Smoking Behavior of US Youths: A Comparison Between Child Welfare System and Community Populations

摘要

Objectives. We compared rates of smoking for 2 groups of youths aged 12 to 14 years: those involved in the child welfare system (CW) and their counterparts in the community population. We then investigated factors associated with smoking for each group. Methods. We drew data from 2 national-level US sources: the National Survey of Child and Adolescent Well-Being and the National Longitudinal Study of Adolescent Health. We estimated logistic regression models for 3 binary outcome measures of smoking behavior: lifetime, current, and regular smoking. Results. CW-involved youths had significantly higher rates of lifetime smoking (43% vs 32%) and current smoking (23% vs 18%) than did youths in the community population. For CW-involved youths, delinquency and smoking were strongly linked. Among youths in the community population, multiple factors, including youth demographics and emotional and behavioral health, affected smoking behavior. Conclusions. Smoking prevalence was notably higher among CW-involved youths than among the community population. In light of the persistent public health impact of smoking, more attention should be focused on identification of risk factors for prevention and early intervention efforts among the CW-involved population. Cigarette smoking among US youths persists as a critical public health problem. Notably, 80% to 90% of adult smokers initiate smoking by age 18 years. 1 – 3 Trends in smoking behavior among youths have not paralleled the steady decline evident among adult smokers. 2 Tobacco use is related to more than 400 000 US deaths per year, and direct medical costs attributable to smoking total more than $50 billion in the United States annually. 1 , 4 The public health importance of tobacco use is underscored by the Obama administration's prioritization of smoking prevention and cessation. 5 Youths involved with the child welfare system (CW) face unique experiences that may put them at elevated risk for smoking compared with youths without similar experiences. 6 , 7 Youths enter the CW system as a result of case investigations conducted by local child protective services agencies. This population includes both youths receiving services in their homes and those in out-of-home care. The lives of CW-involved youths are characterized by problems such as child abuse, neglect, poverty, domestic violence, and parental substance abuse. 8 Although CW cases are typically referred on the basis of parent behavior, these youths are also at high risk for mental health disorders, substance use, and other psychosocial problems. 6 , 8 – 10 However, we are unaware of any studies examining cigarette smoking among CW youths in comparison with community samples to determine whether a difference in smoking-prevalence risk exists for these youths. It is important to determine whether CW-involved youths are at higher risk for smoking so that targeted prevention and intervention strategies can be developed. Among community youths, studies have demonstrated that some subgroups (e.g., age, gender, race/ethnicity, region) are at higher risk for both lifetime and current smoking. 2 Boys are more likely to initiate smoking, but they smoke more infrequently than girls do. 2 , 11 , 12 Racial/ethnic minority youths smoke less than do their White peers. 11 – 13 Parent education and family structure are associated with lifetime, current, and regular smoking, with youths from households of lower socioeconomic status smoking at higher rates. 14 – 17 Smoking is also linked to emotional well-being, including internalizing and externalizing behaviors and parent–child closeness. Depression is related to increased smoking behavior. 18 – 23 Engaging in delinquent acts is associated with increased youth smoking. 11 , 15 , 24 Youths who report having a close relationship with their parents are less likely to be regular smokers. 25 Several longitudinal studies have connected youth smoking with behavioral outcomes in adolescence and adulthood. Early-onset smokers are 3 times more likely by grade 12 to regularly use tobacco and marijuana, use hard drugs, sell drugs, have multiple drug problems, drop out of school, and engage in stealing and other delinquent behaviors. 26 In addition, long-term emotional and physical health—such as reduced adult life satisfaction, more severe nicotine dependence, and higher smoking quantities—are associated with youth smoking. 27 , 28 Our purpose in the current study was to investigate whether CW-involved youths were at greater risk for smoking than were community youths and to determine whether factors associated with smoking behavior were similar among both populations. We focused explicitly on early adolescence because smoking initiation occurs most often between the ages of 12 and 14 years, 2