarette promotional offers are effectively reaching most industry-targeted groups. Importantly, young adults, who have the greatest long-term customer potential, are responding.

The potential impact of a low-nitrosamine smokeless tobacco product on cigarette smoking in the United States: estimates of a panel of experts.

OBJECTIVE: To predict the impact on tobacco use in the US of a "harm reduction" policy that requires that the smokeless tobacco product meet low nitrosamine standards, but could be marketed with a warning label consistent with the evidence of relative health risks. METHODS: Low nitrosamine smokeless tobacco (LN-SLT) and cigarette use are predicted by a panel of experts using a modified Delphi approach. We specify a thought experiment to isolate the changes that would occur after the new LN-SLT policy was implemented. RESULTS: The panel predicted that the new policy would accelerate a decrease in smoking prevalence from 1.3 to 3.1 percentage points over 5 years compared to the current SLT product policy, with greater effects on males than females. Introduction of the new product was also predicted to result in modest additional use of SLT overall, with the greatest increases among males who initiated tobacco use under the new policy. CONCLUSION: An overall consensus was reached that the introduction of a new LN-SLT product under strict regulations would increase SLT use, but reduce overall smoking prevalence. This reduction would likely yield substantial health benefits, but uncertainties surround the role of marketing and other tobacco control policies.

What fraction of young adults are at risk for future smoking, and who are they?

Recent evidence indicates that higher smoking rates among young adults in the United States may be related in part to increased initiation during young adulthood. The tobacco industry, restricted from overtly targeting adolescents, appears to be focusing on young adults. Thus it is important to estimate the percentage and identify the characteristics of the young adult population (aged 18-29 years) at risk for future smoking. This group would include all current established smokers (smoked at least 100 cigarettes in their lifetime), current experimenters, former established smokers, and former experimenters at risk for smoking again, as well as never-smokers who do not rule out future smoking. Using data from the population-based 2002 California Tobacco Survey (N = 9,364 young adults aged 18-29 years), we designated groups of young adults at risk and identified factors associated with risk. Altogether, 86.7+/-1.5% of current and former established smokers were at risk for future smoking, and 59.6+/-4.3% of former established smokers were at risk. Over half (52.2+/-2.0%) of all experimenters but only 9.0+/-1.2% of never-smokers were at risk. Overall, 43.0+/-1.2% of the young adult population was at risk. Although different demographic and other factors were associated with risk among former established smokers, experimenters, and never-smokers, three factors were consistently associated in each group: Younger age, not having a smoke-free home, and going to bars and clubs. We conclude that the group of young adults at risk for future smoking is sizable and presents a fertile target for tobacco industry efforts to promote smoking. Counter-efforts might include promotion of smoke-free environments.

Why does adult African-American smoking prevalence in California remain higher than for non-Hispanic whites?

OBJECTIVES: To explain why, contrary to national trends, adult California African-American (AA) smoking prevalence remains higher than for non-Hispanic Whites (W) and to explore how future rates might change. METHODS: Data from the random-digit-dialed California Tobacco Surveys from 1990 to 2002 (N=16,000-21,000) allowed for the examination of differences in current smoking prevalence, ever smoking (uptake), and successful smoking cessation over time by race/ethnicity and age group. RESULTS: African-American (AA) adolescent (12-17 years) smoking prevalence was lower than Ws through 1996, but similar thereafter because of marked declines for Ws. After 1990, AA young adult (18-29 years) smoking prevalence was consistently 25% lower than Ws', and no evidence of delayed AA smoking initiation was seen. However, among older age groups (30-44 years and 45+ years), AA smoking prevalence was much higher, yielding higher overall adult (18+ years) prevalence. While ever smoking (uptake) was generally lower among AAs, successful cessation (5+ years) was much lower among AA adults, especially older age groups. CONCLUSIONS: Continued higher adult California AA smoking prevalence results from less successful quitting in older age groups. Increased successful cessation is critical for reducing near-term prevalence. Long-term forecasting is difficult because both AA and W adolescents now smoke at comparably low rates.

How do smokers control their cigarette expenditures?

When faced with high cigarette prices, smokers can potentially control cigarette expenditures by limiting consumption or seeking cheaper cigarettes. The present study examined both these options and whether the use of price-minimizing strategies (the second option) could counteract a further price increase without smokers having to reduce consumption. Data for 5,109 smokers who purchased manufactured cigarettes were from the 2002 cross-sectional, population-based, random-digit-dialed California Tobacco Survey. We used logistic regression to examine which smokers used consumption-limiting or price-minimizing strategies, and multiple linear regression to determine how much price-minimizing strategies reduced the average price paid per pack. Overall, 32.3% of California smokers said they limited consumption and 74.1% used at least one of the five price-minimizing strategies identified: choosing cheaper retail outlets (61.1%), using promotional offers (35.2%), choosing cheaper brands (28.7%), purchasing by the carton (27.7%), and using low-tax or nontaxed sources (6.3%). Different groups of smokers used different strategies. Except for the use of promotional offers, all price-minimizing strategies significantly reduced the price paid per pack. Carton purchasers saved 1.01 US dollars/pack, and those buying from low-tax or nontaxed sources saved 1.23 US dollars/pack. However, pack buyers were reluctant to purchase cartons, mostly because they thought they might smoke too much, or because they considered the upfront cost unaffordable. The average California smoker could potentially save 0.33-0.66 US dollars/pack or 6.00-12.00 US dollars/month by using other price-minimizing strategies. Reducing consumption by 3 cigarettes/day could save a smoker 18.00 US dollars/month. Whereas price-minimizing strategies appeared to save money, cutting consumption could save even more. Thus further substantial tax increases would likely have the desired effect.

Facilitating adolescent smoking: who provides the cigarettes?

PURPOSE: Most adolescent smokers obtain cigarettes through social sources. We examine the extent to which cigarettes are provided by facilitators of legal age to purchase cigarettes. DESIGN: Analyses of data from the 1999 California Tobacco Survey, a large population-based, random-digit-dialed telephone survey, are reported. SETTING: California. SUBJECTS: Data were from a subset of 1239 adolescent (12-17 years) respondents who reported ever having smoked a cigarette. The response rate for all adolescents selected for interview was 75.5%. MEASURES: We describe cigarette providers to adolescents in social (cigarettes given to the adolescent) and economic (someone else buys cigarettes for the adolescent) transactions by the reported facilitator's age. RESULTS: Of the 82.2% +/- 2.6% of adolescents who had ever smoked who usually obtained cigarettes from others, 21.6% +/- 2.5% used economic transactions; most (60.6% +/- 3.4%) were given cigarettes. The majority (73.3% +/- 3.6%) of those relying on social sources were given cigarettes by someone < 18 years of age; very few were given cigarettes by someone 21+ years old. Most (90.4% +/- 2.0%) usually given cigarettes reported friends as facilitators. Of those who relied on economic transactions, 56.1% +/- 6.6% reported facilitators who were 18- to 20-year-olds, another 24.7% +/- 6.3% had suppliers > or = 21 years of age. Altogether, 80.8% +/- 5.8% of facilitators in economic transactions were > or = 18 years of age. CONCLUSIONS: Until peer approval of smoking and sharing cigarettes and adult facilitation of adolescent smoking is reduced, it will be difficult to significantly reduce adolescents' access to cigarettes.